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THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE 


DESIGNED  FOR    THE   USE  OF  PRACTITIONERS 
AND   STUDENTS  OF  MEDICINE 


BY 

WILLIAM   OSLER,   M.  D. 

Fellow  of  the  Royal  Society  ;  Fellow  of  the  Royal  College  of  Physicians, 

London  ;  Professor  of  Medicine  in  the  Johns  Hopkins  University  and 

Physician-in-chief  to  the  Johns   Hopkins   Hospital,   Baltimore  ; 

formerly    Professor   of   the    Institutes   of    Medicine,    McGill 

University,  Montreal ;  and  Professor  of  Clinical  Medicine 

in  the  University  of  Pennsylvania,  Philadelphia 


FIFTH    EDITION 


NEW  YORK  AND  LONDON 

D.    APPLETON    AND    COMPANY 

1904 


Copyright,  1893,  1895,  1898,  1901,  1902,  1903,  1904, 
By   D.    APPLETON   AND   COMPANY. 


PRINTED   AT   THE   APPLETON    PRESS, 
NEW    YORK,    U.  S.  A. 


TO    THE 

iHemorg  of  mu  ®eacl)cr0: 
WILLIAM  ARTHUE  JOHNSON, 

PEIEST  OF  THE  PARISH   OF  WESTON,    ONTAEIO. 

JAMES  BOVELL, 

OF  THE  TORONTO   SCHOOL   OF  MEDICINE,    AND   OP  THE 
UNIVERSITY   OF  TRINITY   COLLEG:^,    TORONTO. 

ROBERT  PALMER  HOWARD, 

DEAN   OF   THE  MEDICAL   FACULTY   AND   PROFESSOR  OF  MEDICINE, 
MCGILL  UNIVERSITY,    MONTREAL. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/principlespracti1904osle 


PKEFACE. 


A  WORD  of  explanation  on  the  appearance  so  soon  of  a  new  edition, 
breaking  the  orderly  triennial  sequence  of  previous  editions.  Through  an 
oversight,  the  fourth  edition  was  not  copyrighted  in  Great  Britain,  and 
an  unauthorized  edition  was  promptly  issued  at  a  greatly  reduced  price, 
which  has  interfered  with  the  legitimate  sale  of  the  book  in  Great  Britain 
and  Canada.  In  no  other  way  than  by  the  issue  of  this,  a  new  edition,  could 
copyright  be  obtained.  I  have  taken  the  opportunity  to  make  a  number 
of  additions  and  alterations.  A  great  many  corrections  have  been  made  at 
the  suggestions  of  friends  and  correspondents,  to  whom  I  am  much  indebted. 

W.  0. 
Johns  Hopkins  Hospital. 


PKEFACE  TO  THE  FOURTH  EDITION. 


Many  and  important  changes  have  been  made  in  this  edition.  The 
article  on  Typhoid  Fever  has  been  in  great  part  rewritten,  and  there  is 
embodied  in  it  the  additional  experience  of  my  clinic.  The  subject  of 
malaria  has  had  to  be  recast,  and  the  important  new  matter  on  etiology 
and  prophylaxis  has  been  added.  Dysentery,  Yellow  Fever,  and  the  Plague 
have  attracted  the  attention  of  so  many  workers  that  it  is  difl&cult  to  keep 
pace  with  the  rapid  progress  of  our  knowledge.  I  have  tried  to  bring 
these  articles  up  to  date,  and  in  rewriting  them  have  kept  in  mind  the 
needs  of  physicians  practicing  in  the  tropics.  On  the  all-important  dis- 
ease. Pneumonia,  the  student  will  find  many  new  paragraphs.  I  have 
incorporated  in  the  article  on  Diphtheria  the  model  work  which  has  been 
done  by  McCollom  and  by  Councilman  and  his  colleagues  at  the  Boston 
City  Hospital.  On  Small-pox,  Cerebro-spinal  Fever,  Eheumatic  Fever,  and 
many  others  of  the  acute  infections,  new  points  are  added  on  diagnosis 
and  treatment. 

Dr.  Futcher,  my  first  assistant,  has  analyzed  for  this  edition  the  ex- 
perience of  my  clinic  for  the  past  twelve  years  on  Diabetes  and  Gout,  in 
which  sections  much  new  matter  has  been  incorporated.  The  sections  on 
Obesity  and  Arthritis  Deformans  have  been  changed. 

Practically  new  articles,  in  whole  or  in  part,  are  those  on  Acute  Tuber- 
culosis, Diseases  of  the  Pancreas,  Splenic  Anaemia,  Arsenical  Poisoning, 
Herpes  Zoster,  Adiposis  Dolorosa,  Fibrinous  Bronchitis,  Albumosuria, 
Oxaluria,  Meniere's  Disease,  Aphasia,  Combined  Sclerosis  of  the  Cord, 
Myasthenia  Gravis,  Congenital  Aneurism,  Surgical  Treatment  of  Aneurism 
and  Scurvy. 

Dr.  McCrae  has  analyzed  for  this  edition  the  material  of  the  clinic  on 
Pernicious  Anaemia  and  Leukemia. 

Minor  changes,  too  numerous  to  mention,  have  been  incorporated,  and 
my  aim  has  been  to  deserve — and,  if  possible,  to  repay  in  some  slight  meas- 


X  CONTENTS. 

PAGE 

XXXI.  Actinomycosis.        . 235 

XXXII.  Syphilis    . 238 

Acquired 240 

Congenital 242 

Visceral 244 

XXXIII.  Gonorrhoeal  Infection 255 

XXXIV.  Tuberculosis ~      ...  258 

1.  General  Etiology  and  Morbid  Anatomy 258 

2.  Acute  Tuberculosis 273 

3.  Tuberculosis  of  the  Lymphatic  System 280 

4.  "            of  the  Lungs  (Phthisis,  Consumption)      ....  289 

5.  "            of  the  Alimentary  Canal 317 

6.  "           of  the  Liver 320 

7.  "            of  the  Brain  and  Spinal  Cord 321 

8.  "           of  the  Genito-urinary  System 322 

9.  "           of  the  Mammary  Gland 327 

10.  "           of  the  Circulatory  System 327 

11.  Diagnosis  of  Tuberculosis .        .  328 

12.  Prognosis  in  Tuberculosis      .        .        . 328 

13.  Prophylaxis  in  Tuberculosis 330 

14.  Treatment  of  Tuberculosis      • 331 

XXXV.  Leprosy 338 

XXXVI.  Infectious  Diseases  of  Doubtful  Nature 342 

1.  Febricula  (Ephemeral  Fever) 342 

2.  Weil's  Disease         ...     - 344 

3.  Milk-sickness  .        .        .        .      ' 344 

4.  Glandular  Fever 345 

5.  Mountain  Fever 346 

6.  Miliary  Fever  (Sweating  Sickness) 346 

7.  Foot  and  Mouth  Disease 347 


SECTION  II. 
DISEASES  DUE  TO  ANIMAL  PARASITES. 

I.  Psorospermiasis 349 

1,  Internal  Psorospermiasis 349 

2.  Cutaneous  Psorospermiasis 350 

II.  Parasitic  Infusoria - 351 

in.  Distomiasis ^^l 

IV.  Diseases  caused  by  Nematodes 352 

1.  Ascariasis ^^" 

2.  Trichiniasis .354 

3.  Anchylostomiasis 359 


4.  Filariasis 

5.  Dracontiasis 


360 
362 


6.  Other  Nematodes 364 

Acanthocephala 365 

V.  Diseases  caused  by  Cestodes 365 

1.  Intestinal  Cestodes ;  Tape-worms 365 

2.  Visceral  Cestodes ^^^ 

Cyaticercus  Cellulosae ^^^ 

Echinococcus  Disease 370 

Multilocular  Echinococcus 374 


CONTENTS.  xi 

PAGE 

VI.  Parasitic  Arachnida     .        .        .        .        • 375 

VII.  Parasitic  Insects 376 

VIII.  Myiasis 378 

SECTION  III. 
THE  INTOXICATIONS  AND  SUN-STROKE. 

I.  Alcoholism 380 

1.  Acute  Alcoholism 380 

2.  Chronic  Alcoholism          .        .        .        .   • 380 

3.  Delirium  Tremens ■ 383 

II.  Morphia  Habit 384 

III.  Lead  Poisoning 386 

IV.  Arsenical  Poisoning 390 

V.  Food  Poisoning 391 

1.  Meat  Poisoning 391 

2.  Poisoning  by  Milk  Products 393 

3.  Poisoning  by  Shell-fish  and  Fish    .    , .  393 

4.  Grain  Poisoning 394 

VI.  Sun-stroke 395 

SECTION  IV. 

CONSTITUTIONAL   DISEASES. 

I.  Arthritis  Deformans 399 

II.  Chronic  Rheumatism 405 

III.  Muscular  Rheumatism 406 

IV.  Gout 407 

V.  Diabetes  Mellitus 418 

VI.  Diabetes  Insipidus        . 432 

VII.  Rickets 434 

VIII.  Obesity 439 

SECTION   V. 

DISEASES  OP  THE   DIGESTIVE  SYSTEM. 

I.  Diseases  of  the  Mouth 441 

Stomatitis 441 

Aphthous  Stomatitis 441 

Ulcerative  Stomatitis 442 

Parasitic  Stomatitis  (Thrush) 443 

Gangrenous  Stomatitis 444 

Mercurial  Stomatitis 444 

Eczema  of  the  Tongue 445 

Leukoplakia  buccalis 446 

II.  Diseases  of  the  Salivary  Glands 446 

Supersecretion 446 

Xerostomia 447 

Inflammation  of  the  Salivary  Glands 447 

III.  Diseases  of  the  Pharynx 448 

Circulatory  Disturbances 448 

Acute  Pharyngitis 448 

Chronic  Pharyngitis 449 


xii  CONTENTS. 

% 

FACE 

Ulceration  of  the  Pharynx 449 

,        Acute  Infectious  Phlegmon  of  the  Pharynx    .......  450 

Retro-pharyngeal  Abscess 450 

Angina  Ludoviei 450 

IV.  Diseases  of  the  Tonsils 451 

Acute  Tonsillitis 451 

Follicular  or  Lacunar  Tonsillitis      .        . 451 

Suppurative  Tonsillitis 453 

Chronic  Tonsillitis 454 

V.  Diseases  of  the  CEsophagus  . 458 

Acute  CEsophagitis 458 

Spasm  of  the  CEsophagus 459 

Stricture  of  the  Oesophagus 460 

Cancer  of  the  Oesophagus 461 

Rupture  of  the  CEsophagus 463 

Dilatations  and  Diverticula 463 

VI.  Diseases  of  the  Stomach 463 

Acute  Gastritis .        . 463 

Phlegmonous  Gastritis 464 

Toxic  Gastritis 465 

Diphtheritic  Gastritis 465 

Mycotic  Gastritis 466 

Chronic  Gastritis  (Chronic  Dyspepsia) 466 

Dilatation  of  Stomach 474 

Peptic  Ulcer  (Gastric  and  Duodenal) .        .  478 

Cancer  of  Stomach 486 

Hypertrophic  Stenosis  of  the  Pylorus 494 

Haemorrhage  from  the  Stomach 495 

Neuroses  of  the  Stomach 497 

VII.  Diseases  of  the  Intestines 505 

1.  Diseases  of  the  Intestines  associated  with  Diarrhoea 505 

Catarrhal  Enteritis :  Diarrhoea 505 

Enteritis  in  Children 608 

Diphtheritic  or  Croupous  Enteritis 513 

Phlegmonous  Enteritis 513 

Ulcerative  Enteritis 513 

2.  Appendicitis  (Typhlitis  and  Perityphlitis) 519 

3.  Intestinal  Obstruction - .        .        .        .  531 

4.  Constipation  (Costiveness) 538 

5.  Enteroptosis  (Glenard's  Disease) 541 

6.  Miscellaneous  Affections 544 

Mucous  Colitis •  644 

Dilatation  of  the  Colon 545 

Intestinal  Sand 546 

Affections  of  the  Mesentery 546 

VIII.  Diseases  of  the  Liver 548 

1.  Jaundice  .(Icterus) 548 

3.  Icterus  Neonatorum     . 651 

3.  Acute  Yellow  Atrophy 551 

4.  Affections  of  the  Blood-vessels  of  the  Liver 553 

5.  Diseases  of  the  Bile-passages  and  Gall-bladder 555 

6.  Cholelithiasis 661 

7.  Cirrhoses  of  the  Liver 569 

8.  Abscess  of  the  Liver 577 


CONTENTS. 


xm 


FAOE 

9.  New  Growths  in  the  Liver 582 

10.  Fatty  Liver 585 

11.  Amyloid  Liver 586 

12.  Anomalies  in  Form  and  Position  of  the  Liver 587 

IX.  Diseases  of  the  Pancreas 688 

1.  Haemorrhage 588 

2.  Acute  Pancreatitis 589 

8.  Chronic  Pancreatitis 592 

4.  Pancreatic  Cysts 592 

5.  Tumors  of  the  Pancreas 594 

6.  Pancreatic  Calculi 595 

X.  Diseases  of  the  Peritonaeum 596 

1.  Acute  General  Peritonitis    ;        .        .        . 596 

2.  Peritonitis  in  Infants 600 

3.  Localized  Peritonitis 600 

4.  Chronic  Peritonitis 602 

5.  New  Growths  in  the  Peritonseura 604 

6.  Ascites  (Hydro-peritonseum) ' .        .        .  605 

SECTION  VI. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

I.  Diseases  of  the  Nose 610 

Acute  Coryza 610 

Chronic  Nasal  Catarrh 611 

Autumnal  Catarrh  (Hay  Fever) 612 

Epistaxis 614 

IS.  Diseases  of  the  Larynx 615 

1.  Acute  Catarrhal  Laryngitis 615 

2.  Chronic  Laryngitis 616 

3.  (Edematous  Laryngitis 617 

4.  Spasmodic  Laryngitis  (Laryngismus  stridulus) 617 

5.  Tuberculous  Laryngitis 619 

6.  Syphilitic  Laryngitis 620 

III.  Diseases  of  the  Bronchi 621 

1.  Acute  Bronchitis 621 

2.  Chronic  Bronchitis 623 

3.  Bronchiectasis 626 

4.  Bronchial  Asthma 628 

5.  Fibrinous  Bronchitis 632 

IV.  Diseases  of  the  Lungs 634 

1.  Circulatory  Disturbances  in  the  Lungs 634 

2.  Broncho-pneumonia  (Capillary  Bronchitis) 641 

3.  Chronic  Interstitial  Pneumonia  (Cirrhosis  of  Lung) 649 

4.  Pneumonokoniosis 652 

5.  Emphysema 654 

Compensatory  Emphysema 655 

Hypertrophic  Emphysema 655 

Atrophic  Emphysema 659 

Acute  Vesicular  Emphysema 660 

Interstitial  Emphysema 660 

6.  Gangrene  of  the  Lung 660 

7.  Abscess  of  the  Lung 662 

8.  New  Growths  in  the  Lungs 663 


xiv  CONTENTS. 

PAGE 

V.  Diseases  of  the  Pleura 665 

1.  Acute  Pleurisy .        •  665 

Fibrinous  or  Plastic  Pleurisy     . 665 

Sero-flbrinous  Pleurisy 666 

Purulent  Pleurisy  (Empyema)    .........  671 

Tuberculous  Pleurisy 673 

Other  Varieties  of  Pleurisy 673 

2.  Chronic  Pleurisy 678 

3.  Hydrothorax 680 

4.  Pneumothorax  (Hydro-pneumothorax  and  Pyo-pneumothorax)  .        .        .  681 

5.  Affections  of  the  Mediastinum 684 


SECTION  VII. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

I.  Diseases  of  the  Pericardium 688 

1.  Pericarditis -•.....  688 

3,  Other  Affections  of  the  Pericardium 697 

II.  Diseases  of  the  Heart _  ...  698 

1.  Endocarditis 698 

Acute  Endocarditis 698 

Chronic  Endocarditis 705 

2.  Chronic  Valvular  Disease 707 

General  Introduction 707 

Aortic  Incompetency 709 

Aortic  Stenosis ...  715 

Mitral  Incompetency •        •        •        •        •  717 

Mitral  Stenosis 721 

Tricuspid  Valve  Disease 725 

Pulmonary  Valve  Disease '        '       '  '^'^'^ 

Combined  Valvular  Lesions        .        .        .        .'       •        •        ■        •        .728 

3.  Hypertrophy  and  Dilatation  . 735 

Hypertrophy  of  the  Heart •        •        .     ■  .    735 

Dilatation  of  the  Heart        .        .        .        .       , 741 

4.  Affections  of  the  Myocardium •        .746 

Aneurism  of  the  Heart - "^^^ 

Rupture  of  the  Heart - '^^^ 

New  Growths  and  Parasites '•        •        .754 

Wounds  and  Foreign  Bodies 754 

5.  Neuroses  of  the  Heart '^^^ 

Palpitation    .        , ' '    '     *  IS 

Arrhythmia J™ 

Rapid  Heart  (Tachycardia) 758 

Slow  Heart  (Bradycardia) "^^^ 

Angina  Pectoris 3^^ 

6.  Congenital  Affections  of  the  Heart         .        .     -.        .        .        •        •        'I 

III.  Diseases  of  the  Arteries ^^^^ 

1.  Degenerations 

2.  Arterio-sclerosis  (Arterio-capillary  Fibrosis) 770 

776 

3.  Aneurism 

Aneurism  of  the  Thoracic  Aorta •        *    III 

Aneurism  of  the  Abdominal  Aorta 786 

Aneurism  of  the  Branches  of  the  Abdominal  Aorta 787 


CONTENTS.  XV 

PAGE 

Arterio-venous  Aneurism 788 

Congenital  Aneurism 788 

SECTION  VIII. 

DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

I.  Anaemia 789 

Secondary  Anaemia 789 

Primary  or  Essential  Anasmia 792 

II.  Leukaemia 802 

III.  Hodgkin's  Disease 809 

IV.  Purpura         . 814 

V.  Haemophilia 819 

VI.  Scurvy 821 

VII.  Status  Lymphaticus 826 

VIII.  Diseases  of  the  Suprarenal  Bodies 828 

IX.  Diseases  of  the  Spleen 832 

X.  Diseases  of  the  Thyroid  Gland 835 

Goitre 835 

Tumors  of  the  Thyroid 836 

Exophthalmic  Goitre 836 

Myxcedema 840 

XI.  Diseases  of  the  Thymus  Gland 843 

SECTION  IX. 

DISEASES  OF  THE  KIDNEYS. 

I.  Malformations 846 

II.  Movable  Kidney §46 

III.  Circulatory  Disturbances 849 

IV.  Anomalies  of  the  Urinary  Secretion 850 

1.  Anuria 850 

2.  Hematuria 851 

3.  Haemoglobinuria         .        .        ■. 852 

4.  Albuminuria       . 854 

5.  Pyuria  (Pus  in  the  Urine) 858 

6.  Chyluria  (Non-parasitic) 859 

7   Lithuria 859 

8.  Oxaluria 861 

9.  Cystinuria 861 

10   Phosphaturia      ...                862 

11.  Indicanuria 863 

12.  Melanuria 863 

13.  Pneumaturia       . ....  864 

14.  Other  Substances 864 

V.  Uraemia 865 

VI.  Acute  Bright's  Disease ....  869 

VII.  Chronic  Bright's  Disease 874 

Chronic  Parenchymatous  Nephritis 875 

Chronic  Interstitial  Nephritis 877 

VIII.  Amyloid  Disease 884 

IX.  Pyelitis 886 

X.  Hydronephrosis 889 


xvi  CONTENTS. 

PAOK 

XI.  Nephrolithiasis  (Renal  Calculus) 891 

XII.  Tumors  of  the  Kidney 896 

XIII.  Cystic  Disease  of  the  Kidney       .        .        .        .        , 898 

XIV.  Perinephric  Abscess 900 

SECTION  X. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

I.  General  Introduction 901 

II.  System  Diseases    .        . 919 

1.  Introduction 919 

2.  Diseases  of  the  Afferent  or  Sensory  System 920 

Locomotor  Ataxia 920 

3.  Diseases  of  the  Efferent  or  Motor  Tract 928 

Of  the  Whole  Tract 928 

Progressive  (Central)  Muscular  Atrophy 928 

Bulbar  Paralysis 932 

Progressive  Neural  Muscular  Atrophy 933 

The  Muscular  Dystrophies 933 

System  Diseases  of  the  Upper  Motor  Segment 936 

Spastic  Paralysis  of  Adults .        .        .  937 

Spastic  Paralysis  of  Infants 938 

Hereditary  Spastic  Paraplegia 940 

Erb's  Syphilitic  Spinal  Paralysis 940 

Secondary  Spastic  Paralysis 941 

Hysterical  Spastic  Paraplegia 941 

System  Diseases  of  the  Lower  Motor  Segment 941 

Chronic  Anterior  Polio-myelitis 941 

Ophthalmoplegia 942 

Acute  Anterior  Polio-myelitis 942 

Acute  and  Subacute  Polio-myelitis  in  Adults 946 

Acute  Ascending  (Landry's)  Paralysis 946 

Myasthenia  Gravis 947 

4.  Combined  System  Diseases 947 

Ataxic  Paraplegia 948 

Primary  Combined  Sclerosis  (Putnam) 949 

Hereditary  Ataxia  (Friedreich's  Ataxia) 949 

Progressive  Interstitial  Hypertrophic  Neuritis  of  Infants     .        .        .  951 

Toxic  Combined  Sclerosis 951 

III.  Diffuse  Diseases  of  the  Nervous  System 951 

1.  Affections  of  the  Meninges 951 

Diseases  of  the  Dura  Mater  (Pachymeningitis)       .        .        .        .        .  951 

HaBmorrhagic  Pachymeningitis 952 

Diseases  of  the  Pia  Mater 954 

Simple  Meningitis  of  Infants 957 

2.  Scleroses  of  the  Brain 957 

Insular  Sclerosis 959 

3.  Chronic  Diffuse  Meningo-encephalitis 960 

IV.  Diffuse  and  Focal  Diseases  of  the  Spinal  Cord 964 

1.  Topical  Diagnosis 964 

2.  Affections  of  the  Blood-vessels 966 

Congestion 966 

Anaemia 966 

Embolism  and  Thrombosis 966 


CONTENTS.  xvii 

PAOI 

Endarteritis 967 

Hfemorrhage  into  the  Spinal  Membranes 967 

Haemorrhage  into  the  Spinal  Cord 968 

Caisson  Disease 969 

8.  Compression  of  the  Spinal  Cord 970 

Lesions  of  the  Cauda  Equina  and  Conus  Mednllaris     ....  973 

4.  Tumors  of  the  Spinal  Cord  and  its  Membranes 973 

5.  Syringomyelia 975 

6.  Acute  Myelitis 976 

V.  Diffuse  and  Focal  Diseases  of  the  Brain 979 

1.  Topical  Diagnosis 979 

2.  Aphasia 988 

8.  Affections  of  the  Blood-vessels 994 

Hyperff>mia 994 

Anai'mia 995 

(Edema  of  the  Brain 997 

Cerebral  Hivmorrhage 997 

Embolism  and  Thrombosis 1008 

Aneurism  of  the  Cerebral  Arteries 1013 

Endarteritis 1014 

Thrombosis  of  the  Cerebral  Sinuses  and  Veins 1015 

Hemiplegia  in  Children 1017 

4.  Tumors,  Infectious  Granulomata,  and  Cysts  of  the  Brain       .        .        .  1030 

5.  Inflammation  of  the  Brain 1034 

Acute  Encephalitis 1034 

Abscess  of  the  Brain 1035 

6.  Hydrocephalus 1038 

VI.  Diseases  of  the  Peripheral  Nerves 1031 

1.  Neuritis  (Inflammation  of  the  Bundles  of  Nerve  Fibres).        .        .        .  1031 

2.  Neuromata 1037 

3.  Diseases  of  the  Cerebral  Nerves 1038 

Olfactory  Nerves  and  Tracts ^       .        .  1038 

Optic  Nerve  and  Tract 1039 

Lesions  of  the  Retina 1039 

Lesions  of  the  Optic  Nerve         . 1040 

Affections  of  the  Chiasma  and  Tract 1041 

Affections  of  the  Tract  and  Centres 1043 

Motor  Nerves  of  the  Eyeball 1045 

Fifth  Nerve 1050 

Facial  Nerve 1051 

Auditory  Nerve 1056 

The  Cochlear  Nerve 1056 

The  Vestibular  Nerve 1058 

Glosso-pharyngeal  Nerve 1059 

Pneumogastric  Nerve 1060 

Spinal  Accessory 1063 

Hypoglossal  Nerve 1066 

4.  Diseases  of  the  Spinal  Nerves 1067 

Cervical  Plexus 1067 

Brachial  Plexus 1069 

Lumbar  and  Sacral  Plexuses 1078 

Sciatica 1078 

VII.  General  and  Functional  Diseases 1075 

1.  Acute  Delirium  (Bell's  Mania) 1075 

B 


xviii       '  CONTENTS. 

FAOB 

3.  Paralysis  Agitans 1076 

Other  Forms  of  Tremor 1079 

3.  Acute  Chorea  (Sydenham's  Chorea ;  St.  Vitus's  Dance) ....  1079 

4.  Other  Affections  described  as  Chorea 1088 

5.  Infantile  Convulsions  (Eclampsia)   .        .        .    ^ 1091 

6.  Epilepsy    . 1093 

7.  Migraine 1102 

8.  Neuralgia 1104 

9.  Professional  Spasms ;  Occupation  Neuroses 1107 

10.  Tetany 1109 

11.  Hysteria 1111 

13.  Neurasthenia 1122 

13.  The  Traumatic  Neuroses 1183 

14.  Other  Forms  of  Functional  Paralysis 1136 

Periodical  Paralysis 1136 

Astasia;  Abasia 1136 

VIII.  Vaso-motor  and  Trophic  Disorders 1137 

1.  Raynaud's  Disease 1137 

3.  Erythromelalgia 1139 

3.  Angio-neurotic  CEdema 1140 

4.  Facial  Hemiatrophy 1141 

5.  Acromegaly 1143 

Osteitis  Deformans 1144 

Hypertrophic  Pulmonary  Arthropathy        .        .        .   '    .        .        .  1144 

Leontiasis  Ossea 1145 

Micromegaly 1145 

6.  Scleroderma 1145 

Ainhum 1147 

SECTION  XI. 
DISEASES  OF  THE  MUSCLES. 

I.  Myositis 1148 

II.  Myotonia  (Thomsen's  Disease) 1149 

III.  Paramyoclonus  Multiplex 1150 


CHAKTS  AND  ILLUSTRATIONS. 


CHAKT  PAGE 

I.  Typhoid  Fever  with  Relapse 15 

II.  Illustrating  the  Blood  Changes  in  Typhoid  Fever 20 

III.  Typhoid  Fever — Haemorrhage  from  the  Bowels  * 24 

IV.  Illustrating  Influence  of  Baths  in  Typhoid  Fever 44 

V.  Relapsing  Fever  (after  Murchison) .        .        . 55 

VI.  Small-pox  (after  Striimpell) 60 

VII.  Scarlet  Fever 78 

VIII.  Measles 86 

IX.  Temperature,  Pulse,  and  Respiration  Chart  in  Pneumonia  ....  116 
X.  Showing  Coincident  Drop  in  the  Fever  and  in  the  Leucocytes  in  Pneu- 
monia          131 

XI  a.  Malaria — Double  Tertian  Infection — Quotidian  Fever        ....  210 

XI  i.  ^stivo-autumnal  Infection — Remittent  Fever 210 

XI  c.  -S^stivo-autumnal  Fever — Quotidian  Paroxysms 211 

Xld.  Quartan  Fever 211 

XII.  Chronic  Tuberculosis,  Two-hourly  Chart  for  Three  Days      ....  305 

XIII.  Case  of  Sun-stroke  treated  with  Ice-bath.     Recovery.     (Rectal  Tempera- 

tures)           397 

XIV.  Showing  Uric  Acid  and  Phosphoric  Acid  Output  in  a  Case  of  Acute  Gout  .  412 
XV.  Illustrating  Influence  of  Diet  on  Sugar  and  Amount  of  Urine  in  Diabetes  .  430 

XVI.  Diagrams  after  Martins,  showing  schematically  the  Power  of  the  Heart 

Muscle 708 

XVII.  Blood  Chart,  illustrating  Anaemia  in  Purpura  HaBmorrhagica      .        .        .  790 

XVIII.  Blood  Chart,  illustrating  Chlorosis 793 

XIX.  Blood  Chart,  illustrating  Pernicious  Anaemia 798 

XX.  Blood  Chart,  illustrating  Leukaemia 807 

XXI.  Blood  Chart,  illustrating  Rapid  Production  of  Anaemia  in  Purpura  Haem- 

orrhagica 817 

FIGURE 

1.  Diagram  of  Motor  Path  (Van  Gehuchten) 903 

2.  Diagram  of  Motor  Path  from  Right  Brain  (Van  Gehuchten)       .        .        .904 

3.  Diagram  of  Cerebral  Localization 907 

4.  Diagram  of  Motor  and  Sensory  Representation  in  the  Internal  Capsule      .  908 

5.  Diagram  of  Motor  and  Sensory  Paths  in  Crura 909 

6.  Diagram  of  Cross-section  of  Spinal  Cord 909 

7,  8.  Head's  Diagrams  of  Skin  Areas  corresponding  to  the  Different  Spinal 

Segments 910,  911 

10.  Diagram  of  Motor  Path  from  Right  Brain 1003 

11.  Diagram  of  Visual  Paths  (Vialet) 1043 

*  The  red  shows  the  two-hourly,  the  black  the  morning  and  evening  temperature. 

six 


"  Experience  is  fallacious  and  judgment  diflficult." 
HipPOCEATES :  Aphorisms,  I. 

"  And  I  said  of  medicine,  that  this  is  an  art  which 
considers  the  constitution  of  the  patient,  and  has 
principles  of  action  and  reasons  in  each  case." 

Plato:  Oorgias. 


A  TEXT-BOOK  ON 
THE  PRACTICE   OF  MEDICINE. 


SECTION  I. 
SPECIFIC   IlSrrECTIOUS  DISEASES. 


I.     TYPHOID    FEVER. 

Definition. — A  general  infection  caused  by  bacillus  typhosus,  charac- 
terized anatomically  by  hyperplasia  and  ulceration  of  the  lymph-follicles 
of  the  intestines,  swelling  of  the  mesenteric  glands  and  spleen,  and  paren- 
chymatous changes  in  the  other  organs.  While  these  lesions  are  almost 
constant,  there  are  cases  in  which  the  local  changes  are  slight  or  absent, 
and  there  are  others  with  intense  localization  of  the  poison  in  the  lungs, 
spleen,  kidneys,  or  cerebro-spinal  system.  Clinically  the  disease  is  marked 
by  fever,  a  rose-colored  eruption,  diarrhoea,  abdominal  tenderness,  tym- 
panites, and  enlargement  of  the  spleen;  but  these  symptoms  are  extremely 
inconstant,  and  even  the  fever  varies  in  its  character. 

Historical  Note. — Huxham,  in  his  remarkable  Essay  on  Fevers,  had 
"taken  notice  of  the  very  great  difference. there  is  between  the  putrid 
malignant  and  the  slow  nervous  fever."  In  1813  Pierre  Bretonneau,  of 
Tours,  distinguished  "  dothienenterite  "  as  a  separate  disease;  and  Petit 
and  Serres  described  entero-mesenteric  fever.  In  1829  Louis'  great  work 
appeared,  in  which  the  name  "  typhoid  "  was  given  to  the  fever.  At  this 
period  typhoid  fever  alone  prevailed  in  Paris,  and  it  was  universally  be- 
lieved to  be  identical  with  the  continued  fever  of  Great  Britain,  where 
in  reality  typhoid  and  typhus  coexisted;  and  the  intestinal  lesion  was 
regarded  as  an  accidental  occurrence  in  the  course  of  ordinary  typhus. 
Louis'  students  returning  to  their  homes  in  different  countries  had  oppor- 
tunities for  studying  the  prevalent  fevers  in  the  thorough  and  systematic 
manner  of  their  master.  Among  these  were  certain  young  American 
physicians,  to  one  of  whom,  Gerhard,  of  Philadelphia,  is  due  the  great 
honor  of  having  first  clearly  laid  down  the  differences  between  the  two 
diseases.  His  papers  in  the  American  Journal  of  the  Medical  Sciences, 
1837,  are  the  first  which  give  a  full  and  satisfactory  account  of  their  clinical 
and  anatomical  distinctions.  The  studies  of  James  Jackson,  Sr.  and  Jr., 
of  Enoch  Hale  and  of  George  C.  Shattuck,  of  Boston,  and  of  Alfred  Stille 
and  Austin  Flint  made  the  subject  very  familiar  in  American  medicine. 
1  1 


2  SPECIFIC  INFECTIOUS  DISEASES. 

In  1842  Elisha  Bartlett's  work  appeared,  in  which,  for  the  first  time  in 
a  systematic  treatise,  typhoid  and  typhus  fever  were  separately  considered 
with  admirable  clearness.  In  Great  Britain  the  recognition  of  the  differ- 
ence J^etween  the  two  diseases  was  very  slow,  and  was  due  largely  to 
A,  P.  Stewart,  of  Glasgow,  and,  finally,  to  the  careful  studies  of  Jenner 
between  1849  and  1850. 

Etiology. — General  Prevalence. — Typhoid  fever  prevails  especially  in 
temperate  climates,  in  which  it  constitutes  the  most  common  continued 
fever.  Widely  distributed  throughout  all  parts  of  the  world,  it  probably 
presents  everywhere  the  same  essential  characteristics,  and  is  everywhere 
an  index  of  the  sanitary  intelligence  of  a  community.  Defective  drainage 
and  contaminated  water  supply  are  the  two  special  conditions  favoring 
the  distribution  and  growth  of  the  bacilli;  filth,  overcrowding,  and  bad 
ventilation  are  accessories  in  lowering  the  resistance  of  the  individuals 
exposed. 

While  improved  sanitation  has  done  much  to  reduce  the  mortality  from 
typhoid  fever,  particularly  in  the  large  cities,  a  reduction  amounting  to 
45.4  per  cent  in  21  out  of  24  English  towns  (Dreschfeld)  (figures  illustrat- 
ing which  will  be  referred  to  under  Prophylaxis),  the  disease  is  still  far  too 
prevalent,  and  in  suburban  and  rural  districts  in  this  country  there  is 
evidence  to  show  that  it  is  on  the  increase.  In  1890  the  death-rate  from 
typhoid  fever  per  100,000  of  population  was,  in  the  United  States,  46.27; 
in  England  and  Wales,  17.9;  in  Italy,  65.8;  in  Austria,  47.0;  and  in  Prus- 
sia, 20.4. 

Since  the  last  edition  of  this  work  was  issued  (1898)  there  have  been 
three  great  object  lessons  in  typhoid  fever. 

(a)  The  Spanish- American  War. — According  to  the  report  of  the  Com- 
mission, consisting  of  Walter  Eeed,  Victor  C.  Vaughan,  and  Edward  0. 
Shakespeare,  one  fifth  of  the  soldiers  in  the  national  encampments  in 
the  United  States  had  typhoid  fever.  Among  107,973  men  there  were 
20,738  cases — 19.26  per  cent.  In  90  per  cent  of  the  volunteer  regiments 
the  disease  broke  out  within  eight  weeks  of  going  into  camp.  The  Com- 
mission points  out  that  typhoid  fever  is  so  widely  distributed  in  this 
country  that  cases  are  likely  to  appear  in  any  regiment  within  a  few 
weeks  after  organization.  So  universal  is  the  disease  that  in  all  modern 
campaigns  it  has  usually  appeared  within  two  months,  and  has  proved  the 
most  fatal  of  camp  diseases.  The  deaths  from  typhoid  fever  were  86.24 
per  cent  of  the  total  deaths.  Camp  pollution,  flies  as  carriers  of  con- 
tagion, the  transportation  of  the  poison  in  the  clothing,  the  dissemination 
of  infection  through  the  air  in  the  form  of  dust  were,  in  the  opinion  of 
the  Commission,  the  important  factors  in  the  widespread  prevalence  of 
the  disease. 

(h)  The  Philadelphia  Epidemic  of  1898-99. — Philadelphia,  a  city  of 
1,300,000  inhabitants,  gets  its  water  from  the  Schuylkill  and  Delaware 
Eivers,  the  watersheds  of  which  are  populous  with  numerous  towns.  The 
water  is  pumped  directly  into  reservoirs,  and  distributed  without  filtration. 
In  1897  the  total  number  of  cases  reported  was  2,994,  with  401  deaths. 
In  the  autumn  of  1898  there  was  a  sudden  increase,  and  1,094  cases  were 


TYPHOID   FEVER.  3 

reported  in  September,  due  in  part,  of  course,  to  the  influx  of  soldiers  with 
typhoid  fever.  The  total  number  of  cases  for  the  year  was  6,097,  with 
639  deaths.  In  the  first  four  months  of  1899  there  were  5,861  cases 
reported,  with  638  deaths.  The  total  for  the  year  was  7,985  cases,  with 
948  deaths. 

(c)  The  South  African  War. — To  end  of  March,  1901,  the  official  returns 
give  for  the  English  army  25,359  cases  of  enteric  or  typhoid  fever,  with 
5,302  deaths.  This  is  a  percentage  of  13.09  per  100,  in  comparison  with 
19.26  in  the  American  army,  and  31.8  among  the  Germans  before  Metz. 
In  South  Africa,  as  in  America,  the  disease  was  essentially  one  of  the 
standing  camps;  troops  constantly  on  the  move  were  rarely  much  affected. 
While  contaminated  water  was  no  doubt  an  important  factor,  as  it  always 
is  in  camp  pollution,  yet  certain  of  the  conditions  of  Africa  were  peculiar. 
Faecal  and  urinary  contamination  must  have  been  very  common,  as  in  the 
cooking,  performed  in  the  open  air,  sand  "  entered  lar-gely  into  every  article 
of  food."  As  there  was  a  perfect  plague  of  flies,  they  were  no  doubt  an 
important  factor  in  the  infection  of  both  food  and  drink.  The  conditions 
in  camp  life  favor  the  personal  infection  from  man  to  man. 

Season. — It  prevails  most  in  the  autumn  months.  Of  1,889  cases  ad- 
mitted to  the  Montreal  General  Hospital  in  twenty  years,  more  than  fifty 
per  cent  were  in  the  months  of  August,  September,  and  October.  Of  829 
cases  treated  during  ten  years  at  the  Johns  Hopkins  Hospital,  460  occurred 
during  these  months.  It  has  been  well  called  the  autumnal  fever.  It  has 
been  observed  to  be  especially  prevalent  in  hot  and  dry  seasons.  According 
to  Pettenkofer,  epidemics  are  most  common  when  the  ground-water  is  low, 
under  which  circumstances  the  springs  and  water-sources  drain  more  thor- 
oughly contaminated  foci  and  are  more  likely  to  be  highly  charged  with 
poison.  It  may  be  also,  as  Baumgarten  suggests,  that  in  dry  seasons  the 
poison  is  more  disseminated  in  the  dust. 

Sex. — Males  and  females  are  about  equally  liable  to  the  disease,  but 
males  with  typhoid  are  much  more  frequently  admitted  into  hospitals. 

Age. — Typhoid  fever  is  a  disease  of  youth  and  early  adult  life.  The 
greatest  susceptibility  is  between  the  ages  of  fifteen  and  twenty-five.  Of 
829  cases  treated  to  May  15,  1899,  in  my  wards  at  the  Johns  Hopkins 
Hospital  there  were  under  fifteen  years  of  age,  99;  between  fifteen  and 
twenty,  159;  between  twenty  and  thirty,  393;  between  thirty  and  forty, 
125;  between  forty  and  fifty,  40;  between  fifty  and  sixty,  6;  above  sixty, 
6;  age  not  given,  1.*  Cases  are  rare  over  sixty,  although  Manges  believes 
that  they  are  more  common  than  the  records  show.  As  the  course  is  often 
atypical  the  diagnosis  may  be  uncertain.  In  two  of  my  cases  the  disease 
was  not  recognized  until  the  autopsy.  It  is  not  very  infrequent  in  child- 
hood, but  infants  are  rarely  attacked.  Murchison  saw  a  case  at  the  sixth 
month.  There  is  no  evidence  that  the  disease  is  congenital  even  in  cases 
in  which  the  mother  has  contracted  it  late  in  pregnancy. 

Immunity. — Not  all  exposed  to  the  infection  take  the  disease.  Some 
families  seem  more  susceptible  than  others.     One  attack  usually  protects. 

*  The  figures  here  given  are  from  the  Studies  on  Typhoid  Fever,  I,  II,  and  III,  in  vols, 
iv,  V,  and  viii  of  the  Johns  Hopkins  Hospital  Reports. 


4  SPECIFIC  INFECTIOUS  DISEASES. 

Ttvo  attacks  have  been  described  within  a  year.  "  Of  2,000  cases  of  enteric 
fever  at  the  Hamburg  General  Hospital,  only  14  persons  were  affected  twice 
and  only  1  person  three  times"  (Dreschfeld). 

Bacillus  typhosus. — The  researches  of  Eberth,  Koch,  Gaffky,  and  others 
have  shown  that  there  is  a  special  micro-organism  constanlly  associated 
with  typhoid  fever,  (a)  General  Cliaracters. — It  is  a  rather  short,  thick, 
flagellated,  motile  bacillus,  with  rounded  ends,  in  one  of  which,  sometimes 
in  both  (particularly  in  cultures),  there  can  be  seen  a  glistening  round 
body,  at  one  time  believed  to  be  a  spore;  but  these  polar  structures  are 
probably  only  areas  of  degenerated  protoplasm.  It  grows  readily  on  various 
nutritive  media,  and  can  now  be  differentiated  from  bacillus  coli  com- 
munis, with  which,  and  with  certain  other  bacilli,  it  is  apt  to  be  confounded. 
This  organism  fulfils  two  of  the  requirements  of  Koch's  law — ^it  is  con- 
stantly present,  and  it  grows  outside  the  body  in  a  specific  manner.  The 
third  requirement,  the  production  of  the  disease  experimentally  by  the 
cultures,  has  not  yet  been  met.  Probably  the  animals  used  for  experi- 
mentation are  not  susceptible  to  typhoid  fever.  The  bacilli  or  their  toxins 
inoculated  in  large  quantities  into  the  blood  of  rabbits  are  pathogenic, 
and  in  some  instances  ulcerative  and  necrotic  lesions  in  the  intestine  may 
be  produced.  But  sunilar  intestinal  lesions  may  be  caused  by  other  bac- 
teria, including  bacillus  coli  communis. 

Cultures  are  killed  within  ten  minutes  by  a  temperature  of  60°  C. 
They  may  live  for  eighteen  weeks  at  —-5°  C,  although  most  die  within 
two  weeks,  and  all  within  twenty-two  weeks  (Park).  The  typhoid  bacillus 
resists  ordinary  drying  for  months,  unless  in  very  thin  layers,  when  it  is 
knied  in  five  to  fifteen  days.  The  direct  rays  of  the  sun  completely  destroy 
them  in  from  four  to  ten  hours'  exposure.  Bouillon  cultures  are  destroyed 
by  carbolic  acid,  1  to  300,  and  by  corrosive  sublimate,  1  to  2,500. 

(b)  Distrilution  in  the  Body. — In  recent  t}^hoid  infections  the  bacilli 
are  found  in  the  lymphoid  tissues  of  the  intestines,  in  the  mesenteric 
glands,  in  the  spleen,  in  the  bone  marrow,  in  the  liver,  and  in  the  bile. 
They  occur  also  in  irregular  clumps  in  the  contents  of  the  intestines  and 
in  the  stools;  and  since  the  introduction  of  improved  methods  of  cultiva- 
tion (Eisner,  Piorkowski)  they  have  been  demonstrated  in  the  latter  in 
about  50  per  cent  of  the  cases  examined.  They  may,  however,  be  incapable 
of  demonstration  even  in  fatal  cases.  The  bacilli  may  be  demonstrated 
in  the  blood  and  rose  spots  in  a  majority  of  the  cases.  They  occur  in  the 
urine  in  25  to  30  per  cent  of  the  cases.  Their  presence  in  sweat  and 
sputa  has  been  reported  in  a  few  instances.  Prom  the  endocardial  vegeta- 
tions, from  meningeal  and  pleural  exudates,  and  from  foci  of  suppuration 
in  various  parts,  the  bacilli  have  also  been  isolated. 

(c)  TJie  Bacilli  Outside  the  Body.— In  sterile  water  the  bacilli  retain 
their  vitality  for  weeks,  but  under  ordinary  conditions,  in  competition  with 
saprophytes,  disappear  within  fourteen  days.  "Wliether  an  increase  in  water 
can  occur  is  not  finally  settled,  but  it  probably  may  take  place  to  some 
extent  at  first.  Their  detection  in  the  water  is  difficult,  and  although 
they  undoubtedly  have  been  found,  many  such  discoveries  previously  re- 
ported are  not  certain  on  account  of  the  inaccurate  differentiation  of  the 


TYPHOID  FEVER.  5 

typhoid  bacillus  and  varieties  of  the  colon  bacillus  closely  resembling  it. 
Both  Prudden  and  Ernst  have  found  it  in  water  filters. 

In  ice  they  may  live  as  long  as  eighteen  weeks,  though  a  majority  die 
within  two  weeks. 

In  milk  the  bacilli  undergo  rapid  development  without  changing  its 
appearance.  They  may  persist  for  three  months  in  sour  milk,  and  may 
live  for  several  days  in  butter  made  from  infected  cream. 

Eobertson  has  shown  that  under  entirely  natural  conditions  typhoid 
bacilli  may  live  in  the  upper  layers  of  the  soil  for  eleven  months.  In 
fseces,  under  ordinary  conditions,  they  may  live  for  months. 

The  direct  infection  by  dust  of  exposed  food-stuffs,  such  as  milk,  is 
very  probable.  The  bacilli  retain  their  vitality  for  many  weeks;  in  gar- 
den earth  twenty-one  days,  in  filter-sand  eighty-two  days,  in  dust  of  the 
street  thirty  days,  on  linen  sixty  to  seventy  days,  on  wood  thirty-two  days. 
(For  additional  details  on  the  bacillus  see  Horton-Smith's  Goulstonian 
Lectures,  1900.) 

Modes  of  Conveyance. — (a)  Contagion. — The  possibility  of  the  direct 
transmission  through  the  air  from  one  person  to  another  must  be  acknowl- 
edged, although,  as  shown  by  Germano,  when  completely  dried  in  air-cur- 
rents, the  specific  bacillus  quickly  dies.  There  are  house  epidemics  in 
which  contamination  of  water  or  food  could  be  almost  positively  excluded. 
The  nurses  and  attendants  who  have  to  do  with  the  stools  and  body-linen 
of  the  patients  are  alone  liable  to  direct  infection.  During  twelve  years 
twenty  physicians,  nurses,  or  patients  contracted  the  disease  in  my  wards.* 
The  contagion  may  be  spread  by  means  of  clothing  and  wash-linen — a  mode 
of  infection  which  is  especially  to  be  feared  in  military  garrisons,  where 
the  same  clothing  is  sometimes  used  by  different  persons. 

(h)  Infection  of  water  is  unquestionably  the  most  common  mode  of 
conveyance.  Many  epidemics  have  been  shown  to  originate  in  the  con- 
tamination of  a  well  or  a  spring.  A  very  striking  one  occurred  at  Plym- 
outh, Pa.,  in  1885,  which  was  investigated  by  Shakespeare.  The  town, 
with  a  population  of  8,000,  was  in  part  supplied  with  drinking-water  from 
a  reservoir  fed  by  a  mountain  stream.  During  January,  February,  and 
March,  in  a  cottage  by  the  side  of  and  at  a  distance  of  from  60  to  80  feet 
from  this  stream,  a  man  was  ill  with  typhoid  fever.  The  attendants  were 
in  the  habit  at  night  of  throwing  out  the  evacuations  on  the  ground  toward 
the  stream.  During  these  months  the  ground  was  frozen  and  covered  with 
snow.  In  the  latter  part  of  March  and  early  in  April  there  was  considerable 
rainfall  and  a  thaw,  in  which  a  large  part  of  the  three  months'  accumulation 


*  Dr.  Futcher  has  kindly  analyzed  for  me  the  cases  of  typhoid  fever  which  have  been 
contracted  in  the  Johns  Hopkins  Hospital  during  the  first  twelve  years  of  its  work,  to 
May,  1901.  There  have  been  20  cases — 3  among  125  house  officers,  2.4  per  cent;  8  among 
291  nurses,  2.7  per  cent.  Seven  patients  contracted  the  disease  while  under  treatment  for 
other  diseases  among  a  total  of  34,500.  Four  of  these  cases  occurred  in  a  small  ward 
epidemic.  One  orderly  contracted  the  disease  while  caring  for  typhoid  patients,  and  one 
woman  in  charge  of  the  linen  room,  where  she  handled  clean  linen  only.  There  were 
3  cases  of  typhoid  fever  contracted  by  physicians  working  in  the  pathological  laboratory. 


6  SPECIFIC  INFECTIOUS  DISEASES. 

of  discharges  was  washed  into  the  brook,  not  60  feet  distant.  At  the  very 
time  of  this  thaw  the  patient  had  numerous  and  copious  discharges.  About 
the  10th  of  April  cases  of  typhoid  fever  broke  out  in  the  town,  appearing 
for  a  time  at  the  rate  of  fifty  a  day.  In  all  about  1,200  people  were 
attacked.  An  immense  majority  of  all  the  cases  were  in  the  part  of  the 
town  which  received  water  from  the  infected  reservoir. 

The  experience  at  Maidstone  in  1897  illustrates  the  widespread  and  seri- 
ous character  of  an  epidemic  when  the  water-supply  becomes  badly  con- 
taminated. The  outbreak  began  about  the  middle  of  September,  and 
within  the  first  two  weeks  509  cases  were  reported.  By  October  27th  there 
were  1,748  cases,  and  by  November  17th  1,848  cases.  In  all,  in  a  popula- 
tion of  35,000,  about  1,900  persons  were  attacked.  No  epidemic  of  the 
same  magnitude  has  ever  occurred  in  England,  and  it  shows  the  terrible 
danger  of  a  badly  constructed  water-supply  easily  contaminated  by  surface 
drainage. 

(c)  Infection  of  Food. — Milk  may  be  the  source  of  infection.  One  of 
the  most  thoroughly  studied  epidemics  due  to  this  cause  was  that  investi- 
gated by  Ballard  in  Islington.  The  milk  may  be  contaminated  by  infected 
water  used  in  cleaning  the  cans.  The  milk  epidemics  have  been  collected 
by  Ernest  Hart  and  by  Kober,  of  Washington. 

The  germs  may  be  conveyed  in  ice,  salads  of  various  sorts,  etc.  The 
danger  of  eating  celery  and  other  uncooked  vegetables,  which  have  grown 
in  soil  on  which  infected  material  has  been  used  as  a  fertilizer,  must  not 
be  forgotten. 

Flies  play  an  important  part  in  the  spread  of  the  disease.  Both  in 
the  Spanish-American  and  in  the  South  African  wars  there  was  a  perfect 
plague  of  flies,  particularly  in  the  enteric-fever  tents,  where  they  swarmed 
over  everything.  Food  left  uncovered  for  a  few  moments  would  be  black 
with  them. 

Oysters  may  become  infected  during  the  process  of  fattening  or  fresh- 
ening. In  the  Middletown  epidemic,  reported  by  H.  W.  Conn,  the  chain 
of  circumstantial  evidence  seems  complete;  Lavis  reports  an  epidemic  oc- 
curring in  Naples  caused  by  infected  oysters;  and  most  suggestive  sporadic 
cases  have  been  recorded  by  Sir  William  Broadbent  and  others. 

C.  J.  Foote  has  made  an  interesting  bacteriological  study  of  the  subject. 
Oysters  taken  from  the  feeding-grounds  in  rivers  contain  a  very  much 
larger  number  of  micro-organisms  of  all  sorts  than  those  from  the  sea.  He 
has  shown,  too,  that  Eberth's  bacillus  will  live  in  the  brackish  water  in 
which  oysters  are  fattened  even  when  frozen;  and  that  it  will  also  live  in 
the  oyster  itself,  and  for  a  longer  time  than  in  the  water  in  which  the 
oyster  grows.  Whether  multiplication  takes  place  in  the  oyster  is  doubt- 
ful. Chantemesse  also  found  typhoid  germs  in  oysters  which  had  lain  in 
infected  sea-water  even  after  they  had  been  transferred  to  and  kept  in 
fresh  water  for  a  time. 

{d)  Contamination  of  the  Soil. — Pettenkofer  holds  that  the  poison  is 
not  eliminated  in  a  condition  capable  of  communicating  the  disease  di- 
rectly, but  that  it  must  first  undergo  changes  in  the  soil,  which  changes 
are  favored  by  the  ground-water. 


TYPHOID  FEVER.  Y 

Filth,  bad  sewers,  or  cesspools  can  not  in  themselves  cause  typhoid 
fever,  but  they  furnish  the  conditions  suitable  for  the  preservation  of  the 
bacillus,  and  possibly  for  its  propagation. 

The  history  of  typhoid  fever  in  Munich,  as  told  anew  by  Childs  (Lan- 
cet, 1898,  ii),  indicates  that  the  soil  pollution  has  much  to  do  with  the  oc- 
currence of  sporadic  cases  and  of  recurrent  outbreaks.  However,  it  has 
been  shown  that  in  the  deeper  layers  of  the  soil,  where  it  would  be  influ- 
enced by  the  ground-water,  the  bacillus  can  not  exist,  much  less  multiply. 

Modes  of  Infection. — While  the  bacillus  has  its  primary  seat  of  action 
in  the  lymphatic  tissues  of  the  intestines,  the  fever  is  very  largely  due 
to  its  growth  in  the  internal  organs.  As  Maclagan  very  well  puts  it,  the 
action  is  dual,  one  a  local  specific  action  of  the  parasite  on  the  glands  of 
the  intestines,  and  a  general  action  of  the  organism  on  the  blood  and 
tissues.  A  single  bacillus  in  ten  days,  as  he  says,  might  produce  a  billion, 
and  the  incubation  represents  the  period  during  which  the  bacilli  are 
being  reproduced. 

We  may  recognize  the  following  groups:  1.  Ordinary  typhoid  fever  with 
marked  enteric  lesions.  An  immense  majority  of  all  the  cases  are  of  this 
character;  and  while  the  spleen  and  mesenteric  glands  are  involved  the 
lymphatic  apparatus  of  the  intestinal  walls  bears  the  brunt  of  the  attack. 
2.  Cases  in  which  the  intestinal  lesions  are  very  slight.  The  intestinal  lesions 
may  be  found  only  after  a  very  careful  search.  In  reviewing  the  cases 
of  "  typhoid  fever  without  intestinal  lesions,"  Opie  and  Bassett  call  atten- 
tion to  the  fact  that  in  many  cases  reported  as  without  lesions  slight  lesions 
really  did  exist,  while  in  others  death  occurred  so  late  that  slight  lesions 
might  have  healed.  In  some  of  the  cases  the  course  of  the  disease  is  that 
of  a  general  septicaemia  with  symptoms  of  severe  intoxication  and  high 
fever  and  delirium.  In  others  the  main  lesions  may  be  in  one  or  more  of 
the  different  organs.  The  parts  attacked  may  be  the  liver,  gall-bladder, 
pleura,  meninges,  or  even  the  endocardium.  3.  Cases  in  which  the  typhoid 
bacillus  enters  the  body  without  causing  any  lesion  of  the  intestine.  In  a  num- 
ber of  the  earlier  cases  reported  as  such  the  demonstration  of  the  typhoid 
bacillus  was  inconclusive.  In  others  the  intestine  showed  tuberculous 
ulcers,  through  which  the  organisms  may  have  entered.  But  after  exclud- 
ing all  these,  a  few  cases  remain  in  which  the  demonstration  of  the  typhoid 
bacillus  was  conclusive,  cases  in  which  death  occurred  early,  and  yet  after 
a  very  careful  search  no  intestinal  lesions  could  be  found  (Pick,  Cheadle, 
Lartigau,  Du  Cazal).  Undoubtedly  the  intestinal  lesions  may  be  so  slight 
as  not  to  be  recognizable  at  autopsy.  However,  the  number  of  such  cases 
is  too  small  to  Justify  the  assertion  that  typhoid  bacilli  can  enter  through 
an  absolutely  intact  intestinal  wall,  though  this  possibility  must  be  borne 
in  mind.  There  is  no  conclusive  evidence  that  typhoid  bacilli  can  ever 
enter  the  body  except  through  the  intestinal  tract.  4.  Mixed  infections. 
It  is  well  to  distinguish,  as  Dreschfeld  points  out,  between  double  infec- 
tions, as  with  bacillus  tuberculosis,  the  diphtheria  bacillus,  and  the  Plas- 
modia of  Laveran,  in  which  two  different  diseases  are  present  and  can  be 
readily  distinguished,  and  the  true  mixed  or  secondary  infections,  in  which 
the  conditions  induced  by  one  organism  favor  the  growth  of  other  patho- 


8  SPECIFIC  INFECTIOUS  DISEASES. 

genie  forms;  thus  in  the  ordinary  typhoid  fever  cases  secondary  infection 
with  the  colon  bacillus,  the  streptococcus,  staphylococcus,  or  the  pneumococ- 
cus,  is  quite  common.  5.  Fevers  due  to  organisms  closely  related  to  bacillus 
typhosus.  During  the  past  few  years  organisms  very  closely  related  to  the 
typhoid  bacillus,  but  differing  in  some  cultural  and  agglutinating  proper- 
ties, have  been  isolated  by  several  observers  (Widal,  Gwyn,  Gushing,  Shott- 
miiller)  from  cases  clinically  like  typhoid.  Whether  these  organisms  have 
borne  any  etiological  relationship  to  the  cases  in  which  they  were  found, 
or  were  only  secondary  invaders  in  cases  of  typhoid  fever,  is  not  yet  certain. 

Products  of  the  Growth  of  the  Bacilli. — Brieger  isolated  from  cultures 
a  poison  belonging  to  the  group  of  ptomaines — typhotoxin.  Later  he  and 
Fraenkel  isolated  a  poison  belonging  to  the  group  of  toxalbumins.  Ac- 
cording to  Pf eiffer,  the  chief  poison  belongs  to  the  intracellular  group  of 
toxins.  Sidney  Martin  has  isolated  a  poison  which  is  in  the  nature  of  a 
secretion,  but  does  not  differ  from  that  contained  within  the  bacterial  cell. 
Injected  into  animals  it  causes  lowering  of  temperature,  diarrhoea,  loss 
of  weight,  and  degeneration  of  the  myocardium.  Its  chemical  nature  is 
not  known.  Similar,  but  weaker,  poisons  may  also  be  isolated  from  cul- 
tures of  bacUlus  coli  communis  and  other  members  of  this  group.  No 
toxins  have  yet  been  isolated  which  cause  changes  in  animals  at  all  com- 
parable to  typhoid  fever  in  human  beings. 

Morbid  Anatomy. — The  statistical  details  under  this  heading  are 
based  upon  eighty  autopsies,  a  majority  of  which  were  performed  at  the 
Montreal  General  Hospital,  and  upon  the  records  of  two  thousand  post- 
mortems at  the  Munich  Pathological  Institute.* 

Intestines. — A  catarrhal  condition  exists  throughout  the  small  and 
large  bowel,  and  to  this  is  due,  in  all  probability,  the  diarrhoea  with  the 
thin  pea-soup-like  stools.  Associated  with  this  catarrh  there  is  some  epi- 
thelial desquamation. 

Specific  changes  occur  in  the  lymphoid  elements  of  the  bowel,  chiefly 
at  the  lower  end  of  the  ileum.  The  alterations  which  occur  are  most  con- 
veniently described  in  four  stages: 

1.  Hyperplasia,  which  involves  the  glands  of-Peyer  in  the  Jejunum  and 
ileum,  and  to  a  variable  extent  those  in  the  large  intestine.  The  follicles 
are  swollen,  grayish- white  in  color,  and  the  patches  may  project  to  a  dis- 
tance of  from  three  to  five  mm.  In  exceptional  cases  they  may  be  still 
more  prominent.  The  solitary  glands,  which  range  in  size  from  a  pin's 
head  to  a  large  pea,  are  usually  deeply  imbedded  in  the  submucosa,  but 
project  to  a  variable  extent.  Occasionally  they  are  very  prominent,  and 
may  be  almost  pedunculated.  Microscopical  examination  shows  at  the 
outset  a  condition  of  hyperaemia  of  the  follicles.  Later  there  is  a  great 
increase  and  accumulation  of  cells  of  the  lymph-tissue  which  may  even 
infiltrate  the  adjacent  mucosa  and  the  muscularis;  and  the  blood-vessels 
are  more  or  less  compressed,  which  gives  the  whitish,  ansemic  appearance 
to  the  follicles.  The  cells  have  all  the  characters  of  ordinary  lymph-cor- 
puscles.   Some  of  them,  however,  are  larger,  epithelioid,  and  contain  several 

*  Milnohener  medicinische  Wochenschrift,  Nos.  3  and  4,  1891. 


TYPHOID  FEVER.  9 

nuclei.  Occasionally  cells  containing  red  blood-corpuscles  are  seen.  This 
so-called  medullary  infiltration,  which  is  always  more  intense  toward  the 
lower  end  of  the  ileum,  reaches  its  height  from  the  eighth  to  the  tenth 
day  and  then  undergoes  one  of  two  changes,  resolution  or  necrosis.  Death 
very  rarely  takes  place  at  this  stage.  Eesolution  is  accomplished  by  a  fatty 
and  granular  change  in  the  cells,  which  are  destroyed  and  absorbed.  A 
curious  condition  of  the  patches  is  produced  at  this  stage,  in  which  they 
have  a  reticulated  appearance,  the  plaques  a  surface  reticulee.  The  swoll- 
en follicles  in  the  patch  undergo  resolution  and  shrink  more  rapidly  than 
the  surrounding  framework,  or  what  is  more  probable  the  follicles  alone, 
owing  to  the  intense  hyperplasia,  become  necrotic  and  disintegrate,  leaving 
the  little  pits.  In  this  process  superficial  haemorrhages  may  result,  and 
small  ulcers  may  originate  by  the  fusion  of  these  superficial  losses  of  sub- 
stance. 

There  is  nothing  distinctive  in  the  hyperplasia  of  the  lymph-follicles 
in  typhoid  fever;  but  apart  from  this  disease  we  rarely  see  in  adults  a 
marked  affection  of  these  glands  with  fever.  In  children,  however,  it  is 
not  uncommon  when  death  has  occurred  from  intestinal  affections,  and  it 
is  also  met  with  in  measles,  diphtheria,  and  scarlet  fever. 

2.  Necrosis  and  Sloughing. — When  the  hyperplasia  of  the  lymph-fol- 
licles reaches  a  certain  grade,  resolution  is  no  longer  possible.  The  blood- 
vessels become  choked,  there  is  a  condition  of  ansemic  necrosis,  and 
sloughs  form  which  must  be  separated  and  thrown  off.  The  necrosis  is 
probably  due  in  great  part  to  the  direct  action  of  the  bacilli.  The  process 
may  be  superficial,  affecting  only  the  upper  part  of  the  mucous  coat,  or  it 
may  extend  to  and  involve  the  submucosa.  The  "  slough  "  may  sometimes 
lie  upon  the  Peyer's  patch,  scarcely  involving  the  epithelium  (Marchand). 
It  is  always  more  intense  toward  the  ileo-caecal  valve,  and  in  very  severe 
cases  the  greater  part  of  the  mucosa  of  the  last  foot  of  the  ileum  may  be 
converted  into  a  brownish-black  eschar.  The  necrotic  area  in  the  solitary 
glands  forms  a  yellowish  cap  which  often  involves  only  the  most  promi- 
nent point  of  a  follicle.  The  extent  of  the  necrosis  is  very  variable.  It 
may  pass  deep  into  the  muscular  coat,  reaching  to  or  even  perforating  the 
peritonseum. 

3.  Ulceration. — The  separation  of  the  necrotic  tissue — the  sloughing — 
is  gradually  effected  from  the  edges  inward,  and  results  in  the  formation 
of  an  ulcer,  the  size  and  extent  of  which  are  directly  proportionate  to  the 
amount  of  necrosis.  If  this  be  superficial,  the  entire  thickness  of  the 
mucosa  may  not  be  involved  and  the  loss  of  substance  may  be  small  and 
shallow.  More  commonly  the  slough  in  separating  exposes  the  submucosa 
and  muscularis,  particularly  the  latter,  which  forms  the  floor  of  a  majority 
of  all  typhoid  ulcers.  It  is  not  common  for  an  entire  Peyer's  patch  to 
slough  away,  and  a  perfectly  ovoid  ulcer  opposite  to  the  mesentery  is 
rarely  seen.  Irregularly  oval  and  rounded  forms  are  most  common.  A 
large  patch  may  present  three  or  four  ulcers  divided  by  septa  of  mucous 
membrane.  The  terminal  6  or  8  inches  of  the  mucous  membrane  of  the 
ileum  may  form  a  large  ulcer,  in  which  are  here  and  there  islands  of 
mucosa,    The  edges  of  the  ulcer  are  usually  swollen,  soft,  sometimes  con- 


10  SPECIFIC  INFECTIOUS  DISEASES. 

gested,  and  often  undermined.  At  a  late  period  the  ulcers  near  the  valve 
may  have  very  irregular  sinuous  borders.  The  base  of  a  typhoid  ulcer 
is  smooth  and  clean,  being  usually  formed  of  the  submucosa  or  of  the 
uMiscularis. 

There  may  be  large  ulcers  near  the  valve  and  swollen  hypersemic  patches 
of  Peyer  in  the  upper  part  of  the  ileum. 

4.  Healing. — This  begins  with  the  development  of  a  thin  granulation 
tissue  which  covers  the  base  and  gives  to  it  a  soft,  shining  appearance. 
The  mucosa  gradually  extends  from  the  edge,  and  a  new  growth  of  epi- 
thelium is  formed.  The  glandular  elements  are  reformed;  the  healed 
ulcer  is  somewhat  depressed  and  is  usually  pigmented.  Occasionally  an 
appearance  is  seen  as  if  an  ulcer  had  healed  in  one  place  and  was  extend- 
ing in  another.  In  death  during  relapse  healing  ulcers  may  be  seen  in 
some  patches  with  fresh  ulcers  in  others. 

We  may  say,  indeed,  that  healing  begins  with  the  separation  of  the 
sloughs,  as,  when  resolution  is  impossible,  the  removal  of  the  necrosed 
part  is  the  first  step  in  the  process  of  repair.  Practically,  in  fatal  cases, 
we  seldom  meet  with  evidences  of  cicatrization,  as  the  majority  of  deaths 
occur  before  this  stage  is  reached. 

Large  Intestine. — The  caecum  and  colon  are  affected  in  about  one  third 
of  the  cases.  Sometimes  the  solitary  glands  are  greatly  enlarged.  The 
ulcers  are  usually  larger  in  the  csecum  than  in  the  colon. 

Perforation  of  the  Bowel. — Incidence  at  Autopsy. — In  114  cases  of  the 
2,000  Munich  autopsies  (5.7  per  cent)  and  in  23  instances  of  my  series,  at 
the  Johns  Hopkins  Hospital  the  intestine  was  perforated.  According  to 
Chomel,  "  the  accident  is  sometimes  the  result  of  ulceration,  sometimes  of 
a  true  eschar,  and  sometimes  it  is  produced  by  the  distention  of  the  intes- 
tine causing  the  rupture  of  tissues  weakened  by  disease."  In  only  a  few 
cases  is  the  perforation  at  the  bottom  of  a  clean  thin-walled  ulcer.  In 
one  instance  it  had  occurred  two  weeks  after  the  temperature  had  become 
normal.  The  sloughs  are,  as  a  rule,  adherent  about  the  site  of  perforation, 
which  in  a  majority  of  the  cases  occur  in  small  deep  ulcers.  There  may  be 
two  or  three  perforations;  in  a  few  instances  they  have  been  very  numer- 
ous. The  orifice  is  usually  within  the  last  foot  of  the  ileum.  In  only  one 
of  my  cases  was  it  distant  18  inches.  In  4  cases  of  my  series  the  appendix 
was  perforated  and  in  2  the  large  bowel.  Peritonitis  was  present  in  every 
instance.  In  167  cases  collected  by  Fitz  the  ileum  was  perforated  in  136, 
the  large  intestine  in  20,  the  appendix  in  5,  Meckel's  diverticulum  in  4, 
and  the  jejunum  in  2.  In  the  large  intestine,  according  to  Hawkins,  the 
sigmoid  flexure  is  the  most  frequent  seat  of  perforation. 

Death  from  hcemorrhage  occurred  in  99  of  the  Munich  cases,  and  in  7 
of  63  deaths  in  my  829  cases.  The  bleeding  seems  to  result  directly 
from  the  separation  of  the  sloughs.  I  was  not  able  in  any  instance  to  find 
the  bleeding  vessel.  In  one  case  only  a  single  patch  had  sloughed,  and  a 
firm  clot  was  adherent  to  it.  The  bleeding  may  also  come  from  the  soft 
swollen  edges  of  the  patch. 

The  mesenteric  glands  at  first  show  intense  hypersemia  and  subsequently 
become  greatly  swollen.    Spots  of  necrosis  are  common.    In  several  of  my 


TYPHOID  FEVER.  H 

cases  suppuration  had  occurred,  and  in  one  a  large  abscess  of  the  mesentery 
was  present.  Fatal  haemorrhage  into  the  peritonseum  may  come  from  rup- 
ture of  a  swollen  gland.  The  bunch  of  glands  in  the  mesentery,  at  the 
lower  end  of  the  ileum,  is  especially  involved.  The  retroperitoneal  glands 
are  also  swollen. 

The  spleen  is  invariably  enlarged  in  the  early  stages  of  the  disease.  In 
only  one  of  my  cases  did  it  exceed  20  ounces  (600  grammes)  in  weight. 
The  tissue  is  soft,  even  diffluent.  Infarction  is  not  infrequent.  Rupture 
may  occur  spontaneously  or  as  a  result  of  injury.  In  the  Munich  autopsies 
there  were  5  instances  of  rupture  of  the  spleen,  one  of  which  resulted 
from  a  gangrenous  abscess. 

The  liver  shows  signs  of  parenchymatous  degeneration.  Early  in  the 
disease  it  is  hyperaemic,  and  in  a  majority  of  instances  it  is  swollen,  some- 
what pale,  on  section  turbid,  and  microscopically  the  cells  are  very  granu- 
lar and  loaded  with  fat.  Nodular  areas  (microscopic)  occur  in  many  cases, 
as  described  by  Handford.  Eeed,  in  Welch's  laboratory,  could  not  deter- 
mine any  relation  between  the  groups  of  bacilli  and  these  areas  (Studies 
II).  Some  of  the  nodules  are  lymphoid,  others  are  necrotic  (Amyot).  In 
12  of  the  Munich  autopsies  liver  abscess  was  found,  and  in  3,  acute  yellow 
atrophy.  Pylephlebitis  may  follow  abscess  of  the  mesentery  or  perforation 
of  the  appendix.  Affections  of  the  gall-bladder  are  not  uncommon,  and 
are  fully  described  under  the  clinical  features. 

Kidneys. — Cloudy  swelling,  with  granular  degeneration  of  the  cells  of 
the  convoluted  tubules,  less  commonly  an  acute  nephritis,  may  be  present. 
Rayer,  Wagner,  and  others  described  the  occurrence  of  numerous  small 
areas  infiltrated  with  round  cells,  which  may  have  the  appearance  of 
lymphomata,  or  may  pass  on  to  softening  and  suppuration,  producing  the 
so-called  miliary  abscesses.  It  is  usually  a  late  change.  The  typhoid  bacilli 
have  been  found  in  these  areas.  They  may  also  be  found  in  the  urine. 
The  kidneys  in  cases  of  typhoid  bacilluria  may  show  no  changes  other 
than  cloudy  swelling.  Diphtheritic  inflammation  of  the  pelvis  of  the  kid- 
ney may  occur.  It  was  present  in  3  of  my  cases,  in  one  of  which  the  tips 
of  the  papillae  were  also  affected.  Catarrh  of  the  bladder  is  not  uncom- 
mon. Diphtheritic  inflammation  of  this  viscus  may  also  occur.  Orchitis 
is  occasionally  met  with. 

Respiratory  Organs. — Ulceration  of  the  larynx  occurs  in  a  certain  num- 
ber of  cases;  in  the  Munich  series  it  was  noted  107  times.  It  may  come 
on  at  the  same  time  as  the  ulceration  in  the  ileum,  but  the  bacilli  have 
not  yet,  I  believe,  been  found  in  the  ulcers.  They  occur  in  the  posterior 
wall,  at  the  insertion  of  the  cords,  at  the  base  of  the  epiglottis,  and  on  the 
ary-epiglottidean  folds.  The  cartilages  are  very  apt  to  become  involved. 
In  the  later  periods  catarrhal  and  diphtheritic  ulcers  may  be  present. 

CEdema  of  the  glottis  was  present  in  20  of  the  Munich  cases,  in  8  of 
which  tracheotomy  was  performed.  Diphtheritis  of  the  pharynx  and  larynx 
is  not  very  uncommon.  It  occurred  in  a  most  extensive  form  in  2  of  my 
cases.  Lobar  pneumonia  may  be  found  early  in  the  disease  (sec  Pneumo- 
TYPHUs),  or  it  may  be  a  late  event.  Hypostatic  congestion  and  the  con- 
dition of  the  lung  spoken  of  as  splenization  are  very  common.     Gangrene 


12  SPECIFIC  INFECTIOUS  DISEASES. 

of  the  lung  occurred  in  40  cases  in  the  Munich  series;  abscess  of  the  lung 
in  14;  hemorrhagic  infarction  in  139.  Pleurisy  is  not  a  very  common 
event.  Fibrinous  pleurisy  occurred  in  about  6  per  cent  of  the  Munich 
cases,  and  empyema  in  nearly  2  per  cent. 

Changes  in  the  Circulatory  System. — Heart  Lesions. — Endocarditis  is 
rare.  I  have  met  with  2  cases.  The  typhoid  bacilli  have  been  found  in 
the  vegetations.  Pericarditis  was  present  in  14  cases  of  the  Munich  au- 
topsies. Myocarditis  is  not  very  infrequent.  Dewevre,  in  a  series  of  48 
eases,  found  in  16  granular  or  fatty  degeneration,  and  in  3  a  proliferating 
endarteritis  in  the  small  vessels.  It  is  remarkable  that  even  in  cases  of 
death  from  heart-failure,  with  intense  fever,  the  cell-fibres  may  present 
little  or  no  observable  change. 

Lesions  of  the  Blood-vessels — Typhoid  Gangrene. — Inflammation  of  the 
arteries  with  thrombus  formation  has  been  frequently  described  in  t}^hoid 
fever.  Bacilli  have  been  found  in  the  thrombi.  The  artery  may  be 
blocked  by  a  thrombus  of  cardiac  origin — an  embolus — but  in  the  great 
majority  of  instances  they  are  autochthonous  and  due  to  arteritis,  oblit- 
erating or  partial.  Thrombosis  in  the  veins  is  very  much  more  frequent 
than  in  the  arteries,  but  is  not  such  a  serious  event.  It  is  most  frequent 
in  the  femoral,  and  in  the  left  more  often  than  the  right.  The  conse- 
quences are  fully  considered  under  the  symptoms. 

Nervons  System. — There  are  very  few  obvious  changes  met  with.  Men- 
ingitis is  extremely  rare.  No  case  occurred  in  our  series.  It  occurred 
in  only  11  of  the  2,000  Munich  cases.  The  exudation  may  be  either  serous, 
sero-fibrinous,  or  purulent,  and  typhoid  bacilli  have  been  frequently  iso- 
lated. Two  interesting  cases  have  been  reported  by  Ohlmacher  from  the 
Cleveland  City  Hospital.  In  both  bacilli  were  found  in  the  meninges.  In 
some  of  the  cases,  as  Kamen's,  the  enteric  lesions  have  been  slight.  Optic 
neuritis,  which  occurs  sometimes  in  typhoid  fever,  has  not,  so  far  as  I  know, 
been  described  in  connection  with  the  meningitis.  The  anatomical  lesion 
of  the  aphasia — seen  not  infrequently  in  children — is  not  known,  possibly 
it  is  an  encephalitis.  Parenchymatous  changes  have  been  met  with  in  the 
peripheral  nerves,  and  appear  to  be  not  very  uncommon,  even  when  there 
have  been  no  symptoms  of  neuritis. 

The  voluntary  muscles  show,  in  certain  instances,  the  changes  described 
by  Zenker,  which  occur,  however,  in  all  long-standing  febrile  affections, 
and  are  not  peculiar  to  typhoid  fever.  The  muscle  substance  within  the 
sarcolemma  undergoes  either  a  granular  degeneration  or  a  hyaline  trans- 
formation. The  abdominal  muscles,  the  adductors  of  the  thighs,  and  the 
pectorals  are  most  commonly  involved.  Eupture  of  a  rectus  abdominis 
has  been  found  post  mortem.  Haemorrhage  may  occur.  Abscesses  may 
develop  in  the  muscles  during  convalescence. 

Symptoms. — In  a  disease  so  complex  as  typhoid  fever  it  will  be  well 
first  to  give  a  general  description,  and  then  to  study  more  fully  the  symp- 
toms, complications,  and  sequelae  according  to  the  individual  organs. 

General  Description. — The  period  of  incubation  lasts  from  ''  eight  to 
fourteen  days,  sometimes  twenty-three"  (Clinical  Society),  during  which 
there  are  feelings  of  lassitude  and  inaptitude  for  work.    The  onset  is  rarely 


TYPHOID   FEVER.  13 

abrupt.  In  the  829  cases  there  occurred  at  onset  chills  in  200,  headache  in 
595,  anorexia  in  414,  diarrhoea  (without  purgation)  in  322,  epistaxis  in 
182,  abdominal  pain  in  227,  constipation  in  152,  pain  in  right  iliac  fossa 
in  6.  The  patient  at  last  takes  to  his  bed,  from  which  event,  in  a  majority 
of  cases,  the  definite  onset  of  the  disease  may  be  dated.  During  the  first 
week  there  is,  in  some  cases  (but  by  no  means  in  all,  as  has  long  been 
taught),  a  steady  rise  in  the  fever,  the  evening  record  rising  a  degree  or  a 
degree  and  a  half  higher  each  day,  reaching  103°  or  104°.  The  pulse  is  rapid, 
from  100  to  110,  full  in  volume,  but  of  low  tension  and  often  dicrotic;  the 
tongue  is  coated  and  white;  the  abdomen  is  slightly  distended  and  tender. 
Unless  the  fever  is  high  there  is  no  delirium,  but  the  patient  complains  of 
headache,  and  there  may  be  mental  confusion  and  wandering  at  night. 
The  bowels  may  be  constipated,  or  there  may  be  two  or  three  loose  move- 
ments daily.  Toward  the  end  of  the  week  the  spleen  becomes  enlarged 
and  the  rash  appears  in  the  form  of  rose-colored  spots,  seen  first  on  the 
skin  of  the  abdomen.  Cough  and  bronchitic  symptoms  are  not  uncommon 
at  the  outset. 

In  the  second  weeJc,  in  cases  of  moderate  severity,  the  symptoms  be- 
come aggravated;  the  fever  remains  high  and  the  morning  remission  is 
slight.  The  pulse  is  rapid  and  loses  its  dicrotic  character.  There  is  no 
longer  headache,  but  there  are  mental  torpor  and  dulness.  The  face  looks 
heavy;  the  lips  are  dry;  the  tongue,  in  severe  cases,  becomes  dry  also. 
The  abdominal  symptoms,  if  present — diarrhoea,  tympanites,  and  tender- 
ness— become  aggravated.  Death  may  occur  during  this  week,  with  pro- 
nounced nervous  symptoms,  or,  toward  the  end  of  it,  from  hsemorrhage  or 
perforation.  In  mild  cases  the  temperature  declines,  and  by  the  four- 
teenth day  may  be  normal. 

In  the  third  week,  in  cases  of  moderate  severity,  the  pulse  ranges  from 
110  to  130;  the  temperature  now  shows  marked  morning  remissions,  and 
there  is  a  gradual  decline  in  the  fever.  The  loss  of  flesh  is  now  more 
noticeable,  and  the  weakness  is  pronounced.  Diarrhoea  and  meteorism 
may  now  occur  for  the  first  time.  Unfavorable  symptoms  at  this  stage  are 
the  pulmonary  complications,  increasing  feebleness  of  the  heart,  and  pro- 
nounced delirium  with  muscular  tremor.  Special  dangers  are  perforation 
and  haemorrhage. 

With  the  fourth  week,  in  a  majority  of  instances,  convalescence  begins. 
The  temperature  gradually  reaches  the  normal  point,  the  diarrhoea  stops, 
the  tongue  cleans,  and  the  desire  for  food  returns.  In  severe  cases  the 
fourth  and  even  the  fifth  week  may  present  an  aggravated  picture  of  the 
third;  the  patient  grows  weaker,  the  pulse  is  more  rapid  and  feeble,  the 
tongue  dry,  and  the  abdomen  distended.  He  lies  in  a  condition  of  pro- 
found stupor,  with  low  muttering  delirium  and  subsultus  tendinum,  and 
passes  the  faeces  and  urine  involuntarily.  Heart-failure  and  secondary 
complications  are  the  chief  dangers  of  this  period. 

In  the  fifth  and  sixth  weeks  protracted  cases  may  still  show  irregular 
fever,  and  convalescence  may  not  set  in  until  after  the  fortieth  day.  In  this 
period  we  meet  with  relapses  in  the  milder  forms  or  slight  recrudescence  of 
the  fever.    At  this  time,  too,  occur  many  of  the  complications  and  sequelae. 


14  SPECIFIC  INFECTIOUS  DISEASES. 

Special  Features  and  Symptoms. — Mode  of  Onset. — As  a  rule,  the 
symptoms  come  on  insidiously,  and  the  patient  is  unable  to  fix  definitely 
the  time  at  which  he  began  to  feel  HI.  The  following  are  the  most  impor- 
tant deviations  from  this  common  course: 

(a)  Onset  with  Pronounced,  sometimes  Sudden,  Nervous  Manifestations. 
— ^Headache,  of  a  severe  and  intractable  nature,  is  by  no  means  an  infre- 
quent initial  symptom.  Again,  a  severe  facial  neuralgia  may  for  a  few 
days  put  the  practitioner  off  his  guard.  In  cases  in  which  the  patients 
have  kept  about  and,  as  they  say,  fought  the  disease,  the  very  first  mani- 
festation may  be  pronounced  delirium.  Such  patients  may  even  leave 
home  and  wander  about  for  days.  In  rare  cases  the  disease  sets  in  with 
the  most  intense  cerebro-spinal  symptoms,  simulating  meningitis — severe 
headache,  photophobia,  retraction  of  the  head,  twitching  of  the  muscles, 
and  even  convulsions.  Occasionally  drowsiness,  stupor,  and  signs  of  basi- 
lar meningitis  may  exist  for  ten  days  or  more  before  the  characteristic 
symptoms  develop;  the  onset  may  be  with  mania. 

(&)  With  Pronounced  Pulmonary  Symptoms. — The  initial  bronchial 
catarrh  may  be  of  great  severity  and  obscure  the  other  features  of  the 
disease.  More  striking  still  are  those  cases  in  which  the  disease  sets  in 
with  a  single  chill,  with  pain  in  the  side  and  all  the  characteristic  features 
of  lobar  pneumonia,  or  of  acute  pleurisy;  or  tuberculosis  is  suspected. 

(c)  With  Intense  0 astro-intestinal  Symptoms. — The  incessant  vomiting 
and  pain  may  lead  to  a  suspicion  of  poisoning,  or  the  case  may  be  sent  to 
the  surgical  wards  for  appendicitis. 

id)  With  symptoms  of  an  acute  nephritis,  smoky  or  bloody  urine,  with 
much  albumin  and  tube-casts. 

ie)  Ambulatory  Form. — Deserving  of  especial  mention  are  those  cases 
of  typhoid  fever  in  which  the  patient  keeps  about  and  attempts  to  do 
work,  or  perhaps  takes  a  long  journey  to  his  home.  He  may  come  under 
observation  for  the  first  time  with  a  temperature  of  104°  or  105°,  and  with 
the  rash  well  out.  Many  of  these  cases  run  a  severe  course,  and  in  general 
hospitals  they  contribute  largely  to  the  total  mortality.  Finally,  there 
are  rare  instances  in  which  typhoid  is  unsuspected  until  perforation,  or  a 
profuse  haemorrhage  from  the  bowels  occurs. 

Facial  Aspect. — Early  in  the  disease  the  cheeks  are  flushed  and  the 
eyes  bright.  Toward  the  end  of  the  first  week  the  expression  becomes 
more  listless,  and  when  the  disease  is  well  established  the  patient  has  a 
dull  and  heavy  look.  There  is  never  the  rapid  anaemia  of  malarial  fever, 
and  the  color  of  the  lips  and  cheeks  may  be  retained  even  to  the  third  week. 

Fever. — (a)  Regular  Course.  (Chart  I.) — In  the  stage  of  invasion  the 
fever  rises  steadily  during  the  first  five  or  six  days.  The  evening  tem- 
perature is  about  a  degree  or  a  degree  and  a  half  higher  than  the  morn- 
ing remission,  so  that  a  temperature  of  104°  or  105°  is  not  uncommon 
by  the  end  of  the  first  week.  Having  reached  the  fastigium  or  height, 
the  fever  then  persists  with  very  slight  daily  remissions.  The  fever  may 
be  singularly  persistent  and  but  little  influenced  by  bathing  or  other 
measures.  At  the  end  of  the  second  and  throughout  the  third  week  the 
temperature  becomes  more  distinctly  remittent.     The  difference  between 


TYPHOID  FEVER. 


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16  SPECIFIC  INFECTIOUS  DISEASES. 

the  morning  and  evening  record  may  be  3°  or  4°,  and  the  morning  tempera- 
ture may  even  be  normal.  It  falls  by  lysis,  and  the  temperature  is  not 
considered  normal  until  the  evening  record  is  at  98.2°. 

(&)  Variations  from  the  typical  temperature  curve  are  common.  We 
do  not  always  see  the  gradual  step-like  ascent  in  the  early  stage;  the  cases 
do  not  often  come  under  observation  at  this  time.  When  the  disease  sets 
in  with  a  chill,  or  in  children  with  a  convulsion,  the  temperature  may  rise 
at  once  to  103°  or  104°.  In  many  cases  defervescence  occurs  at  the  end  of 
the  second  week  and  the  temperature  may  fall  rapidly,  reaching  the  nor- 
mal within  twelve  or  twenty  hours.  An  inverse  type  of  temperature,  hi^h 
in  the  morning  and  low  in  the  evening,  is  occasionally  seen  but  has  no 
especial  significance. 

Sudden  falls  in  the  temperature  may  occur;  thus,  as  shown  in  Chart 
III,  a  drop  of  10°  may  follow  an  intestinal  hemorrhage,  and  the  fall  may 
be  very  apparent  even  before  the  blood  has  appeared  in  the  stools.  Some- 
times during  the  anaemia  which  follows  a  severe  hgemorrhage  from  the 
bowels  there  are  remarkable  oscillations  in  the  temperature.  Hyperpy- 
rexia is  rare.  In  only  33  of  829  cases  did  the  fever  rise  above  106°.  Before 
death  the  fever  may  rise;  the  highest  I  have  known  was  109.5°. 

(c)  Post-typhoid  Variations.  (1)  Recrudescences. — After  a  normal  tem- 
perature of  perhaps  five  or  six  days,  the  fever  may  rise  suddenly  to  102°  or 
103°,  without  constitutional  disturbance,  furring  of  the  tongue,  or  abdomi- 
nal symptoms.  After  persisting  for  from  two  to  four  days  the  tempera- 
ture falls.  Of  829  cases,  79  presented  these  post-typhoid  elevations,  brief 
notes  of  which  are  given  in  the  Studies  on  Typhoid  Fever.  Constipation, 
errors  in  diet,  or  excitement  may  cause  them.  These  attacks  are  a  frequent 
source  of  anxiety  to  the  practitioner.  They  are  very  common,  and  it  is 
not  always  possible  to  say  upon  what  they  depend.  As  a  rule,  if  the  rise 
in  temperature  is  the  result  of  the  onset  of  a  complication,  such  as  pleurisy 
or  thrombosis,  there  is  an  increase  in  the  leucocytes.  Naturally  one  sus- 
pects at  the  outset  a  relapse,  but  there  is  an  absence  of  the  step-like  ascent, 
and  as  a  rule  the  fever  falls  after  lasting  a  few  days. 

(2)  The  8ub-febrile  State  of  Convalescence. — In  children,  in  very  nerv- 
ous patients,  and  in  cases  with  ansemia,  the  evening  temperature  may  keep 
up  for  weeks  after  the  tongue  has  cleaned  and  the  appetite  has  returned. 
This  may  usually  be  disregarded,  and  is  often  best  treated  by  allowing  the 
patient  to  get  up,  and  by  stopping  the  use  of  the  thermometer.  Of  course 
it  is  important  not  to  overlook  any  latent  complications. 

(3)  Hypothermia. — Low  temperatures  in  typhoid  fever  are  common, 
following  the  tubs,  or  spontaneously  in  the  third  and  fourth  week  in  the 
periods  of  marked  remissions,  and  following  haemorrhage.  An  interesting 
form  is  the  persistent  hypothermia  of  convalescence.  For  ten  days  or  more, 
particularly  in  the  protracted  cases  with  great  emaciation,  the  tempera- 
ture may  be  96.5°  or  97°.    It  is  of  no  special  significance. 

{d)  The  Fever  of  the  Relapse. — This  is  a  repetition  in  many  instances 
of  the  original  fever,  a  gradual  ascent  and  maintenance  for  a  few  days  at 
a  certain  height  and  then  a  gradual  decline.  It  is  shorter  than  the  original 
pyrexia,  and  rarely  continues  more  than  two  or  three  weeks.     (Chart  I.) 


TYPHOID   FEVER.  17 

(e)  Afebrile  Typhoid. — There  are  cases  described  in  which  the  chief 
features  of  the  disease  have  been  present  without  the  existence  of  fever. 
They  are  extremely  rare  in  this  country.  I  have  seen  a  case,  afebrile  at  the 
thirteenth  day,  and  in  which  the  rose  spots  and  other  features  persisted 
till  the  twenty-eighth  day. 

(/)  Chills  occur  (a)  sometimes  with  the  fever  of  onset;  (&)  occasion- 
ally at  intervals  throughout  the  course  of  the  disease,  and  followed  by 
sweats  (so-called  sudoral  form);  (c)  with  the  advent  of  complications, 
pleurisy,  pneumonia,  otitis  media,  periostitis,  etc.;  (d)  with  active  anti- 
pyretic treatment  by  the  coal-tar  remedies;  (e)  occasionally  during  the 
period  of  defervescence  without  relation  to  any  complication  or  sequel, 
probably  due  to  a  septic  infection;  (/)  according  to  Herringham,  chills 
may  result  from  constipation.  There  are  cases  in  which  throughout  the 
latter  half  of  the  disease  chills  recur  with  great  severity.  (See  Chills  in 
Typhoid  Fever,  Studies  II.) 

Skin. — The  characteristic  rash  of  the  disease  consists  of  hypersemic 
spots,  which  ajDpear  from  the  seventh  to  the  tenth  day,  usually  at  first 
upon  the  abdomen.  They  are  slightly  raised,  flattened  papules,  which  can 
be  felt  distinctly  by  the  finger,  of  a  rose-red  color,  disappearing  on  pres- 
sure, and  ranging  in  diameter  from  2  to  4  mm.  They  were  present  in  666 
of  our  829  cases.  They  come  out  in  successive  crops,  and  after  persisting 
for  two  or  three  days  they  disappear,  leaving  a  brownish  stain.  The  spots 
may  be  present  upon  the  back,  and  not  upon  the  abdomen.  The  eruption 
may  be  very  abundant  over  the  whole  skin  of  the  trunk,  and  on  the  extremi- 
ties. Of  426  cases  in  which  the  spots  were  looked  for  with  particular  care, 
there  were  39  in  which  they  occurred  on  the  arms,  13  on  the  forearms,  19  on 
the  thighs,  legs  8,  face  3,  hands  1.  The  cases  with  very  abundant  eruption 
are  not  necessarily  more  severe.  As  already  noted,  the  typhoid  bacilli 
have  been  found  in  the  spots.  Of  variations  in  the  rash,  frequently  the 
spots  are  capped  by  small  vesicles.  Cases  that  have  not  been  carefully 
sponged  may  show  sweat  vesicles,  either  miliary  or  sudaminal.  In  25  cases 
in  my  series  there  were  purpuric  spots.  One  of  the  cases  was  true  haemor- 
rhagic  typhoid  fever.  The  rash  may  not  appear  until  the  relapse.  In  12 
cases  in  our  series  the  rose  spots  came  out  after  the  patient  was  afebrile. 

A  branny  desquamation  is  not  rare  in  children.  Occasionally  the  skin 
peels  off  in  large  flakes. 

Among  other  skin  lesions  in  typhoid  fever  the  following  may  be  men- 
tioned: 

Erythema. — It  is  not  very  uncommon  in  the  first  week  of  the  disease  to 
find  a  diffuse  erythematous  blush — E.  typhosum.  Formerly  we  thought 
this  might  be  due  to  quinine. 

The  tache  cerehrale,  a  red  line  with  white  borders,  is  readily  produced 
by  drawing  the  nail  over  the  skin,a  vaso-motor  phenomenon  of  no  special  sig- 
nificance. Sometimes  the  skin  may  have  a  peculiar  mottled  pink  and  white 
appearance.    E.  exudativum,  E.  nodosum,  and  urticaria  may  be  present. 

Herpes. — Herpes  is  certainly  rare  in  typhoid  fever  in  comparison  with 
its  great  frequency  in  malarial  fever  and  in  pneumonia.     It  was  noted  in 
29  of  our  829  cases,  usually  on  the  lips. 
2 


18  SPECIFIC  INFECTIOUS  DISEASES. 

The  taclies  Neudtres — Peliomata — Maculce  cerulece. — These  are  pale-blue 
or  steel-gray  spots,  subcuticular,  from  4  to  10  mm.  in  diameter,  of  irregu- 
lar outline  and  most  abundant  about  the  chest,  abdomen,  and  thighs. 
They  sometimes  give  a  very  striking  appearance  to  the  skin.  It  can  be 
readily  seen  that  the  injection  is  in  the  deeper  tissues  and  not  superficial. 
This  rash  is  quite  without  significance.  Since  my  attention  was  called  to 
its  association  with  body  lice,  I  have  met  with  no  instance  in  which  these 
were  not  present.  Several  French  observers  maintain  that  they  are  due  to 
the  irritating  effects  of  the  fiuid  secreted  by  pediculi  (vide  Hewetson,  Johns 
Hopkins  Hospital  Bulletin,  vol.  v).  They  are  not  peculiar  to  typhoid  fever 
(Duckworth). 

Shin  Gangrene. — In  children  noma  may  occur;  occasionally,  as  reported 
by  McFarland  in  the  Philadelphia  epidemic  of  1898,  there  were  many 
cases  with  multiple  areas  of  gangrene  of  the  skin. 

Sweats. — At  the  height  of  the  fever  the  skin  is  usually  dry.  Profuse 
sweating  is  rare,  but  it  is  not  very  uncommon  to  see  the  abdomen  or  chest 
moist  with  perspiration,  particularly  in  the  reaction  which  follows  the 
bath.  Sweats  in  some  instances  constitute  a  striking  feature  of  the  dis- 
ease. They  may  occasionally  be  associated  with  chilly  sensations  or  actual 
chills.  Jaccoud  and  others  in  France  have  especially  described  this  sudoral 
form  of  typhoid  fever.  There  may  be  recurring  paroxysms  of  chill,  fever, 
and  sweats  (even  several  in  twenty-four  hours),  and  the  case  may  be  mis- 
taken for  one  of  intermittent  fever.  The  fever  toward  the  end  of  the 
second  week  and  during  the  third  week  may  be  intermittent.  The  char- 
acteristic rash  is  usually  present,  and,  if  absent,  the  negative  condition  of 
the  blood  is  sufficient  to  exclude  malaria.  The  sweating  may  occur  chiefly 
in  the  third  and  fourth  weeks. 

(Edema  of  the  skin  occurs:  1.  As  the  result  of  vascular  obstruction, 
most  commonly  of  a  vein,  as  in  thrombosis  of  the  femoral  vein. 

2.  In  connection  with  nephritis,  very  rarely. 

3.  In  association  with  the  anaemia  and  cachexia. 

The  hair  falls  out  after  the  attack,  but  complete  baldness  is  rare.  I 
have  once  seen  permanent  baldness.  The  nutrition  of  the  nails  suffers, 
and  during  and  after  convalescence  transverse  ridges  may  occur. 

A  peculiar  odor  is  exhaled  from  the  skin  in  some  eases.  Whether  3ue 
to  a  cutaneous  exhalation  or  not,  there  certainly  is  a  very  distinctive  smell 
connected  with  many  patients.  Nathan  Smith  describes  it  as  of  a  "  semi- 
cadaverous,  musty  character." 

LinecB  atrophicce. — Lines  of  atrophy  may  appear  on  the  skin  of  the  abdo- 
men and  lateral  aspects  of  the  thighs,  similar  to  those  seen  after  preg- 
nancy. They  have  been  attributed  to  neuritis,  and  Duckworth  has  reported 
a  case  in  which  the  skin  adjacent  to  them  was  hyperaesthetic. 

Bed-sores  are  not  uncommon  in  protracted  cases,  with  great  emacia- 
tion. As  a  rule,  they  result  from  pressure  and  are  seen  upon  the  sacrum, 
more  rarely  the  ilia,  the  shoulders,  and  the  heels.  These  are  less  com- 
mon, I  think,  since  the  introduction  of  hydrotherapy.  Scrupulous  care 
and  watchfulness  do  much  for  their  prevention,  but  it  is  to  be  remem- 
bered that  in  cases  with  profound  involvement  of  the  nerve  centres  acute 


TYPHOID   FEVER.  I9 

bed-sores  of  the  back  and  heels  may  occur  with  very  slight  pressure,  and 
with  astonishing  rapidity. 

Boils  constitute  a  common  and  troublesome  sequel  of  the  disease. 
They  appear  to  be  more  frequent  after  hydrotherapy. 

Circulatory  System. — The  blood  presents  important  changes.  The  fol- 
lowing statements  are  based  on  studies  which  W.  S.  Thayer  has  made  in 
my  wards  (Studies  I  and  III):  During  the  first  two  weeks  there  may  be 
little  or  no  change  in  the  blood.  Profuse  sweats  or  copious  diarrhoea  may, 
as  Hayem  has  shown,  cause  the  corpuscles — as  in  the  collapse  stage  of 
cholera — to  rise  above  normal.  In  the  third  week  a  fall  usually  takes 
place  in  corpuscles  and  haemoglobin,  and  the  number  may  sink  rapidly 
even  to  1,300,000  per  c.  mm.,  gradually  rising  to  normal  during  conva- 
lescence. When  the  patient  first  gets  up,  there  may  be  a  slight  fall  in  the 
number  of  corpuscles.  The  average  maximum  loss  is  about  1,000,000  to 
the  c.  mm. 

The  amount  of  hsemoglobin  is  always  reduced,  and  usually  in  a  greater 
relative  proportion  than  the  number"  of  red  corpuscles,  and  during  recov- 
ery the  normal  color  standard  is  reached  at  a  later  period.  The  number 
of  colorless  corpuscles  is  subnormal  throughout  the  course.  Cold  baths 
increase  temporarily  the  number  in  the  peripheral  circulation.  The  ab- 
sence of  leucocytosis  may  be  at  times  of  real  diagnostic  value  in  distin- 
guishing typhoid  fever  from  various  septic  fevers  and  acute  inflammatory 
processes.  The  relative  proportion  of  the  leucocytes  shows  fairly  constant 
variations,  the  large  mononuclear  and  transitional  forms  are  increased, 
while  the  polynuclear  neutrophiles  are  diminished  often  below  60  or  even 
50  per  cent.  This  is  in  marked  contrast  to  the  condition  in  other  acute 
diseases  in  which  the  polynuclear  neutrophiles  are  increased.  ^\Tien  an 
acute  inflammatory  process  occurs  in  typhoid  fever  the  leucocytes  show 
an  increase  in  the  polynuclear  forms,  and  this  may  be  of  great  diagnostic 
moment,  as  in  perforation. 

The  accompanying  blood-chart  shows  these  changes  well.     (Chart  II.) 

The  post-typhoid  angemia  may  reach  an  extreme  grade.  In  one  of  my 
<i?ises  the  blood-corpuscles  sank  to  1,300,000  per  c.  mm.  and  the  haemo- 
globin to  about  20  per  cent.  These  severe  grades  of  ansemia  are  not  com- 
mon in  my  experience.  In  the  Munich  statistics  there  were  54  cases  with 
general  and  extreme  anaemia. 

Of  changes  in  the  blood  plasma  very  little  is  known. 

The  pulse  in  typhoid  fever  presents  no  special  characters.  It  is  in- 
creased in  rapidity,  but  not  always  in  proportion  to  the  height  of  the 
fever.  As  a  rule,  in  the  first  week  it  is  above  100,  full  in  volume  and  often 
dicrotic.  There  is  no  acute  disease  with  which,  in  the  early  stage,  a 
dicrotic  pulse  is  so  frequently  associated.  Even  with  high  fever  the  pulse 
may  not  be  greatly  accelerated.  As  the  disease  progresses  the  pulse  be- 
comes more  rapid,  feebler,  and  small.  In  the  extreme  prostration  of  severe 
cases  it  may  reach  150  or  more,  and  is  a  mere  undulation — the  so-called 
running  pulse.  The  lowered  arterial  pressure  is  manifest  in  the  dusky 
lividity  of  the  skin  and  coldness  of  the  hands  and  feet. 

During  convalescence  the  pulse  gradually  returns  to  normal,  and  occa- 


20 


SPECIFIC  INFECTIOUS  DISEASES. 


sionally  becomes  very  slow.  After  no  other  acute  fever  do  we  so  fre- 
quently meet  with  bradycardia.  I  have  counted  the  pulse  as  low  as  30, 
and  instances  are  on  record  of  stUl  fewer  beats  to  the  minute. 


100^ 

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.OEC-,t89 

JANUARY,  ,189.1 

FEBRUARY 

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BLACK,   RED  CORPUSCLES. 


RED,  HAEMAGLOBIH. 


MEAN  NORM. 

NUMBER  OF 

WHITE 

CORPUSCLES 


BLUE,    COLORLESS  CORPUSCLES. 


Chaet  II. 


The  heart-sounds  may  be  normal  throughout  the  course.  In  severe 
cases,  the  first  sound  becomes  feeble  and  there  is  often  to  be  heard,  at  the 
apex  and  along  the  left  sternal  margin,  a  soft -systolic  murmur.  Absence 
of  the  first  sound  is  rare.  Gallop  rhythm  is  not  uncommon.  In  the  ex- 
treme feebleness  of  the  graver  forms,  the  first  and  second  sound  become  very 
similar,  and  the  long  pause  is  much  shortened  (embryocardia).  I  am  much 
impressed  with  the  rarity  of  grave  heart  symptoms  in  typhoid  fever. 

Of  cardiac  complications,  pericarditis  is  rare  and  has  been  met  with 
chiefly  in  children  and  in  association  with  pneumonia.    It  was  present  in 


TYPHOID  FEVER.  21 

only  one  of  my  cases  and  occurred  in  only  14  of  the  2,000  Munich  post- 
mortems. Endocarditis  is  also  uncommon.  I  have  seen  only  2  cases;  and 
there  were  only  11  cases  noted  in  the  Munich  records.  Myocarditis  is  more 
common.  The  following  statement  may  be  made  with  reference  to  the 
condition  of  the  heart-muscle  in  this  disease:  In  protracted  cases  the  mus- 
cle-fibre is  usually  soft,  flabby,  and  of  a  pale  yellowish-brown  color.  The 
softening  may  be  extreme,  though  rarely  of  the  grade  described  by  Stokes, 
in  which,  when  held  apex  up  by  the  vessels,  the  organ  collapsed  over  the 
hand,  forming  a  mushroom-like  cap.  Microscopically,  the  fibres  may  show 
little  or  no  change,  even  when  the  impulse  of  the  heart  has  been  extremely 
feeble.  A  granular  parenchymatous  degeneration  is  common.  Fatty  de- 
generation may  be  present,  particularly  in  long-standing  cases  with  ansemia. 
The  hyaline  change  is  not  common.  The  segmenting  myocarditis,  in  which 
the  cement  substance  is  softened  so  that  the  muscle-cells  separate,  has 
also  been  found,  but  probably  as  a  post-mortem  change. 

Complications  in  the  Arteries. — Obliteration  of  large  or  small  arterial 
trunks  is  one  of  the  rare  complications  of  typhoid  fever.  A  considerable 
number  of  cases  are  scattered  through  the  literature.  The  obliteration 
may  be  due  either  to  embolism  or  to  thrombosis.  In  a  majority  of  cases 
the  femoral  artery  is  involved  and  gangrene  of  the  foot  and  leg  occurs. 
In  several  cases  there  has  been  obliteration  of  both  femorals  with  extension 
of  the  clot  into  the  aorta  with  gangrene  of  both  legs.  In  a  case  which 
I  saw  with  Eoddick,  of  Montreal,  the  obliteration  of  the  left  femoral 
occurred  on  the  sixteenth  day.  On  the  twentieth  day  the  patient  had 
pain  in  the  right  leg  and  there  was  no  pulsation  in  the  femoral  artery. 
Gangrene  gradually  developed  in  both  feet,  and  death  took  place  in  the 
sixth  week.  In  these  cases  the  condition  is  probably  due  to  thrombosis, 
not  embolism,  and  is  associated  with  a  blood  state  which  favors  clotting, 
or  with  a  local  arteritis,  a  view  strongly  supported  by  Auden  in  a  recent 
study.  Keen  refers  to  46  cases  of  arterial  gangrene,  of  which  8  were  bilat- 
eral, 19  on  the  right  side,  and  19  on  the  left. 

Thrombi  in  the  Veins. — This  not  infrequent  complication  was  present 
in  16  of  829  cases — 7  in  left  femoral,  4  in  popliteal,  4  in  the  long 
saphenous,  and  1  in  a  superficial  vein.  The  more  common  occurrence  in 
the  left  crural  vein  is  due  possibly,  as  suggested  by  Liebermeister,  to  the 
fact  that  in  the  left  common  iliac  vein,  being  crossed  by  the  right  iliac 
artery,  the  flow  of  blood  is  not  so  free  as  in  the  right  vein.  Thrombosis 
is  indicated  by  enlargement  and  oedema  of  the  limb.  It  is  not  a  very 
unfavorable  complication.  In  a  Montreal  case  the  thrombus  suppurated 
and  there  was  pya?mia.  Occasionally  the  thrombosis  may  extend  into 
the  pelvic  veins  and  into  the  vena  cava.  I  saw  a  thrombus  in  the  right 
circumflex  iliac  vein  alone,  and  the  superficial  veins  on  the  right  side 
of  the  abdomen  were  in  consequence  greatly  enlarged.  Sudden  death  has 
been  caused  by  dislodgment  of  a  thrombus  and  plugging  of  the  pulmonary 
artery.  Typhoid  bacilli  have  been  found  in  the  wall  of  the  vein  and  in 
the  clot.  Gangrene  never  follows  clotting  in  the  vein  alone.  The  phleg- 
masia alba  dolens  which  results  gradually  disappears  as  the  collateral  cir- 
culation is  established.     It  may  be  weeks  before  the  swelling  subsides. 


23  SPECIFIC  INFECTIOUS  DISEASES. 

Some  patients  have  to  wear  a  bandage  for  years,  and  in  a  few  instances 
the  leg  remains  permanently  enlarged.     The  pain  is  variable. 

Infarcts  in  the  kidneys,  spleen,  and  lungs  are  by  no  means  uncommon 
in  typhoid  fever.  They  are  associated  usually  with  thrombosis  in  the  arte- 
ries, rarely  with  embolism. 

Typhoid  Gangrene. — Following  blocking  of  the  femoral  or  popliteal 
arteries  the  leg  becomes  numb  and  cold.  There  may  be  complete  anaes- 
thesia with  motor  jDaralysis,  and  occasionally  a  good  deal  of  pain.  There 
is  rarely  much  swelling;  gradually  the  skin  becomes  discolored  and  the 
process  of  dry  gangrene  begins.  When  both  artery  and  vein  are  involved 
the  gangrene  is  usually  moist,  and  spreads  more  rapidly.  In  a  number  of 
cases  the  gangrene  is  not  specially  localized  to  vascular  areas;  thus  the  dis- 
tribution in  the  cases  collected  by  Keen  is  as  follows:  Ears,  6  cases;  nose, 
10  cases;  face,  neck,  and  trunk,  47  cases;  anus,  5  cases;  genitals,  30  cases; 
legs,  126  eases. 

Digestive  System. — Loss  of  appetite  is  early,  and,  as  a  rule,  the  relish 
for  food  is  not  regained  until  convalescence.  Thirst  is  constant,  and 
should  be  fully  and  freely  gratified.  Even  when  the  mind  becomes  be- 
numbed and  the  patient  no  longer  asks  for  water,  it  should  be  freely  given. 
The  tongue  presents  the  changes  inevitable  in  a  prolonged  fever,  but  there 
are  no  distinctive  characters.  Early  in  the  disease  it  is  moist,  swollen,  and 
coated  with  a  thin  white  fur,  which,  as  the  fever  progresses,  becomes 
denser.  It  may  remain  moist  throughout.  In  severe  cases,  particularly 
those  with  delirium,  the  tongue  becomes  very  dry,  partly  owing  to  the  fact 
that  such  patients  breathe  with  the  mouth  open.  It  may  be  covered  with 
a  brown  or  brownish-black  fur,  or  with  crusts  between  which  are  cracks 
and  fissures.  Acute  glossitis  occurred  in  one  case  at  the  onset  of  the 
relapse.  In  these  cases  the  teeth  and  lips  may  be  covered  with  a  dark 
brownish  matter  called  sordes — a  mixture  of  food,  epithelial  debris,  and 
micro-organisms.  By  keeping  the  mouth  and  tongue  clean  from  the  out- 
set the  fissures,  which  are  extremely  painful,  may  be  prevented.  During 
convalescence  the  tongue  gradually  becomes  clean,  and  the  fur  is  thrown 
off,  almost  imperceptibly  or  occasionally  in  flakes. 

The  secretion  of  saliva  is  often  diminished;  salivation'  is  rare. 

Parotitis  was  present  in  45  of  the  2,000  Munich  cases.  It  occurred  in 
12  eases  in  my  series;  of  these,  4  died.  It  is  most  frequent  in  the  third 
week  in  very  severe  cases.  Extensive  sloughing  may  follow  in  the  tissues 
of  the  neck.  Usually  unilateral,  and  in  a  majority  of  cases  going  on  to 
suppuration,  it  is  regarded  as  a  very  fatal  complication,  but  recovery  has 
followed  in  eight  of  my  cases.  It  undoubtedly  may  arise  from  extension 
of  inflammation  along  Steno's  duct.  This  is  probably  not  so  serious  a 
form  as  when  it  arises  from  metastatic  inflammation.  In  two  of  my  cases 
the  submaxillary  glands  were  involved  alone.  Parotitis  may  occur  after  the 
.  fever  has  subsided.  A  remarkable  localized  sweating  in  the  parotid  region 
is  an  occasional  sequel  of  the  abscess. 

The  pharynx  may  be  the  seat  of  slight  catarrh.  Sometimes  the  fauces 
are  deeply  congested.  Membranous  pharyngitis,  a  serious  and  fatal  com- 
plication, may  come  on  in  the  third  week.     Difficulty  in  swallowing  may 


TYPHOID  FEVER.  23 

result  from  ulcers  of  the  oesophagus,  and  in  one  of  our  eases  stricture  fol- 
lowed.*   Thyroiditis  may  occur  with  abscess  formation. 

The  gastric  symptoms  are  extremely  variable.  Nausea  and  vomiting 
are  not  common.  There  are  instances,  however,  in  which  vomiting,  re- 
sisting all  measures,  is  a  marked  feature  from  the  outset,  and  may  directly 
cause  death  from  exhaustion.  Vomiting  does  not  often  occur  in  the  second 
and  third  week,  unless  associated  with  some  serious  complication.  In  a 
few  of  these  cases  ulcers  have  been  found  in  the  stomach.  Hsematemesis 
may  occur. 

Intestinal  Symptoms. — Diarrhoea  is  a  very  variable  symptom,  occurring 
in  from  20  to  30  per  cent  of  the  cases.  Of  829  cases  322  had  diarrhoea 
before  entering,  163  during  their  stay  in,  hospital.  The  small  percentage 
may  be  due  to  the  fact  that  we  use  no  purges  or  intestinal  antiseptics.  Its 
absence  must  not  be  taken  as  an  indication  that  the  intestinal  lesions  are 
of  slight  extent.  I  have  seen,  on  several  occasions,  the  most  extensive  infil- 
tration and  ulceration  of  the  Peyer's  glands  of  the  small  intestine,  with 
the  colon  filled  with  solid  faeces.  The  diarrhoea  is  caused  less  by  the  ulcers 
than  by  the  associated  catarrh,  and,  as  in  tuberculosis,  it  is  probable  that 
when  this  is  m  the  large  intestine  the  discharges  are  more  frequent.  It  is 
most  common  toward  the  end  of  the  first  and  throughout  the  second  week, 
but  it  may  not  occur  until  the  third  or  even  the  fourth  week.  The  number 
of  discharges  ranges  from  3  to  8  or  10  in  the  twenty-four  hours.  They  are 
usually  abundant,  thin,  grayish-yellow,  granular,  of  the  consistency  and 
appearance  of  pea-soup,  and  resemble  very  much,  as  Addison  remarked,  the 
normal  contents  of  the  small  bowel.  The  reaction  is  alkaline  and  the  odor 
offensive.  On  standing,  the  discharges  separate  into  a  thin  serous  layer, 
containing  albumin  and  salts,  and  a  lower  stratum,  consisting  of  epithelial 
debris,  remnants  of  food,  and  numerous  crystals  of  triple  phosphates. 
Blood  may  be  in  small  amount,  and  only  recognized  by  the  microscope. 
Sloughs  of  the  Peyer's  glands  occur  either  as  grayish-yellow  fragments  or 
occasionally  as  ovoid  masses,  an  inch  or  more  in  length,  in  which  portions 
of  the  bowel  tissue  may  be  found.  The  bacilli  are  not  found  in  the  stools 
until  the  end  of  the  first  or  the  middle  of  the  second  week. 

Hcemorrliage  from  the  bowels  is  a  serious  complication,  occurring  in 
from  3  to  5  per  cent  of  all  cases.  It  had  occurred  in  99  of  the  2,000  fatal 
Munich  cases.  In  829  cases  treated  in  my  wards,  haemorrhage  occurred 
in  50,  and  in  7  death  occurred  directly  from  the  haemorrhage.  Of  60 
cases  reported  by  E.  G.  Curtin,  28  died.  It  was  present  in  3.77  per  cent  of 
Murchison's  1,564  cases.  There  may  be  only  a  slight  trace  of  blood  in  the 
stools,  but  too  often  it  is  a  profuse,  free  haemorrhage,  which  rapidly  proves 
fatal.  It  occurs  most  commonly  between  the  end  of  the  second  and  the 
beginning  of  the  fourth  week,  the  time  of  the  separation  of  the  sloughs. 
Occasionally  it  results  simply  from  the  intense  hypersemia.  It  usually 
comes  on  without  warning.  A  sensation  of  sinking  or  collapse  is  experi- 
enced by  the  patient,  the  temperature  falls,  and  may,  as  in  the  annexed 
chart,  drop  8°  or  10°  in  a  few  hours.    Fatal  collapse  may  supervene  before 


*  Mitchell,  CEsophageal  Complications  in  Typhoid  Fever  (Studies  III). 


24 


SPECIFIC  IXFECTIOtJS.  DISEASES. 


the  blood  appears  in  tlie  stool.     Hseniorrhage  usually  occurs  in  cases  of 
considerable  seyerity.     Graves  and  Trousseau  held  that  it  was  not  a  very 

dangerous  symptom,  but  statistics  show  that  death  follows  in  from  30  to 
50  per  cent  of  the  eases. 


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It  must  not  be  forgotten  that  melfena  may  also  be  part  of  a  general 
hsemorrhagic  tendency  (to  be  referred  to  later),  in  which  case  it  is  associ- 
ated with  petechige  and  hematuria.  There  may  be  a  special  family  pre- 
disposition to  intestinal  haemorrhages  in  typhoid  fever. 

Meteorism,  a  frequent  symptom,  is  not  serious  if  of  moderate  grade, 
but  when  excessive  is  usually  of  HI  omen.     Owincr  to  defective  tone  in  the 


TYPHOID  FEVER.  25 

walls,  in  severe  cases  to  their  infiltration  with  serum,  gas  accumulates  in 
the  small  and  large  bowels,  particularly  in  the  latter.  Pushing  up  the 
diaphragm,  it  interferes  very  much  with  the  action  of  the  heart  and  lungs, 
and  may  also  favor  perforation.  Gurgling  in  the  right  iliac  fossa  exists 
in  a  large  proportion  of  all  the  cases,  and  indicates  simply  the  presence 
of  gas  and  fluid  faeces  in  the  colon  and  caecum. 

Abdominal  pain  and  tenderness  were  present  in  three-fifths  of  a  series 
of  500  cases  studied  in  my  wards  by  T.  McCrae.  In  some  it  was  only  pres- 
ent at  the  onset.  Pain  occurred  during  the  course  in  about  one-third  of  the 
cases.  This  is  due  in  some  instances  to  conditions  apart  from  the  bowel 
lesions,  such  as  pleurisy,  distention  of  the  bladder,  and  phlebitis.  It  may 
be  associated  with  diarrhoea,  severe  constipation,  a  painful  spleen,  or  acute 
abdominal  complications.  Pain  occurs  with  some  cases  of  hsemorrhage, 
but  is  most  constantly  present  with  perforation.  In  a  large  group  no  cause 
could  be  found  for  the  pain,  and  if  other  symptoms  be  associated  the  con- 
dition may  lead  to  error  in  diagnosis.  Operation  for  appendicitis  has  been 
performed  in  the  early  stage  of  typhoid  fever,  owing  to  the  combination 
of  pain  in  the  right  iliac  fossa,  fever  and  constipation.  This  has  happened 
twice  at  the  Johns  Hopkins  Hospital. 

Perforation. — The  patient's  life  may  depend  upon  an  early  recognition 
of  the  condition.  It  occurred  in  23  of  829  cases  in  our  series,  2.7  per  cent. 
Nearly  one  half  of  the  cases  occur  in  the  third  and  fourth  weeks  (Pitz). 
It  may  occur  as  early  as  the  first  week,  or  as  late  as  the  sixteenth  week. 
While  it  may  occur  in  very  mild  cases,  a  large  proportion  occur  in  the 
more  severe  forms,  particularly  in  those  associated  with  meteorism  and 
with  haemorrhage. 

The  symptoms  are,  first,  those  of  the  perforation  itself;  secondly,  those 
of  the  consecutive  peritonitis.  By  far  the  most  important  single  symp- 
tom of  the  perforation  is  pain,  sudden,  sharp,  paroxysmal,  and  of  increasing 
severity.  It  is  rarely  absent,  except  in  the  small  group  of  cases  with  pro- 
found toxaemia  and  coma.  The  pain  is  most  frequently  in  the  hypogastric 
region,  and  to  the  right  of  the  middle  line.  As  it  occurs  in  the  lowermost 
coils  of  the  ileum,  irritability  of  the  bladder  may  be  early,  with  frequent 
micturition  and  pain  extending  toward  the  penis.  On  palpation  there 
may  be  general  tenderness  in  the  hypogastric  region,  or  only  localized 
tenderness  on  deep  pressure.  There  may  be  early  muscle  rigidity  and  in- 
creased tension,  and  spasm  on  any  attempt  to  palpate.  In  a  few  instances, 
with  the  pain  of  perforation,  the  patient  has  signs  of  shock,  fall  in  tem- 
perature, increase  in  the  rapidity  of  the  pulse,  and  a  tendency  to  sweat. 
The  pbysician  should  note  in  writing,  at  once,  after  the  onset  of  pain,  the 
condition  of  the  abdomen,  particularly  the  character  of  the  respiratory 
movements,  the  degree  of  distention,  and  the  area  of  liver  flatness.  A 
leucocyte  count  should  be  made. 

In  a  few  instances,  as  in  a  remarkable  case  recently  reported  by  J. 
Milton  Miller,  the  perforation  is  completely  closed  by  a  tag  of  omentum. 
The  symptoms  of  typhoid  peritonitis  may  be  masked  and  entirely  over- 
looked in  a  profound  toxaemia.  Tliey  are  general  and  local.  The  facies 
of  the  patient  usually  changes,  there  are  increased  pallor,  a  pinched  ex- 


/ 


26  SPECIFIC  INFECTIOUS  DISEASES. 

pression,  and,  as  the  symptoms  progress,  the  Hippocratic  facies,  with  dusky 
suffusion  of  the  face  and  clammy  perspiration.  The  temperature  may 
drop  at  the  onset  of  the  perforation,  but  usually  rises  with  the  progress 
of  the  peritonitis.  The  pulse  quickens,  becoming  finally  running  and 
thready,  and  there  is  embryocardia.  Increase  in  the  frequency  of  respira- 
tion is  almost  constant.  Hiccough  may  occur  early,  more  frequently  a 
late  symptom.    Vomiting  is  a  common  symptom. 

The  local  abdominal  features  are  often  more  important  than  the  gen- 
eral, as  it  is  surprising  to  notice  how  excellent  the  condition  of  a  patient 
may  be  with  perforative  peritonitis.  Limitation  of  the  respiratory  move- 
ments is  usually  present,  perhaps  confined  to  the  hypogastric  area.  In- 
creasing distention  is  the  rule,  but  perforation  and  peritonitis  may  occur, 
it  is  to  be  remembered,  with  an  abdomen  flat  or  even  scaphoid.  Increasing 
pain  on  pressure,  increasing  muscle  spasm  and  tension  of  the  wall  are  im- 
portant signs.  Percussion  may  reveal  a  flat  note  in  the  flanks,  due  to' 
exudate.  Auscultation  may  show  absence  of  peristalsis,  and  auscultatory 
percussion  my  possibly  show  the  presence  of  air  free  in  the  peritonaeum. 
A  friction  may  be  present  within  twelve  hours  of  the  onset  of  the  per- 
foration. Obliteration  of  the  liver  flatness  in  the  nipple  line  may  be 
caused  by  excessive  tympany.  Eapid  obliteration  of  liver  flatness  in  a  flat, 
or  a  not  much  distended  abdomen,  is  a  valuable  sign.  Examination  of  the 
rectum  may  show  fullness  in  the  pelvis,  or  tenderness. 

In  a  majority  of  all  cases  there  is  a  rise  in  the  leucocytes,  and  when 
present  may  be  a  valuable  help,  but  it  is  not  constant. 

General  peritonitis,  without  perforation  of  the  bowel,  may  occur  by 
extension  from  an  ulcer,  or  by  rupture  of  a  softened  mesenteric  gland, 
or,  as  in  one  recent  case  in  my  series,  from  inflammation  of  the  Fallopian 
tubes.    It  was  present  in  2.2  per  cent  of  the  Munich  autopsies. 

The  spleen  is  usually  enlarged,  and  the  edge  was  felt  below  the  costal 
margin  in  71  per  cent  of  my  cases.  Percussion  is  uncertain,  as,  owing  to 
distention  of  the  stomach  and  colon,  even  the  normal  area  of  dullness  may 
not  be  obtainable.  I  have  seen  a  very  large  spleen  post  mortem,  when 
during  life  the  increase  in  size  was  not  observable. 

Liver. — Symptoms  on  the  part  of  this  organ  are  rare. 

(a)  Jaundice  was  present  in  only  3  cases  of  my  series.  Catarrh  of 
the  ducts,  toxaemia,  abscess,  and  occasionally  gall-stones  are  the  usual 
causes. 

(&)  Abscess. — Solitary  abscess  is  exceedingly  rare  and  occurred  in  but 
2  cases  in  my  series.  It  may  follow  the  intestinal  lesion  or  more  commonly 
one  of  the  complications,  as  parotitis  or  necrosis  of  bone.  Suppurative 
pylephlebitis,  which  is  more  frequent  than  abscess,  may  follow  perforation 
of  the  appendix.     Suppurative  cholangitis  has  been  described. 

(c)  Cholecystitis  is  a  comparatively  frequent  complication.  Camac  * 
has  collected  115  cases,  in  21  of  which  perforation  occurred.  Pain  in  the 
region  of  the  gall-bladder  is  the  most  constant  symptom.  Tenderness, 
muscle   spasm  with  rigidity,   and  a  gall-bladder   tumor   are   present   in 

*  Studies  in  Typhoid  Fever,  Series  III,  Johns  Hopkins  Hospital  Reports,  vol.  viii. 


TYPHOID  FEVER.  27 

a  majority  of  the  cases.  Jaundice  is  inconstant.  With  perforation  there 
may  be  a  marked  drop  in  the  fever  and  the  onset  of  signs  of  peritonitis. 
In  simple  cholecystitis  the  urgency  of  the  symptoms  may  abate,  and  re- 
covery may  follow.  Suppuration  may  occur  with  infection  of  the  bile  pas- 
sages. Months  or  years  after  (eighteen  years  in  Hunner's  case)  the  bacilli 
may  cause  cholecystitis  or  gall-stones.  Typhoid  bacilli  have  been  found  by 
Gushing  as  a  cause  of  cholecystitis  in  a  patient  who  had  never  had  typhoid 
fever. 

(d)  GaU-8tones. — Bernheim  called  attention  to  the  frequency  of  chole- 
lithiasis after  typhoid  fever.  It  is  probably  associated  with  the  presence 
of  typhoid  bacilli  in  the  gall-bladder  (see  under  Gail-Stones). 

Respiratory  System. — Epistaxis,  an  early  symptom,  precedes  typhoid 
fever  more  commonly  than  any  other  febrile  afEection.  It  is  occasionally 
profuse  and  serious. 

Laryngitis  is  not  very  common.  The  ulcers  and  the  perichondritis 
have  already  been  described.  (Edema,  apart  from  ulceration,  is  rare.  In 
this  country  the  laryngeal  complications  of  typhoid  fever  seem  much  less 
frequent  than  on  the  Continent.  I  have  twice  seen  severe  perichondritis; 
both  of  the  cases  recovered,  one  after  the  expectoration  of  large  portions 
of  the  thyroid  cartilage. 

Keen  and  Liining  have  collected  221  cases  of  serious  surgical  complica- 
tions of  the  larynx.  General  emphysema  may  follow  the  perforation  of  an 
ulcer.    Stenosis  is  a  very  serious  sequence. 

From  some  recent  studies  it  would  appear  that  paralysis  of  the  laryn- 
geal muscles  is  much  more  common  than  we  have  supposed.  Przedborski 
(Volkmann's  Sammlung,  No.  182)  has  systematically  examined  the  larynx 
in  100  consecutive  cases  and  found  25  with  paralysis.  The  condition  is 
nearly  always  due  to  neuritis,  sometimes  in  connection  with  affections  of 
other  nerves. 

Bronchitis  is  one  of  the  most  frequent  initial  symptoms.  It  is  indi- 
cated by  the  presence  of  sibilant  rales.  The  smaller  tubes  may  be  involved, 
producing  urgent  cough  and  even  slight  cyanosis.  Collapse  and  lobular 
pneumonia  may  also  occur. 

Lobar  pieumonia  is  met  with  under  two  conditions: 

1.  It  may  be  the  initial  symptom  of  the  disease.  After  an  indisposition 
of  a  day  or  so,  the  patient  is  seized  with  a  chill,  has  high  fever,  pain  in  the 
side,  and  within  forty-eight  hours  there  are  signs  of  consolidation  and  the 
evidences  of  an  ordinary  lobar  pneumonia.  The  intestinal  symptoms  may 
not  occur  until  toward  the  end  of  the  first  week  or  later;  the  pulmonary 
symptoms  persist,  crisis  does  not  occur;  the  aspect  of  the  patient  changes, 
and  by  the  end  of  the  second  week  the  clinical  picture  is  that  of  typhoid 
fever.  Spots  may  then  be  present  and  doubts  as  to  the  nature  of  the  case 
are  solved.*  In  other  instances,  in  the  absence  of  a  characteristic  eruption, 
the  case  remains  doubtful,  and  it  is  impossible  to  say  whether  the  disease 
has  been  pneumonia,  in  which  the  so-called  typhoid  symptoms  have  devel- 
oped, or  whether  it  was  typhoid  fever  with  early  implication  of  the  lungs. 
This  condition  may  depend  upon  an  early  localization  of  the  typhoid  bacil- 
lus in  the  lung.    I  have  twice  performed  autopsies  in  cases  of  this  pneumo- 


28  SPECIFIC  INFECTIOUS  DISEASES. 

typhus,  as  it  is  called  by  the  French  and  Germans,  and  can  speak  posi- 
tively of  its  onset  with  all  the  symptoms  of  a  frank  pneumonia. 

2.  Lobar  pneumonia  forms  a  serious  and  by  no  means  infrequent  com- 
plication of  the  second  or  third  week.  It  was  present  in  over  8  per  cent 
of  the  Munich  cases.  The  symptoms  are  usually  not  marked.  There  may 
be  no  rusty  sputa,  and,  unless  sought  for,  the  condition  is  frequently  over- 
looked. Infarction,  abscess,  and  gangrene  are  occasionally  pulmonary  com- 
plications. 

Hypostatic  congestion  of  the  lungs  and  oedema,  due  to  enfeebled  circu- 
lation in  the  later  periods  of  the  disease,  are  very  common.  The  physical 
signs  are  defective  resonance  at  the  bases,  feeble  breath-sounds,  and,  on 
deep  inspiration,  moist  rales. 

HcBinoptysis  may  occur.  Creagh  reports  a  case  in  which  it  caused 
death. 

Pleurisy  was  present  in  about  8  per  cent  of  the  Munich  autopsies.  It 
may  occur  at  the  outset — pleuro-typhoid — or  slowly  during  convalescence, 
in  which  case  it  is  almost  always  purulent  and  due  to  the  typhoid  bacilli. 

Pneumothorax  is  rare.  Hale  "\^Tiite  has  reported  two  cases,  in  both 
of  which  pleurisy  existed.  After  death,  no  lesions  of  the  lungs  or  bronchi 
were  discovered.  The  condition  may  be  due  to  straining,  or  to  the  rup- 
ture of  a  small  pygemic  abscess.    It  may  occur  also  during  convalescence. 

Nervous  System. — Cerebrospinal  Form. — As  already  noted,  the  disease 
may  set  in  with  intense  and  persisting  headache,  or  an  aggravated  form 
of  neuralgia.  There  are  cases  in  which  the  effect  of  the  poison  is  mani- 
fested on  the  nervous  system  early  and  with  the  greatest  intensity.  There 
are  headache,  photophobia,  retraction  of  the  neck,  marked  twitchings 
of  the  muscles,  rigidity,  and  even  convulsions.  In  such  cases  the  diag- 
nosis of  meningitis  is  invariably  made.  I  have  examined  post  mortem  three 
such  cases,  in  two  of  which  the  diagnosis  of  cerebro-spinal  fever  had  been 
made.  In  not  one  of  them  was  there  any  trace  of  meningeal  inflammation, 
only  the  most  intense  congestion  of  the  cerebral  and  spinal  pia.  Menin- 
gitis, however,  may  occur,  but  is  extremely  rare,  as  shown  by  the  Munich 
record,  in  which  there  were  only  11  among  the  2,000  cases.  With  the  evi- 
dence obtained  by  lumbar  puncture  and  the  presence  or  absence  of  Kernig's 
sign  the  diagnosis  of  meningitis  is  now  more  easily  made.  A  number  of 
genuine  cases  of  meningitis  have  been  reported  of  late  years,  and  the  litera- 
ture is  quite  fully  given  by  Hofmann  *  to  July,  1900.  In  at  least  10  cases 
the  typhoid  bacillus  has  been  isolated  in  pure  culture.  Marked  convulsive 
movements,  local  or  general,  with  coma  and  delirium,  are  seen  also  in 
thrombosis  of  the  cerebral  veins  and  sinuses. 

Delirium,  usually  present  in  very  severe  cases,  is  certainly  less  frequent 
untler  a  rigid  plan  of  hydrotherapy.  It  may  exist  from  the  outset,  but 
usually  does  not  occur  until  the  second  and  sometimes  not  •until  the 
third  week.  It  may  be  slight  and  only  nocturnal.  It  is,  as  a  rule,  a  quiet 
delirium,  though  there  are  cases  in  which  the  patient  is  very  noisy  and 
constantly  tries  to  get  out  of  bed,  and,  unless  carefully  watched,  may  es- 

*  Deutsche  medicinische  Wochenschrift,  July  12,  1900. 


Ti^PHOID  FEVER.  29 

cape.  The  patient  does  not  often  become  maniacal.  In  heavy  drinkers 
the  delirium  may  have  the  character  of  delirium  tremens.  Even  in  cases 
which  have  no  positive  delirium,  the  mental  processes  are  usually  dulled 
and  the  aspect  is  listless  and  apathetic.  In  severe  cases  the  patient  passes 
into  a  condition  of  unconsciousness.  The  eyes  may  be  open,  but  he  is  ob- 
livious to  all  surrounding  circumstances  and  neither  knows  nor  can  indi- 
cate his  wants.  The  urine  and  faeces  are  passed  involuntarily.  In  this 
pseudo-wakeful  state,  or  coma  vigil,  as  it  is  called,  the  eyes  are  open  and 
the  patient  is  constantly  muttering.  The  lips  and  tongue  are  tremulous; 
there  are  twitchings  of  the  fingers  and  wrists — subsultus  tendinum  and 
carphologia.  He  picks  at  the  bedclothes  or  grasps  at  invisible  objects. 
These  are  among  the  most  serious  symptoms  of  the  disease  and  always 
indicate  danger. 

Convulsions  in  typhoid  fever  are  rare.  In  children  they  may  occur  at 
the  onset.  In  September,  1896,  a  child  of  ten  years  was  admitted  in  coma 
following  a  sudden  convulsion  after  a  full  meal.  This  was  the  starting- 
point  of  a  severe  attack  of  typhoid.  Their  rarity  may  be  gathered  from  the 
fact  that  in  2,960  cases  Murchison  met  with  convulsions  in  6  only.  They 
may  be  associated  wi.th  an  acute  encephalitis  or  with  thrombi  in  the  arte- 
ries or  in  the  veins.  In  the  case  of  my  late  assistant.  Dr.  Oppenheimer,  the 
convulsions  occurred  on  the  eighth  day  of  the  fever,  and  proved  fatal 
in  twelve  hours.  Thrombosis  of  the  branches  of  the  left  middle  cerebral 
artery  was  found.  In  other  instances,  as  in  one  reported  by  J.  W.  Moore, 
no  brain  lesions  are  found.  In  very  nervous  women  I  have  seen  hysterical 
convulsions.    Five  cases  are  reported  in  Studies  II  and  III. 

Neuritis,  which  is  not  uncommon,  may  be  local,  or  a  widespread  affec- 
tion of  the  nerves  of  the  legs  or  of  both  arms  and  legs. 

Local  Neuritis. — This  may  occur  during  the  height  of  the  fever  or  after 
convalescence  is  established.  It  may  set  in  with  agonizing  pain,  and  with 
sensitiveness  of  the  affected  nerve  trunks.  The  local  neuritis  may  affect 
the  nerves  of  an  arm  or  of  a  leg,  and  involve  chiefly  the  extensors,  so  that 
there  is  wrist-drop  or  foot-drop.  The  arm  or  leg  may  be  much  swollen 
and  the  skin  over  it  erythematous.  Painful  muscles  are  not  uncommon, 
particularly  in  the  calves.  I  have  reported  a  series  of  cases  (Studies  III). 
Painful  cramps  may  also  occur.  In  some  of  the  cases  of  painful  legs  the 
condition  is  a  myositis;  in  others  the  swelling  and  pain  may  be  due  to 
thrombosis  in  the  deeper  veins. 

A  curious  condition,  probably  a  local  neuritis,  is  that  Avhich  was  first 
described  by  Handf ord  as  tender  toes,  and  which  appears  to  be  much  more 
common  after  the  cold-bath  treatment.  The  tips  and  pads  of  the  toes, 
rarely  the  pads  at  their  bases,  become  exquisitely  sensitive,  so  that  the 
patient  can  not  bear  the  weight  of  the  bedclothes.  There  is  no  discolora- 
tion and  no  swelling,  and  it  disappears  usually  within  a  week  or  ten  days. 

Multiple  neuritis  in  typhoid  fever  comes  on  usually  during  convales- 
cence. The  legs  may  be  affected,  or  the  four  extremities.  The  cases  are 
often  difficult  to  differentiate  from  those  with  subacute  poliomyelitis.  Re- 
covery is  the  rule.  Of  4  cases  with  involvement  of  arms  and  legs,  3  recov- 
ered completely  and  1  improved  (Studies  II).  ^ 


30  SPECIFIC  INFECTIOUS  DISEASES. 

Poliomyelitis  may  occur  "with  the  symptoms  of  acute  ascending  paral- 
ysis and  prove  fatal  in  a  few  days.  More  frequently  it  is  less  acute,  and 
causes  either  a  paraplegia  or  a  limited  atrophic  paralysis  of  one  arm  or  leg. 

Hemiplegia  is  a  rare  complication.  Francis  Hawkins  has  collected  17 
cases  from  the  literature;  aphasia  was  present  in  12.  The  lesion  is  usually 
thromhosis  of  the  arteries,  less  often  a  meningo-encephalitis.  The  aphasia 
may  disappear.    Four  cases  of  hemiplegia  are  given  in  Studies  III. 

True  tetany  occurs  sometimes,  and  has  been  reported  in  connection  with 
certain  epidemics.  It  may  set  in  during  the  full  height  of  the  disease. 
The  complication  is  extremely  rare  in  this  country,  and  Janeway,  so  far  as 
I  know,  has  alone  re^oorted  instances. 

Post-fehrile  insanity  is  perhaps  more  frequent  after  typhoid  than  after 
any  other  disease.  Wood  regards  it  as  confusional  insanity,  the  result  of 
impaired  nutrition  and  exhaustion  of  the  nervous  centres.  Of  5  cases 
reported  in  Studies  I,  4  recovered.  Mental  dulness  with  hesitancy  of 
speech  and  melancholia  may  follow.     The  outlook  is  usually  good. 

Special  Senses. — Eye. — Conjunctivitis,  simple  or  phlyctenular,  some- 
times with  keratitis  and  iritis,  may  develop.  Panophthalmitis  has  been  re- 
ported in  one  case  in  association  with  haemorrhage  (Finlay).  Loss  of  accom- 
modation may  occur,  usually  in  the  asthenia  of  convalescence.  Oculo-motor 
paralysis  has  been  seen,  due  probably  to  neuritis.  Eetinal  haemorrhages 
may  occur  alone  or  in  association  with  other  liEemorrhagic  features.  Double 
optic  neuritis  has  been  described  in  the  course  of  the  fever.  It  may  be 
independent  of  meningitis.  Atrophy  may  follow,  but  these  complications 
are  excessively  rare.  Cataract  may  follow  inflammation  of  the  uveal  tract. 
Other  rare  complications  are  thrombosis  of  the  orbital  veins  and  orbital 
haemorrhage.  (See  De  Schweinitz  in  Keen's  monograph  for  full  considera- 
tion of  the  subject.) 

Ear. — Otitis  media  is  not  infrequent,  2.5  per  cent  in  Hengst's  collected 
cases.  We  have  never  found  the  typhoid  bacillus  in  the  discharge.  Seri- 
ous results  are  rare;  only  one  case  of  mastoid  disease  occurred.  The  otitis 
may  set  in  with  a  chill  and  an  aggravation  of  the  fever. 

Renal  System. — Eetention  of  urine  is  an  early  symptom  and  may  be  the 
cause  of  abdominal  pain.  It  may  recur  throughout  the  attack.  Suppres- 
sion of  urine  is  rare.  The  urine  is  usually  diminished  at  first,  has  the 
ordinary  febrile  characters,  and  the  pigments  are  increased.  Later  in  the 
disease  it  is  more  abundant  and  lighter  in  color. 

Tlie  Diazo-reaction  of  Ehrlich. — Two  solutions  are  employed,  kept  in 
separate  bottles:  one  containing  a  saturated  solution  of  sulphanilic  acid 
in  a  solution  of  hydrochloric  acid  (50  cc.  to  1,000  cc);  the  other  a  half  per 
cent  solution  of  sodium  nitrite.  To  make  the  test,  a  few  cubic  centimetres 
of  urine  are  placed  in  a  small  test-tube  with  an  equal  quantity  of  a  mix- 
ture of  the  solution  of  the  sulphanilic  acid  (10  cc.)  and  the  sodium  nitrite 
(1  cc),  the  whole  being  thoroughly  shaken.  One  cubic  centimetre  of  am- 
monia is  then  allowed  to  flow  carefully  down  the  side  of  the  tube,  forming 
a  colorless  zone  above  the  yellow  urine,  and  at  the  junction  of  the  two  a 
deep  brownish-red  ring  will  be  seen  if  the  reaction  is  present.  With  normal 
urine  a  lighter  brownish  ring  is  produced,  without  a  shade  of  red.     The 


TYPHOID  FEVER.  31 

color  of  the  foam  of  the  mixed  urine  and  reagent,  and  the  tint  they  produce 
when  largely  diluted  with  water,  are  characteristic,  being  in  both  cases 
of  a  delicate  rose-red  if  the  diazo-reaction  be  present;  but  if  not,  brownish- 
yellow.  It  was  found  in  543  of  796  cases.  It  may  be  present  previous  to 
the  occurrence  of  the  rash,  and  as  late  as  the  twenty-second  day.  The  value 
of  the  test  is  lessened  by  its  occurrence  in  cases  of  miliary  tuberculosis,  in 
malarial  fever,  and  occasionally  in  the  acute  diseases  associated  with  high 
fever.  The  urotoxic  coejSicient  in  typhoid  fever  is  high  and  is  said  to  be 
increased  by  the  tubs. 

Baccilluria  occurs  in  about  one  third  of  the  cases,  caused  by  the  typhoid 
bacilli.  The  urine  may  be  turbid  from  their  presence  and  in  the  test- 
tube  give  a  peculiar  shimmer.  There  may  be  millions  of  bacilli  to  the  cubic 
millimetre  without  pyuria  or  any  symptoms  of  renal  or  bladder  trouble. 
The  bacilli  may  be  present  in  the  urine  for  years  after  the  attack  (see 
Gwyn,  Studies  III).  Of  51  cases  during  the  session  of  1900-1901  in  my 
clinic.  Cole  found  typhoid  bacilli  in  the  urine  in  16. 

The  renal  complications  in  typhoid  fever  may  be  thus  grouped: 

(a)  Febrile  albuminuria  is  common  and  of  no  special  significance.  It 
was  present  in  616  of  829  cases,  74  per  cent.  Tube  casts  were  present  in 
391  cases,  47  per  cent.     Hcenioglohinuria  occurred  in  one  case. 

(&)  Acute  nephritis  at  the  onset  or  during  the  height  of  the  disease 
— the  nephro-typhus  of  the  Germans,  the  fievre  typlio'ide  a  forme  renale  of 
the  French — may  set  in,  with  all  the  symptoms  of  acute  Bright's  disease, 
masking  in  many  instances  the  true  nature  of  the  malady.  After  an 
indisposition  of  a  few  days  there  may  be  fever,  pain  in  the  back,  and 
the  passage  of  a  small  amount  of  bloody  urine. 

(c)  Nephritis  during  convalescence  is  rare,  and  is  usually  associated 
with  anasmia  and  oedema.  Chronic  nephritis  is  a  most  exceptional  sequel 
of  the  disease. 

(d)  The  lymphomatous  nephritis,  described  by  E.  Wagner,  and  already 
referred  to  in  the  section  on  morbid  anatomy,  produces,  as  a  rule,  no 
symptoms. 

(e)  Pyuria,  a  not  uncommon  complication,  may  be  associated  with  the 
typhoid  or  the  colon  bacillus,  less  often  with  staphylococci.  It  disappears 
during  convalescence.  It  is  usually  due  to  a  simple  catarrh  of  the  bladder, 
rarely  to  an  intense  cystitis. 

(/)  Post-typhoid  Pyelitis. — One  or  both  kidneys  may  be  involved,  either 
at  the  height  of  the  disease  or  during  convalescence.  There  may  be  blood 
and  pus  at  first,  later  pus  alone,  varying  in  amount.  A  severe  pyelo- 
nephritis may  follow.    Perinephric  abscess  is  a  rare  sequel. 

Generative  System. — Orchitis  is  occasionally  met  with.  Kinnicutt  has 
collected  53  cases  in  the  literature.  It  is  usually  associated  with  a  catarrhal 
urethritis.  Induration  or  atrophy  may  occur,  and  more  rarely  suppura- 
tion. It  was  present  in  2  cases  in  my  series,  and  in  a  third  recent  one 
during  convalescence.  In  1  case  double  hydrocele  developed  suddenly 
on  "the  nineteenth  day  (Dunlap). 

Acute  mastitis,  which  may  go  on  to  suppuration,  is  a  rare  complication. 
It  was  present  in  2  cases  of  my  series. 


33  SPECIFIC  INFECTIOUS  DISEASES. 

Osseous  System. — Among  the  most  common  and  troublesome  of  the 
seqnelge  of  the  disease  are  the  lotie  lesions.  Of  337  cases  collected  by 
Keen  there  were  periostitis  in  110,  necrosis  in  85,  and  caries  in  13.  They 
are,  I  am  snre,  much  more  frequent  than  the  figures  indicate.  Six  cases 
came  under  my  notice  in  the  course  of  a  year,  and  formed  the  basis  of 
Parsons'  paper  (Studies  II).  The  legs  are  chiefly  inyolved.  In  Keen's 
series  the  tibia  was  afEected  in  91  cases,  the  ribs  in  40.  A  majority  of 
the  cases  occur  after  convalescence  is  established.  Of  51  cases  in  which 
bacteriological  examinations  were  made,  in  13  pyogenic  bacteria  were 
found;  in  38  there  were  typhoid  bacilli  (Keen).  The  typhoid  bone  lesion  is 
apt  to  form  what  the  old  writers  called  a  cold  abscess.  Only  a  few  of  the 
cases  are  acute.  Chronicity,  indolence,  and  a  remarkable  tendency  to 
recurrence  are  perhaps  the  three  most  striking  features  of  the  typhoid 
bone  lesions.  If  not  thoroughly  treated  sinuses  may  remain,  and  tj'phoid 
bacilli  have  been  found  in  these  old  lesions  for  as  long  as  seven  or  more 
years. 

Arthritis  was  present  in  5  cases  of  my  series.  Eheumatic  and  septic 
forms  are  described,  as  well  as  a  typhoid  arthritis  proper.  The  complica- 
tion is  exceedingly  rare,  and  yet  Keen  has  collected  from  the  literature 
84  cases.  One  of  the  most  important  points  relating  to  it  is  the  frequency 
with  which  spontaneous  dislocations  occur,  particularly  of  the  hip. 

Typlioid  Spine  (Gibney). — During  the  disease  in  protracted  cases,  more 
often  during  convalescence,  the  patient  complains  of  pain  in  the  lumbar 
and  sacral  regions,  perhaps  after  a  slight  jar  or  shock.  Stiffness  of  the 
back,  pain  on  movement,  and  tenderness  on  pressure  are  the  chief  features, 
but  there  are  in  addition  marked  nervous,  sometimes  hysterical  manifes- 
tations. The  diagnosis  of  spondylitis.  Pott's  disease,  or  perinephritic  ab- 
scess, etc.,  may  be  made.  The  examination  is  negative.  The  patient 
is  afebrile,  as  a  rule.  The  outlook  is  good.  In  rare  instances  there  may 
be  perispondylitis,  but  usually  the  condition  is  a  neurosis  (Studies  I). 

The  muscles  may  be  the  seat  of  the  degeneration  already  referred  to, 
but  it  rarely  causes  any  symptoms.  Haemorrhage  occasionally  occurs  into 
the  muscles,  and  late  in  protracted  cases  abscesses  may  develop. 

Post-typhoid  Septicaemia  and  Pyaemia. — In  very  protracted 
cases  there  may  recur  after  defervescence  a  slight  fever  (100°-101°),  with 
sweats,  which  is  possibly  septic.  In  other  cases  for  two  or  three  weeks  there 
are  recurring  chills,  often  of  great  severity.  They  are  usually  of  no  mo- 
ment in  the  absence  of  signs  of  complication.     (See  Studies  II  -and  III.) 

Typhoid  pyaemia  is  not  very  uncommon,  (a)  Extensive  furuncalosis 
may  be  associated  with  irregular  fever  and  leucocytosis.  (&)  Following 
the  fever  there  may  be  multiple  subcutaneous  "  cold  "  abscesses,  often  with 
a  dark,  thin  bloody  pus.  A  score  or  more  of  these  may  appear  in  different 
parts.  Pratt  has  isolated  the  bacillus  in  pure  culture  from  the  subcutane- 
ous abscesses,  (c)  A  crural  thrombus  may  suppurate  and  cause  a  wide- 
spread pyemia,  {d)  In  rare  instances  suppuration  of  the  mesenteric 
glands,  of  a  splenic  infarct,  a  sloughing  parotid  bubo,  a  perinephric  or  peri- 
rectal abscess,  acute  necrosis  of  the  bones,  or  a  multiple  suppurative  ar- 
thritis may  cause  pyasmia. 


TYPHOID  FEVER.  33 

Association  of  otter  Diseases. — Erysipelas  is  a  rare  complica- 
tion, most  commonly  met  with  during  convalescence.  In  1,420  cases  at 
Basel  it  occurred  10  times.  Griesinger  states  that  it  is  met  with  in  2 
per  cent.  Measles  may  develop  during  the  fever  or  in  convalescence. 
Chicken-pox  and  noma  have  been  reported  in  children.  Pseudo-membra- 
nous inflammations  may  occur  in  the  pharynx,  larynx,  or  genitals. 

Malarial  and  typhoid  fevers  may  be  associated,  but  a  majority  of  the 
cases  of  so-called  typho-malarial  fever  are  either  remittent  malarial  fever 
or  true  typhoid.  It  is  interesting  to  note  that  among  the  829  cases  of 
typhoid  fever  plasmodia  were  found  in  the  blood  during  the  course  of  the 
disease  in  only  1  case.  (See  Lyon,  Studies  III.)  Many  of  our  typhoid-fever 
cases  came  from  malarious  regions. 

Typhoid  Fever  and  Tuberculosis. — (a)  The  diseases  may  coexist.  In  -4 
of  my  80  autopsies  there  were  tuberculous  lesions,  (h)  Miliary  tuberculosis 
is  often  mistaken  for  typhoid  fever;  they  may  indeed  coexist,  (c)  Cases 
of  pulmonary  tuberculosis  may  begin  with  a  low  fever,  and  features  sug- 
gestive of  enteric.  Cases  of  this  kind  have  led  to  the  belief  that  tubercu- 
losis" often"  follows  typhoid  fever,  (d)  There  are  cases  of  typhoid  fever 
with  pulmonary  or  pleuritic  symptoms  which  suggest  at  the  outset  tuber- 
culosis. 

In  epilepsy  and  in  chronic  chorea  the  fits  and  movements  usually  cease 
during  an  attack,  and  in  typhoid  fever  in  a  diabetic  subject  the  sugar  may 
be  absent  during  the  height  of  the  disease. 

Varieties  of  Typhoid. — Typhoid  fever  presents  an  extremely  com- 
plex symptomatology.  Many  forms  have  been  described,  some  of  which 
present  exaggeration  of  common  symptoms,  others  modification  in  the 
course,  others  again  greater  intensity  of  action  of  the  poison  on  certain 
organs.  A^.we  have  seen,  when  the  nervous  system  is  specially  involved, 
it  has  been  called  the  cerebro-spinal  form;  when  the  kidneys  are  early  and 
severely  affected,  nephro-typhoid;  when  the  disease  begins  with  pulmo- 
nary symptoms,  pneumo-typhoid;  with  pleurisy,  pleuro-typhoid;  when  the 
disease  is  characterized  throughout  by  profuse  sweats,  the  sudoral  form 
of  the  disease.  It  is  a  mistake,  I  think,  to  recognize  or  speak  of  these  as 
.varieties.  It  is  enough  to  remember  that  typhoid  has  no  fixed  and  con- 
stant course,  that  it  may  set  in  occasionally  with  symptoms  localized  in 
certain  organs,  and  that  many  of  its  symptoms  are  extremely  variable — in 
one  epidemic  uniform  and  text-book-like,  in  another  slight  or  not  met  with. 
This  diversified  symptomatology  has  led  to  many  clinical  errors,  and  in  the 
absence  of  the  salutary  lessons  of  morbid  anatomy  it  is  not  surprising  that 
practitioners  have  so  often  been  led  astray.  We  may  recognize  with  Mur- 
chison  the  following  varieties: 

1.  The  mild  and  abortive  forms.  It  is  very  important  for  the  practi- 
tioner to  recognize  the  mild  type  of  typhoid  fever,  often  spoken  of  as 
gastric  fever  or  even  regarded  as  simple  febricula.  In  this  form,  the 
typhus  levissimus  of  Griesinger,  the  symptoms  are  similar  in  kind  but  alto- 
gether less  intense  than  in  the  graver  attacks,  although  the  onset  may 
be  sudden  and  severe.  The  temperature  rarely  reaches  103°,  and  the 
fever  of  onset  may  not  show  the  gradual  ascending  evening  record.     The 


34  SPECIFIC  INFECTIOUS  DISEASES. 

spleen  is  enlarged,  the  rose-spots  may  be  marked;  often  they  are  very 
few  in  number.  The  diarrhoea  is  variable,  often  it  is  not  present.  In  such 
cases  the  symptoms  may  persist  for  from  ten  to  fourteen  days. 

In  the  abortive  form  the  symptoms  of  onset  may  be  marked  with  shiv- 
ering and  fever  of  103°  or  even  higher.  The  date  of  onset  is  often  defi- 
nite, a  point  upon  which  Jiirgensen  lays  great  stress.  Eose-spots  may 
occur  from  the  second  to  the  fifth  day.  Early  in  the  second  week  or  at 
the  end  of  the  first  week  the  fever  falls,  often  with  profuse  sweating,  and 
convalescence  is  established.  In  this  abortive  form  relapse  may  occur  and 
may  occasionally  prove  severe.  When  typhoid  fever  prevails  extensively 
these  cases  are  not  uncommon.  I  agree  with  J.  C.  Wilson,  who  states  that 
they  are  not  nearly  so  common  in  this  country  as  in  Europe. 

2.  The  grave  form  is  usually  characterized  by  high  fever  and  pro- 
nounced nervous  symptoms.  In  this  category,  too,  come  the  very  severe 
cases,  setting  in  with  pneumonia  and  Bright's  disease,  and  with  the  very 
intense  gastro-intestinal  or  cerebro-spinal  symptoms. 

3.  The  latent  or  ambulatory  form  of  typhoid  fever,  which  is  particu- 
larly common  in  hospital  practice.  The  symptoms  are  usually  slight, 
and  the  patient  scarcely  feels  ill  enough  to  go  to  bed.  He  has  languor, 
perhaps  slight  diarrhoea,  but  keeps  about  and  may  even  attend  to  his  work 
throughout  the  entire  attack.  In  other  instances  delirium  sets  in.  The 
worst  cases  of  this  form  are  seen  in  sailors,  who  keep  up  and  about,  though 
feeling  ill  and  feverish.  When  brought  to  the  hospital  they  often  have 
symptoms  of  a  most  severe  type  of  the  disease.  Hasmorrhage  or  perfora- 
tion may  be  the  first  marked  symptom  of  this  ambulatory  type.  Sir  W. 
Jenner  has  called  attention  to  the  dangers  of  this  form^  and  particularly 
to  the  grave  prognosis  in  the  case  of  persons  who  have  travelled  far  with 
the  disease  in  progress. 

HwmorrJiagic  Typhoid  Fever. — This  is  excessively  rare.  Among  Ous- 
kow's  6,513  cases  there  were  4  fatal  cases  with  general  hemorrhagic  fea- 
tures. Only  one  instance  was  present  in  our  829  cases.  Haemorrhages 
may  be  marked  from  the  outset,  but  more  commonly  they  come  on  during 
the  course  of  the  disease.  The  condition  is  not  necessarily  fatal.  Our 
case  recovered,  as  did  several  of  those  reported  by  IsTicholls  from  the  Eoyal 
Victoria  Hospital,  Montreal.     (See  Hamburger,  Studies  III.) 

An  afebrile  typhoid  fever  is  recognized  by  authors.  Liebermeister  says 
that  the  cases  were  not  uncommon  at  Basel.  The  patients  presented  las- 
situde, depression,  headache,  furred  tongue,  loss  of  appetite,  slow  pulse, 
and  even  the  spots  and  enlarged  spleen.  I  have  seen  the  temperature 
normal  on  the  sixteenth  day,  while  the  spots  did  not  come  out  until  later. 

Typhoid  Fever  in  ChUdren. — Cases  are  not  uncommon  under  the  age 
of  ten,  but  the  disease  is  rare  in  infants  under  two  years  of  age.  Cases 
have  been  reported,  however,  in  sucklings  (nine  months,  Fuller;  four  and 
a  half  months,  Ogle),  and  perforation  has  been  met  with  in  an  infant  five 
days  old.  Epistaxis  rarely  occurs;  the  rise  in  temperature  is  less  gradual; 
the  initial  bronchial  catarrh  is  often  observed.  The  nervous  symptoms  may 
be  prominent;  there  are  wakefulness  and  delirium;  diarrhoea  is  often  ab- 
sent.   The  rash  may  be  very  slight,  but  the  most  copious  eruption  I  have 


TYPHOID   FEVER.  35 

ever  seen  was  in  a  child  of  eight.  The  abdominal  symptoms  are  often 
mild.  Fatal  haemorrhage  and  perforation  are  rare.  Among  the  sequelae, 
aphasia,  noma,  and  bone  lesions  may  be  mentioned  as  more  common  in 
children  than  in  adults.  The  mortality  of  typhoid  fever  in  children  is 
low.  In  cases  fatal  early  in  the  disease  only  a  careful  bacteriological 
examination  can  decide  whether  the  swollen  Peyer's  patches  and  mesen- 
teric glands — not  uncommon  in  children  with  fever — depend  upon  infec- 
tion with  typhoid  bacilli. 

Typhoid  Fever  in  the  Aged. — After  the  fortieth  year  the  disease  runs  a 
less  favorable  course,  and  the  mortality  is  very  high.  Of  63  fatal  cases, 
7  were  over  forty  years  of  age;  1  was  aged  sixty-three,  another  seventy. 
The  fever  is  not  so  high,  but  complications  are  more  common,  particu- 
larly pneumonia  and  heart-failure. 

Typhoid  Fever  in  Pregnancy. — Pregnancy  affords  no  immunity  against 
typhoid.  In  1,079  of  our  cases  to  Jan.  1,  1901,  289  of  which  were  females, 
there  were  4  cases.  Goltdammer  noted  26  pregnancies  in  600  cases  of 
typhoid  fever  in  the  female.  It  is  more  commonly  seen  in  the  first  half 
of  pregnancy.  The  pregnancy  is  interrupted  in  about  65  per  cent  of  the 
cases,  usually  in  the  second  week  of  the  disease.  Of  310  cases,  abortion 
or  premature  delivery  occurred  in  199.  In  233  of  these  cases  the  ma- 
ternal mortality  was  37,  or  16  per  cent.  Pregnancy  has  not  been  found 
to  be  a  contra-indication  to  the  cold  bath.  Dobbin  (Studies  III)  reports 
a  remarkable  case  of  puerperal  infection  with  bacillus  typhosus,  and  a 
similar  case  has  been  recorded  by  Blumer. 

Typhoid  Fever  in  the  Foetus. — From  the  recent  studies  of  Fordyce, 
J.  I.  Morse,  and  F,  W.  Lynch,  we  may  conclude  that  the  typhoid  bacillus 
may  pass  through  the  placenta  to  the  child,  causing  a  typhoid  septicsemia, 
without  intestinal  lesions.  Lynch  has  recently  collected  16  such  cases. 
Infection  of  the  foetus  does  not  necessarily  follow,  but  when  infected  the 
child  dies,  either  in  utero  or  shortly  after  birth.  The  Widal  reaction  has 
been  obtained  with  foetal  blood.  Its  presence  does  not  indicate  that  the 
child  has  survived  infection  in  utero,  as  the  agglutinating  substances  may 
filter  through  the  placenta.  They  may  also  be  transmitted  to  the  nursling 
through  the  milk,  and  cause  a  transient  reaction.  The  reaction  could  not 
be  obtained  with  foetal  blood  from  which  typhoid  bacilli  were  cultivated 
(Lynch). 

Relapse. — Eelapses  vary  in  frequency  in  different  epidemics,  and,  it 
would  appear,  in  different  places.  The  percentages  of  different  authors 
range  from  3  per  cent  (Murchison),  11  per  cent  (Baumler),  to  15  or  18 
per  cent  (Immermann).  In  Wagner's  clinic,  from  1882  to  1886,  there  were 
49  relapses  in  561  cases.  In  829  cases  there  were  86  relapses,  10.3  per 
cent. 

We  may  recognize  the  ordinary,  the  intercurrent,  and  the  spurious  re- 
lapse. 

The  ordinary  relapse  sets  in  after  complete  defervescence.  The  average 
duration  of  the  interval  in  Irving's  cases  was  a  little  over  five  days. 

In  one  of  my  cases  there  was  complete  apyrexia  for  twenty-three  days, 
followed  by  a  relapse  of  forty-one  days'  duration;  then  apyrexia  for  forty- 


36  SPECIFIC  INFECTIOUS  DISEASES. 

two  days,  followed  by  a  second  relapse  of  two  weeks'  duration.  As  a  rule, 
two  of  the  three  important  symptoms — step-like  temperature  at  onset,  rose- 
ola, an  enlarged  spleen — should  be  present  to  Justify  the  diagnosis  of  a  re- 
lapse. The  intestinal  symptoms  are  variable.  The  onset  may  be  abrupt  with 
a  chill,  or  the  temperature  may  have  a  typical  ascent,  as  shown  in 
Chart  I.  The  number  of  relapses  range  from  1  to  5.  Da  Costa  twice  saw  5 
relapses.  The  attack  is  usually  less  severe  and  of  shorter  duration.  Of 
Murchison's  53  cases,  the  mean  duration  of  the  first  attack  was  about 
twenty-six  days;  of  the  relapse,  fifteen  days.  The  mortality  of  relapse 
eases  is  not  high. 

The  intercurrent  relapse  is  common,  often  most  severe,  and  is  respon- 
sible for  a  great  many  of  the  most  protracted  cases.  The  temperature 
drops  and  the  patient  improves;  but  after  remaining  between  100°  and 
102°  for  a  few  days,  the  fever  again  rises  and  the  patient  enters  upon 
another  attack,  which  may  be  even  more  protracted,  and  of  much  greater 
intensity  than  the  original  one. 

Spurious  relapses  are  very  common.  They  have  already  been  referred 
to  on  page  16,  under  post-typhoid  elevations  of  temperature.  They  are 
recrudescences  of  the  fever  due  to  a  number  of  causes.  It  is  not  always 
easy  to  determine  whether  a  relapse  is  present,  particularly  in  cases  in 
which  the  fever  persists  for  only  five  or  seven  days  without  rose-spots  and 
without  enlargement  of  the  spleen. 

Undoubtedly  a  reinfection  from  within,  yet  of  the  conditions  favoring 
the  occurrence  of  relapse  we  as  yet  know  little.  Durham  has  advanced  an 
interesting  theory:  Every  typhoid  infection  is  a  complex  phenomenon 
caused  by  groups  of  bacilli  alike  in  species  but  not  identical,  as  shown  by 
their  serum  reactions.  The  antitoxin  formed  in  the  blood  during  the 
jDrimary  attack  neutralizes  only  one  (or  several)  groups,  the  remaining 
groups  still  preserving  their  pathogenic  power.  Following  an  error  in  diet, 
or  some  indiscretion,  these  latter  groups  may  multiply  sufficiently  to  cause  a 
reinfection.  Multiple  relapses  may  be  similarly  explained.  Bacteriological 
proof  of  this  interesting  theory  has  not  yet  been  given. 

Diagnosis. — There  are  several  points  to  note.  In  the  first  place,  ty- 
phoid fever  is  the  most  common  of  all  continued  fevers.  Secondly,  it  is 
extraordinarily  variable  in  its  manifestations.  Thirdly,  there  is  no  such 
hybrid  malady  as  typho-malarial  fever.  Fourthly,  errors  in  diagnosis  are 
inevitable,  even  under  the  most  favorable  conditions.  Lastly,  let  the 
"  cock-sure  "  physician,  who  never  makes  mistakes,  read  the  Eeport  of  the 
Commission  on  Typhoid  Fever  during  the  Spanish- American  War. 

Data  foe  Diagxosis. — (a)  General. — ISTo  single  symptom  or  feature  is 
characteristic.  The  onset  is  often  suggestive,  particularly  the  occurrence 
of  epistaxis,  and  (if  seen  from  the  start)  the  ascending  fever.  The  steadi- 
ness of  the  fever  for  a  week  or  longer  after  reaching  the  fastigium  is  an 
important  point.  The  irregular  remittent  character  in  the  third  week, 
and  the  intermittent  features  with  chills,  are  conunon  sources  of  error. 
While  there  is  nothing  characteristic  in  the  pulse,  dicrotism  is  so  miich 
more  common  early  in  typhoid  fever  that  its  presence  is  always  suggestive. 
The  rash  is  the  most  valuable  single  sign,  and  with  the  fever  usually 


TYPHOID  FEVER.  37 

clinches  the  diagnosis.  The  enlarged  spleen  is  of  less  importance,  since 
it  occurs  in  all  febrile'  conditions,  but  with  the  fever  and  the  rash  it  com- 
pletes a  diagnostic  triad  of  the  disease.  The  absence  of  leucocytosis  and 
the  presence  of  Ehrlich's  reaction  are  valuable  accessory  signs. 

(6)  Specific. — (1)  Isolation  of  Typhoid  Bacilli  from  the  Blood. — New 
methods  have  given  better  results  in  this  procedure.  Cole  has  recently 
isolated  the  organisms  in  12  cases  in  my  wards,  in  6  before  the  Widal 
was  positive.  The  method  is  exceedingly  valuable  in  the  acute  septic  forms. 
The  hypodermic  puncture  of  a  vein  for  the  blood  causes  little  or  no  pain. 

(2)  Isolation  of  Typhoid  Bacilli  from  the  Stools. — Cultures  from  the 
stools  by  the  methods  of  Eisner,  His,  and  especially  Piorkowski,  have,  in 
the  hands  of  some  observers,  proved  of  diagnostic  value.  The  difficulties, 
however,  are  considerable  and  results  not  certain. 

(3)  Isolation  of  Typhoid  Bacilli  from  the  Urine. — Neumann,  Horton- 
Sraith,  Eichardson,  and  Gwyn  have  shown  the  great  frequency  of  typhoid 
bacilli  in  the  urine.  In  some  cases  they  may  be  obtained  before  the  Widal 
test  is  positive.  Eoutine  cultures  do  not  offer  great  difficulties,  and  may 
frequently  be  of  diagnostic  value. 

("i)  Isolation  of  Typhoid  Bacilli  from  the  Rose-spots. — Neufeld,  Cursch- 
mann,  and  Richardson  have  demonstrated  the  presence  of  the  bacilli  in 
rose-spots  in  32  of  40  cases  examined.  As  the  procedure  causes  consider- 
able discomfort  it  can  not  be  used  as  a  routine  method. 

(5)  The  Agglutination  Test. — In  1894  Pfeiffer  showed  that  cholera 
spirilla,  when  introduced  into  the  peritonaeum  of  an  immunized  animal, 
or  when  mixed  with  the  serum  of  immunized  animals,  lose  their  motion 
and  break  up.  This  "  Pf eiffer's  phenomenon  "  of  agglutination  and  im- 
mobilization was  thoroughly  studied  by  Durham  and  also  by  A.  S.  Griin- 
baum,  and  the  specificity  of  the  reaction  demonstrated.  Widal  took  the 
method,  and  made  it  available  in  clinical  work. 

Methods. — (a)  Macroscopic  or  Slow  Method. — The  diilficulties  are  not 
compensated  for  by  its  supposed  greater  reliability,  and  it  is  not  in  gen- 
eral use  in  this  country  or  in  England. 

(6)  Microscopic  or  Rapid  Method. — The  serum  is  mixed  with  a  young 
bouillon  culture  of  the  typhoid  bacillus,  or  with  a  suspension  of  a  young 
agar  culture,  in  such  a  manner  as  to  dilute  the  serum  to  the  required 
degree.  A  hanging-drop  preparation  of  the  mixture  is  made,  and  if  the 
reaction  is  positive  the  bacilli  will  within  a  given  time  lose  their  motility 
and  collect  in  clumps.  Wyatt  Johnston  introduced  the  use  of  dried  blood. 
It  is  convenient,  but  does  not  permit  accurate  dilutions.  The  use  of  glass 
bulbs  to  obtain  the  serum,  and  small  glass  pipettes  to  make  accurate  dilu- 
tions, is  of  value.  As  Cabot  says,  "  the  test  is  a  quantitative,  not  a  quali- 
tative, one."  Both  the  degree  of  dilution  and  the  time  limit  are  of  im- 
portance. A  safe  standard,  and  the  one  in  use  at  the  Johns  Hopkins  Hos- 
pital, is  a  dilution  of  1-50  and  a  time  limit  of  one  hour. 

Results. — Cabot's  collection  of  5,978  eases  gives  a  positive  reaction  in 

97.2  per  cent.    A  positive  reaction  was  obtained  in  93  per  cent  of  849  cases 

tested  before  the  eighth  day.     It  may  not  appear  until  the  relapse.     In 

4  of  my  cases  it  developed  on  the  twenty-second,  twenty-sixth,  thirty-fifth, 

3 


38  SPECIFIC  INFECTIOUS  DISEASES. 

and  forty-second  days,  respectively.  It  may  be  present  even  twenty  or 
thirty  years  subsequent  to  the  attack  of  fever. 

T\niile  on  the  whole  the  serum  reaction  is  of  very  great  value,  there 
are  certain  difficulties  and  objections  which  must  be  considered.  A  per- 
fectly characteristic  case  with  haemorrhages,  rose-spots,  etc.,  may  give 
no  reaction  throughout.  In  other  cases  the  reaction  is  much  delayed, 
becoming  positive  only  during  convalescence,  or  even  during  a  relapse.* 

CoMirox  SorECES  of  Eeeoe  in  Diagxosis. — An  early  and  intense 
localization  of  the  infection  in  certain  organs  may  give  rise  to  doubt 
at  first. 

Cases  coming  on  with  severe  headache,  photophobia,  delirium,  twitching 
of  the  muscles  and  retraction  of  the  head  are  almost  invariably  regarded  as 
cerebrospinal  meningitis.  Under  such  circumstances  it  may  for  a  few 
days  be  impossible  to  make  a  satisfactory  diagnosis.  I  have  thrice  per- 
formed autopsies  on  cases  of  this  kind  in  which  no  suspicion  of  typhoid 
fever  had  been  present,  the  intense  cerebro-spinal  manifestations  having 
dominated  the  scene.  Until  the  appearance  of  abdominal  symptoms,  or 
the  rash,  it  may  be  quite  impossible  to  determine  the  nature  of  the  case. 
Cerebro-spinal  meningitis  is,  however,  a  rare  disease;  typhoid  fever  a  very 
common  one,  and  the  onset  with  severe  nervous  s}Tnptoms  is  by  no  means 
infrequent.  Fully  one  half  of  the  cases  of  so-called  braia-fever  belong  to 
this  category.    The  lumbar  puncture  is  now  a  great  help. 

I  have  already  spoken  of  the  misleading  pulmonary  symptoms,  which 
occasionally  develop  at  the  very  outset  of  the  disease.  The  bronchitis 
rarely  causes  error,  though  it  may  be  intense  and  attract  the  chief  atten- 
tion. More  difficult  are  the  cases  setting  in  with  chill  and  followed  rapidly 
by  pneumonia.  I  have  brought  such  a  case  before  the  class  one  week  as 
typical  pneumonia,  and  a  fortnight  later  shown  the  same  case  as  undoubt- 
edly one  of  typhoid  fever.  In  another  case,  in  which  the  onset  was  with 
definite  pneumonia,  no  spots  developed,  and,  though  there  were  diarrhoea, 
meteorism,  and  the  most  pronounced  nervous  symptoms,  the  doubt  still 
remains  whether  it  was  a  case  of  typhoid  fever  or  one  of  pneumonia  in 
which  severe  secondary  symptoms  developed.  There  is  less  danger  of 
mistaking  the  pneumonia  which  develops  at  the  height  of  the  disease,  and 
yet  this  is  possible,  as  in  a  case  admitted  a  few  years  ago  to  my  wards — 
a  man  aged  seventy,  insensible,  with  a  dry  tongue,  tremor,  ecch3Tnoses 
upon  the  wrists  and  ankles,  no  rose-spots,  enlargement  of  the  spleen,  and 
consolidation  of  his  right  lower  lobe.  It  was  very  natural,  particularly 
since  there  was  no  history,  to  regard  such  a  case  as  senile  pneumonia  with 
profound  constitutional  disturbance,  but  the  autopsy  showed  the  char- 
acteristic lesions  of  typhoid  fever.  Early  involvement  of  the  pleura  or  the 
kidneys  may  for  a  time  obscure  the  diagnosis. 

Of  diseases  with  which  typhoid  fever  may  be  confounded,  malaria,  cer- 
tain forms  of  pyemia,  acute  tuberculosis,  and  tuberculous  peritonitis  are 
the  most  important. 

*  There  seems  to  be  a  rainiinum  of  risk  in  workinjr  with  typhoirl  cultures  and  in  work- 
ing at  the  Widal  reaction.  I  know  of  no  case  in  which  the  disease  has  been  contracted 
directly  from  this  source. 


TYPHOID   FEVER.  39 

From  malarial  fever,  typhoid  is,  as  a  rule,  readily  recognized.  There 
is  no  such  disease  as  typho-malarial  fever — that  is,  a  separate  and  distinct 
malady.  Typhoid  fever  and  malarial  fever  may  coexist  in  the  same  patient. 
Of  829  cases  of  typhoid  fever,  in  only  a  single  instance  were  the  malarial 
parasites  found  in  the  blood  during  the  fever.  In  patients  returning  from 
Cuba  and  Porto  Eico  during  the  late  war  the  two  conditions  were  often 
found  together,  but  in  this  country  it  is  excessively  rare.  The  term  typho- 
malarial  fever  should  be  abandoned,  and  doctors  should  stop  the  falsifi- 
cation of  vital  statistics  by  death  certificates  signed  with  this  diagnosis. 
The  principle  is  bad  and  the  practice  is  worse,  since  it  gives  a  false  sense 
of  security,  and  may  prevent  proper  measures  of  prophylaxis.  The  au- 
tumnal type  of  malarial  fever  may  present  a  striking  similarity  in  its  early 
days  to  typhoid  fever.  DifEerentiation  may  be  made  only  by  the  blood 
examination.  There  may  be  no  chills,  the  remissions  may  be  extremely 
slight,  there  is  a  history  perhaps  of  malaise,  weakness,  diarrhoea,  and  some- 
times vomiting.  The  tongue  is  furred  and  white,  the  cheeks  flushed, 
the  spleen  slightly  enlarged,  and  the  temperature  continuous,  or  with  very 
slight  remissions.  The  sestivo-autumnal  variety  of  the  malarial  parasite 
may  not  be  present  in  the  circulating  blood  for  several  days.  Every  year 
we  have  one  or  two  cases  in  which  the  diagnosis  is  in  doubt  for  a  few 
days. 

Pycsmia. — The  long-continued  fever  of  obscure,  deep-seated  suppura- 
tion, without  chills  or  sweats,  may  simulate  t3'phoid.  The  more  chronic 
cases  of  ulcerative  endocarditis  are  usually  diagnosed  enteric  fever.  The 
presence  or  absence  of  leucocytosis  is  an  important  aid.  The  Widal  reac- 
tion and  the  blood  cultures  now  offer  additional  and  valuable  help. 

Acute  miliary  tuberculosis  is  not  infrequently  mistaken  for  typhoid 
fever.  The  points  in  differential  diagnosis  will  be  discussed  under  that 
disease.  Tuberculous  peritonitis  in  certain  of  its  forms  may  closely  simu- 
late typhoid  fever,  and  will  be  referred  to  in  another  section. 

The  early  abdominal  pain,  etc.,  may  lead  to  the  diagnosis  of  appendi- 
citis.    (See  Appendicitis.) 

Prognosis. — (a)  Death-rate. — The  mortality  is  very  variable,  ranging 
in  private  practice  from  5  to  12  and  in  hospital  practice  from  7  to  20  per 
cent.  In  some  large  epidemics  the  death-rate  has  been  very  low.  In  the 
recent  outbreak  at  Maidstone,  England,  it  was  between  7  and  8  per  cent. 
In  recent  years  the  deaths  from  typhoid  fever  have  certainly  diminished, 
and,  under  the  influence  of  Brand,  the  reintroduction  of  hydrotherapy 
has  reduced  the  mortality  in  institutions  in  a  remarkable  manner,  even 
as  low  as  5  or  6  per  cent.  Of  the  829  cases  treated  to  May  15,  1899,  in 
my  wards,  7.5  per  cent  died.  The  Metropolitan  Fever  Hospitals  still 
show  a  high  rate  of  mortality — about  17  per  cent — and  Dreschfeld  gives 
17.18  per  cent  as  the  doath-ratc  in  the  Monsall  Fever  Hospital  for  the  ten 
years  ending  1894.  The  mortality  in  the  Spanish-American  War  was  very 
low — 7  per  cent — and  may  be  attributed  to  the  picked  set  of  men  and  to  the 
care  and  attention  which  the  patients  received.  In  South  Africa  the 
mortality  was  20.9  per  cent  to  March  31,  1901. 

(b)  Special  Features  in  Prognosis. — Unfavorable  symptoms  are  high 


40  SPECIFIC  INFECTIOUS  DISEASES. 

fever,  toxic  symptom's  with  delirium,  meteorism,  and  haemorrhage.  Fat 
subjects  stand  typhoid  fever  badly.  The  mortality  in  women  is  greater 
than  in  men.  The  complications  and  dangers  are  more  serious  in  the  am- 
bulatory form  in  which  the  patient  has  kept  about  for  a  week  or  ten  days. 
Early  involvement  of  the  nervous  system  is  a  bad  indication;  and  the  low, 
muttering  delirium  with  tremor  means  a  close  fight  for  life.  Prognostic 
signs  from  the  fever  alone  are  deceptive.  A  temperature  above  104°  may 
be  well  borne  for  many  days  if  the  nervous  system  is  not  involved. 

(c)  Sudden  Death. — It  is  difficult  in  many  cases  to  explain  this  most 
lamentable  of  accidents  in  the  disease.  There  are  cases  in  which  neither 
cerebral,  renal,  nor  cardiac  changes  have  been  found;  there  are  instances 
too  in  which  it  does  not  seem  likely  that  there  could  have  been  a  special 
localization  of  the  toxins  in  the  pneumogastric  centres.  McPhedran,  in 
reporting  a  case  of  the  kind,  in  which  the  post  mortem  showed  no  ade- 
quate cause  of  death,  suggests  that  the  experiments  of  McWilliam  on  sud- 
den cardiac  failure  probably  explain  the  occurrence  of  death  in  certain  of 
the  cases  in  which  neither  embolism  nor  uraemia  is  present.  Under  condi- 
tions of  abnormal  nutrition  there  is  sometimes  induced  a  state  of  delirium 
cordis,  which  may  develop  spontaneously,  or,  in  the  case  of  animals,  on 
slight  irritation  of  the  heart,  with  the  result  of  extreme  irregularity  and 
finally  failure  of  action.  Sudden  death  occurs  more  frequently  in  men 
than  in  women,  according  to  Dewevre's  statistics,  in  a  proportion  of  114  to 
26.  It  may  occur  at  the  height  of  the  fever,  and,  as  pointed  out  by  Graves, 
may  also  happen  during  convalescence. 

Prophylaxis. — In  cities  the  prevalence  of  typhoid  fever  is  directly 
proportionate  to  the  inefficiency  of  the  drainage  and  the  water-supply. 
With  the  improvement  in  drainage  the  mortality  in  many  cities  has  been 
reduced  one  half  or  even  more.  Childs  has  recently  reviewed  the  sanitary 
history  of  Munich  as  far  as  typhoid  fever  is  concerned.  The  annual  mean 
death-rate  per  100,000  inhabitants  was  from  1851  to  1860,  202.4;  from 
1861  to  1870,  147.8;  from  1871  to  1880,  116.7;  from  1881  to  1890,  16;  from 
1891  to  1896,  5.6. 

By  most  rigid  methods  of  disinfection  much  may  be  done  to  prevent 
the  spread  of  infection.  The  recent  work  on  the  frequency  of  typhoid 
bacilli  in  the  excretions,  especially  in  the  urine,  shows  that  every  case  is 
a  source  of  real  and  very  serious  danger  to  the  community.  To  carry  out 
effective  measures  of  prophylaxis  is  quite  as  much  a  part  of  the  physician's 
duty  as  the  care  of  the  patient.  He  should  recognize  that  every  one  in  the 
household  has  probably  been  exposed  to  the  same  source  of  infection  as  the 
patient,  and  he  should  try  to  discover  the  source  and  advise  means  of 
guarding  against  it.  The  following  regulations  are  observed  by  the  nurses 
in  the  Johns  Hopkins  Hospital: 

Dishes  must  be  isolated,  washed  and  dried  separately,  and  boiled  daily. 
Thermometers  must  be  isolated,  kept  in  bichloride  (1-1,000),  which  must  be 
renewed  daily.  Linen,  when  soiled,  must  be  soaked  in  carbolic  (1-20)  for 
two  hours  before  sending  to  the  laundry.  Stools  must  be  thoroughly  mixed 
with  an  equal  amount  of  milk  of  lime,  and  allowed  to  stand  one  hour. 
Urine  must  be  mixed  with  an  equal  amount  of  carbolic  (1-20),  and  allowed 


TYPHOID  FEVER.  41 

to  stand  one  hour.  Bed-pans  and  urinals  must  be  isolated  and  scalded 
after  each  time  of  using.  ^  Syringes  and  rectal  tubes  must  be  isolated  and 
the  latter  boiled  after  using.  Tubs  should  be  scrubbed  daily;  canvases 
changed  daily,  and  soaked  in  carbolic  as  the  linen  is.  Hands  must  be 
scrubbed  and  disinfected  after  giving  tubs  or  working  over  typhoid-fever 
patients.  Blankets,  mattresses,  and  pillows  must  be  sterilized  after  use  in 
steam  sterilizer. 

Preventive  Inoculation. — Following  the  work  of  Haffkine  in  vaccina- 
tion against  cholera,  Wright,  of  Netley,  has  introduced  a  similar  method 
of  vaccination  against  typhoid.  The  material  used  is  a  bouillon  culture 
of  bacillus  typhosus  of  high  virulence,  heated  until  all  organisms  are  dead. 
The  amount-inoculated  should  "  be  such  a  quantity  which,  if  injected  alive, 
would  be  fatal  to  a  350  gm.  guinea-pig."  The  inoculation  is  followed  by 
local  tenderness  and  congestion,  faintness,  possibly  nausea,  fever,  and  rest- 
lessness. Usually  all  symptoms  have  disappeared  after  twenty-four  hours. 
It  is  recommended  that  the  procedure  be  repeated  in  two  weeks.  Follow- 
ing the  injection  there  is  an  increase  in  the  bactericidal  power  of  the 
blood,  and  also  a  very  marked  increase  in  the  agglutinating  power,  which 
may  persist  for  at  least  two  years,  as  in  cases  reported  by  Foulerton.  This 
procedure  has  been  tried  on  a  large  scale  in  India,  and  also  in  the  South 
African  War.  Full  statistics  from  South  Africa  are  not  yet  available,  but 
out  of  1,705  persons  inoculated  at  Ladysmith,  only  2  per  cent  were  attacked^ 
whereas  of  10,529  not  inoculated,  14  per  cent  were  attacked,  and  of  those 
inoculated  the  mortality  was  0.46  per  cent;  of  those  not  inoculated  the  mor- 
tality was  3  per  cent.  On  the  whole  the  experience  so  far  is  strongly  in 
favor  of  inoculation. 

When  epidemics  are  prevalent  the  drinking-water  and  the  milk  used  in 
families  should  be  boiled.  Travellers  should  drink  light  wines  or  mineral 
water  rather  than  ordinary  water  or  milk.  Cp-e  should  be  taken  to  thor- 
oughly cook  oysters  which  have  been  fattened  or  freshened  in  streams  con- 
taminated with  sewage. 

While  in  camps  it  is  easy  to  boil  and  filter  the  water;  with  troops  on 
the  march  it  is  a  very  different  matter,  and  it  is  impossible  to  restrain 
men  from  relieving  their  thirst  the  moment  they  reach  water.  Various 
chemical  methods  have  been  recommended — the  use  of  bromine,  hypo- 
chlorite of  lime,  permanganate  of  potassium,  and  the  tablets  of  sodium 
bisulphate,  none  of  which  are  probably  very  satisfactory. 

Treatment.— (a)  General  Management. — The  profession  was  long  in 
learning  that  typhoid  fever  is  not  a  disease  to  be  treated  mainly  with 
drugs.  Careful  nursing  and  a  regulated  diet  are  the  essentials  in  a  ma- 
jority of  the  cases.  The  patient  should  be  in  a  well-ventilated  room  (or  in 
summer  out  of  doors  during  the  day),  strictly  confined  to  bed  from  the  out- 
set, and  there  remain  until  convalescence  is  well  established.  The  bed 
should  be  single,  not  too  high,  and  the  mattress  should  not  be  too  hard. 
The  woven  wire  bed,  with  soft  hair  mattress,  upon  which  are  two  folds 
of  blanket,  combines  the  two  great  qualities  of  a  sick-bed,  smoothness 
and  elasticity.  A  rubber  cloth  should  be  placed  under  the  sheet.  An  intel- 
ligent nurse  should  be  in  charge.    When  this  is  impossible,  the  attending 


42  SPECIFIC  INFECTIOUS  DISEASES. 

physician  should  write  out  specific  instructions,  regarding  diet,  treatment 
of  the  discharges,  and  the  bed-linen. 

(J)  Diet. — Those  forms  of  food  should  be  given  which  are  digested  with 
the  greatest  ease,  and  which  leave  behind  the  smallest  amount  of  residue 
to  form  faeces.  Some  regard  should  be  paid  to  the  fancies  of  the  patient. 
Milk  is  the  most  suitable  food.  If  used  alone,  three  pints  at  least  may  be 
given  to  an  adult  in  twenty-four  hours,  always  diluted  with  water,  lime- 
water,  or  aerated  waters.  Partially  peptonized  milk,  when  not  distasteful 
to  the  patient,  is  occasionally  serviceable.  The  stools  of  a  patient  on  a 
strict  milk  diet  should  be  examined  with  great  care,  to  see  if  the  milk  is 
entirely  digested.  Fever  patients  often  Teceive  more  than  they  can  utilize 
in  which  case  masses  of  curds  are  seen  in  the  stools,  or  microscopically  fat- 
corpuscles  in  extraordinary  abundance.  Under  these  circumstances  it  is 
best  to  substitute,  for  part  of  the  milk,  mutton  or  chicken  broths,  or  beef- 
juice,  or  a  clear  consomme,  all  of  which  may  be  made  very  palatable  by  the 
addition  of  fresh  vegetable  juices.  If,  however,  diarrhoea  exists,  animal 
broths  are  apt  to  aggravate  it.  Some  patients  will  take  whey,  butter- 
milk, kumyss,  or  matzoon  when  the  ordinary  milk  is  distasteful.  Thin 
barley-gruel,  well  strained,  is  an  excellent  food  for  typhoid-fever  patients. 
Eggs  may  be  given,  either  beaten  up  in  milk  or,  better  still,  in  the  form  of 
albumen-water.  This  is  prepared  by  straining  the  whites  of  eggs  through 
a  cloth  and  mixing  them  with  an  equal  quantity  of  water.  It  may  be  flav- 
ored with  lemon,  and,  if  the  patient  is  taking  spirits,  whisky  or  brandy  is 
very  conveniently  given  with  it.  Patients  who  are  unable  to  take  milk  can 
subsist  for  a  time  on  this  alone.  The  whole  egg  beaten  up  in  milk  or  water 
may  be  used. 

The  patient  should  be  given  water  freely,  which  may  be  pleasantly  cold. 
Iced  tea,  barley-water,  or  lemonade  may  also  be  used,  and  there  is  no  objec- 
tion to  coffee  or  cocoa  in  moderate  quantities.  Fruits  are  not,  as  a  rule, 
allowable,  though  the  juice  of  lemon  or  orange  may  be  given.  Typhoid 
patients  should  be  fed  at  stated  intervals  through  the  day.  At  night  it 
depends  upon  the  general  condition  of  the  patient  whether  he  should  be 
aroused  from  sleep  or  not.  In  mild  cases  it  is  not  well  to  disturb  the 
patient.  When  there  is  stupor,  however,  the  patient  should  be  roused  for 
food  at  the  regular  intervals  night  and  day. 

Alcohol  is  not  necessary  in  all  cases,  but  may  be  given  when  the  weak- 
ness is  marked,  the  fever  high,  and  the  pulse  failing.  In  young  healthy 
adults,  without  nervous  symptoms  and  without  very  high  fever,  it  is  not 
required;  but  when  the  heart-beat  is  feeble  and  the  first  sound  becomes 
obscure,  if  there  are  a  muttering  delirium,  subsultus  tendinum,  and  a  dry 
tongue,  brandy  or  whisky  should  be  freely  given.  In  such  a  case  from 
eight  to  twelve  ounces  of  good  whisky  in  the  twenty-four  hours  is  a  moder- 
ate amount. 

It  is  possible  that  we  give  too  much  food.  Inglis  has  shown  that  cases 
do  very  well  on  cold  water  alone.  The  outcry  against  milk  in  some  quarters 
is,  I  am  sure,  unfounded.  It  causes  less  intestinal  fermentation  than  any 
other  food;  it  rarely  disagrees  when  diluted,  and  when  alternated  with 
egg-albumen  forms  the  ideal  diet  for  typhoid  patients. 


TYPHOID  FEVER.  43 

(c)  Hydrotherapy. — The  use  of  water,  inside  and  outside,  was  no  new 
treatment  in  fevers  at  the  end  of  the  eighteenth  century,  when  James  Currie 
(a  friend  of  Burns  and  the  editor  of  his  poems),  wrote  his  Medical  Reports' 
on  the  Effects  of  ^Yater,  Cold  and  AVarm,  as  a  Eemedy  in  Fevers  and  other 
Diseases.  In  this  country  it  was  used  with  great  effect  and  recommended 
strongly  by  Nathan  Smith,  of  Yale.  Since  1861  the  value  of  bathing  in 
fevers  has  been  specially  emphasized  by  the  late  Dr.  Brand,  of  Stettin. 

Hydrotherapy  may  be  carried  out  in  several  different  ways,  of  which, 
in  typhoid  fever,  the  most  satisfactory  are  by  sponging,  the  wet  pack,  and 
the  full  bath. 

(a)  Cold  Sponging. — The  water  may  be  tepid,  cold,  or  ice-cold,  according 
to  the  height  of  the  fever.  A  thorough  sponge-bath  should  take  from 
fifteen  to  twenty  minutes.  The  ice-cold  sponging  is  quite  as  formidable 
as  the  full  cold  bath,  for  which,  when  there  is  an  insuperable  objection 
in  private  practice,  it  is  an  excellent  alternative.  But  frequently  it  is 
difficult  to  get  the  friends  to  appreciate  the  advantages  of  the  sponging. 
When  such  is  the  case,  and  in  children  and  delicate  persons,  it  can  be 
made  a  little  less  formidable  by  sponging  limb  by  limb  and  then  the  back 
and  abdomen. 

(b)  The  cold  pack  is  not  so  generally  useful  in  typhoid  fever,  but  in 
cases  with  very  pronounced  nervous  symptoms,  if  the  tub  is  not  available, 
the  patient  may  be  wrapped  in  a  sheet  wrung  out  of  water  at  60°  or  65°, 
and  then  cold  water  sprinkled  over  him  with  an  ordinary  watering-pot. 

(c)  The  Bath. — The  tub  should  be  long  enough  so  that  the  patient  can 
be  completely  covered  except  his  head.  Our  rule  for  some  years  has  been 
to  give  a  bath  at  70°  every  third  hour  when  the  temperature  was  above 
102.5°.  The  patient  remains  in  the  tub  for  fifteen  or  twenty  minutes,  is 
taken  out,  wrapped  in  a  dry  sheet,  and  covered  with  a  blanket.  "While  in 
the  tub  the  limbs  and  trunk  are  rubbed  thoroughly,  either  with  the  hand 
or  with  a  suitable  rubber.  It  is  well  to  give  the  first  one  or  two  baths  at 
a  temperature  of  80°  or  85°.  There  is  no  routine  temperature.  If  the 
bath  at  70°  is  not  well  taken,  raise  the  temperature  to  75°  or  80°.  It  is 
important  to  see  that  the  canvas  supports  are  properly  arranged,  and  that 
the  rubber  pillow  is  comfortable  for  the  patient's  head.  The  first  bath 
should  not  be  given  at  night,  and  it  should  be  superintended  by  the  house- 
physician.  The  amount  of  complaint  made  by  the  patient  is  largely  de- 
pendent upon  the  skill  and  care  with  which  the  baths  are  given.  Food 
is  usually  given,  sometimes  a  stimulant,  after  the  bath.  The  blueness  and 
shivering,  which  often  follow  the  bath,  are  not  serious  features.  The  rectal 
temperature  is  taken  immediately  after  the  bath,  and  again  three-quarters 
of  an  hour  later.  Contra-indications  are  peritonitis,  hsemorrhage,  phlebitis, 
severe  abdominal  pain,  and  great  prostration.  The  accompanying  chart 
(Chart  IV)  shows  the  number  of  baths  and  the  influence  on  the  fever  dur- 
ing two  days  of  treatment.  The  good  effects  of  the  baths  are:  (1)  The 
reduction  of  the  fever;  (2)  the  intellect  becomes  clearer,  the  stupor  lessens, 
and  the  muscular  twitchings  disappear;  (3)  a  general  tonic  action  on  the 
nervous  system  and  particularly  on  the  heart;  (4)  insomnia  is  lessened,  the 
patient  usually  falling  asleep  for  two  or  three  hours  after  each  bath;  and 


u 


SPECIFIC  INFECTIOUS  DISEASES. 


(5),  most  important  of  all,  the  mortality  is,  uncler  this  plan  of  trearment, 
reduced  to  a  minimum. 

The  spongings  frequently  have  to  be  substituted  for  the  tubs  in  eases 
of  extreme  weakness,  or  when  there  is  much  meteorism,  or  when  there  is 
marked  collapse  after  the  baths.  While  a  temperature  at  70°  is  usually 
well  borne,  in  the  case  of  children  and  delicate  persons  the  luke-warm  bath 
gradually  cooled  may  be  employed. 


J" 

Temp 
109 

108 

107 

106 

lOo 

101 

103 

103 

101 

100 


97 

96 
Temp 

Pulie 

Eesp 

Stools 

Urine 

Day  of 
Disease. 


«  1}        J«  Jl      28    Jt        « 


Chart  IV. 


The  results  of  hydrotherapy  are  very  gratifying.  By  it  in  general  hos- 
pitals from  6  to  8  patients  in  every  hundred  cases  are  saved.  In  institu- 
tions in  which  the  expectant  or  other  plans  of  treatment  are  employed, 
there  is  a  mortality  of  from  12  to  15  per  cent.  In  many  it  is  as  high  as  17 
per  cent.  There  is  a  remarkable  uniformity  in  the  death-rate  in  hospitals 
which  carry  out  hydrotherapy.  During  the  first  ten  years  to  May  15,  1899, 
there  have  been  treated  in  my  wards  829  cases  of  typhoid  fever  with  a  total 
mortality  of  7.5  per  cent.  This  includes  all  cases,  those  admitted  and  dying 
within -twenty-four  or  forty-eight  hours,  and  those  in  which  the  diagnosis 
was  only  made  at  autopsy.*  Still  more  striking  by  contrast  are  the  figures 
published  by  F.  E.  Hare  from  the  Brisbane  Hospital  (Practitioner,  Sep- 
tember, 1897).     Of  1,828  cases  treated  on  the  general  or  expectant  plan, 

*  From  May,  1889,  when  the  hospital  was  opened,  to  July,  1890,  the  ordinary  expectant 
plan  was  followed. 


TYPHOID  FEVER.  45 

the  mortality  was  14.8  per  cent.  Of  1,902  cases  treated  since  the  intro- 
duction of  hydrotherapy,  the  mortality  was  only  7.5  per  cent.  Equally 
good  results  have  been  obtained  by  J.  C.  Wilson  and  Tyson  in  Philadelphia, 
by  Gilman  Thompson  in  New  York,  and  at  numerous  hospitals  in  Germany 
and  France.  The  important  question  comes  up  whether  the  serious  com- 
plications of  the  disease  are  increased  by  hydrotherapy.  My  own  statistics 
bear  out  Hare's  that  the  remarkable  life-saving  in  hydrotherapy  does  not 
depend  upon  a  diminution  in  the  number  of  fatal  cases  from  perforation 
or  from  haemorrhage.  The  percentage  of  perforation  cases  in  my  series 
was  2.7,  which  is  under  the  average.  At  Brisbane  it  was  2.9  per  cent,  both 
before  and  after  the  introduction  of  bathing.  Hemorrhage  occurs  in  from 
3  to  5  per  cent  of  the  cases.  In  my  series  it  occurred  in  6  per  cent  of  all 
cases  since  the  introduction  of  hydrotherapy.  The  Brisbane  statistics  give 
before  the  introduction  of  hydrotherapy  1.8  per  cent  of  fatal  cases,  and- 
after  the  introduction  1.2  per  cent.  A  careful  study  of  the  recent  statistics 
shows  that  neither  perforation  nor  haemorrhage  is  more  frequent  with 
hydrotherapy.  As  to  relapse,  it  is  more  difficult  to  speak,  the  percentage 
varies  so  widely — from  3  to  16.  It  must  be  remembered  that  more  cases 
are  saved  to  have  relapse.  My  percentage  of  10  is  somewhat  above  the 
average,  but  the  increase  in  the  relapses  is  not  so  great  as  to  seriously  im- 
pugn the  treatment.  Hydrotherapy  does  not  probably  shorten  the  duration 
of  the  stay  in  hospital,  which  was  forty-two  days  in  my  series.  We  do  not, 
however,  send  out  our  typhoid  cases  until  they  are  quite  strong  and  well. 

(d)  Medicinal  Treatment. — In  hospital  practice  medicines  are  not  often 
needed.  A  great  majority  of  my  cases  do  not  receive  a  dose.  In  private 
practice  it  may  be  safer,  for  the  young  practitioner  especiall}',  to  order  a 
mild  fever  mixture.  The  question  of  medicinal  antipyretics  is  important: 
they  are  used  far  too  often  and  too  rashly  in  typhoid  fever.  An  occasional 
dose  of  antifebrin  or  antipyrin  may  do  no  harm,  but  the  daily  use  of  these 
drugs  is  most  injurious.  Quinine  in  moderate  doses  is  still  much  em- 
ployed. The  local  use  of  guiacol  on  the  skin,  3ss  painted  on  the  flank, 
causes  a  prompt  fall  in  the  temperature. 

Antiseptic  Medication. — Very  laudable  endeavors  have  been  made  in 
many  quarters  to  introduce  methods  of  treatment  directed  toward  the 
destruction  of  the  typhoid  bacilli,  or  the  toxic  agent  which  they  produce, 
but  so  far  without  success.  Good  results  have  been  claimed  from  the  car- 
bolic acid  and  iodine  treatment.  Others  advocate  corrosive  sublimate  or 
calomel,  ^-naphthol,  the  salicin  preparations  and  guiacol.  I  can  testify 
to  the  inefficiency  of  the  carbolic  acid  and  iodine  and  of  the  /3-naphthol. 
With  the  mercurial  preparations  I  have  no  experience.  Fortunately  for 
the  patients,  a  majority  of  these  medicines  meet  one  of  the  two  objects 
which  Hippocrates  says  the  physician  should  always  have  in  view — they  do 
no  harm.  Irrigation  of  the  colon  has  been  recommended,  with  a  view  to 
washing  out  the  toxic  matters  (Mosler,  Seibert). 

(e)  Eliminative  and  Antiseptic  Treatment.— Thistle  and  others  have 
advocated  a  combined  eliminative  and  antiseptic  treatment.  To  aid  in 
the  elimination  of  the  poison  the  skin  and  kidneys  are  kept  active  by 
the  use  of  large  quantities  of  water,  which  is  certainly  an  excellent  prac- 


46  /  SPECIFIC  INPECTIOIJS  DISEASES. 


tice.  Of  the  various  antiseptics  employed  it  is  doubtful  if  any  have  the 
slightest  action  on  the  bacilli  in  the  lymphatic  tissues  of  the  bowel.  If, 
as  in  cholera,  the  bacilli  developed  and  produced  the  poison  in  the  in- 
testinal contents,  there  might  be  some  reasonableness  in  this  method, 
but  the  bacilli  multiply  in  the  intestinal  walls,  in  the  mesenteric  glands, 
and  in  the  spleen.  They  are  sometimes  not  found  in  the  stools  until 
the  end  of  the  second  week.  The  systematic  use  of  purgatives  is,  in 
my  opinion,  very  bad  practice.  No  one  feature  in  the  disease  is,  I  think, 
more  serious  than  persistent  diarrhoea.  The  preliminary  calomel  purge, 
so  much  used,  is  not  necessary.  Graves  remarked  that  patients  who  escaped 
active  purgation  before  admission  to  the  hospital  usually  had  much  less 
bowel  trouble. 

(/)  Semin  Therapy. — In  spite  of  many  experiments  and  clinical  trials 
the  results  are  still  unsatisfactory.  An  antityphoid  serum  has  been 
placed  on  the  market,  and  a  few  cases  have  been  reported  with  rapid  im- 
provement. 

{g)  Treatment  of  the  Special  Symptoms. — The  abdominal  pain  and 
tympanites  are  best  treated  with  fomentations  or  turpentine  stupes.  The 
latter,  if  well  applied,  give  great  relief.  Sir  William  Jenner  used  to  lay 
great  stress  on  the  advantages  of  a  well-applied  turpentine  stupe.  He 
^  directed  it  to  be  applied  as  follows:  A  flannel  roller  was  placed  beneath 
the  patient,  and  then  a  double  layer  of  thin  flannel,  wrung  out  of  very  hot 
water,  with  a  drachm  of  turpentine  mixed  with  the  water,  was  applied  to 
the  abdomen  and  covered  with  the  ends  of  the  roller. 

The  meteorisni  is  a  difficult  and  distressing  symptom  to  treat.  Wlien 
the  gas  is  in  the  large  bowel,  a  tube  may  be  passed  or  a  turpentine  enema 
given.  For  tympanites,  with  a  dry  tongue,  turpentine  was  extensively 
used  by  the  older  Dublin  physicians,  and  it  was  introduced  into  this  coun- 
try by  the  late  George  B.  Wood.  Unfortunately,  it  is  of  very  little  service 
in  the  severer  cases,  which  too  often  resist  all  treatment.  Sometimes,  if 
beef-juice  and  albumen-water  are  substituted  for  milk,  the  distension 
lessens.     Charcoal,  bismuth,  and  ^-naphthol  may  be  tried. 

For  the  diarrhoea,  if  severe — that  is,  if  there  are  more  than  three  or 
four  stools  daily — a  starch  and  opium  enema  may  be  given;  or,  by  the 
mouth,  a  combination  of  bismuth,  in  large  doses,  with  Dover's  powder;  or 
the  acid  diarrhoea  mixture,  acetate  of  lead  (grs.  2),  dilute  acetic  acid 
(TT[  15-20),  and  acetate  of  morphia  (gr.  -I— |).  The  stools  should  be  exam- 
ined to  see  that  the  diarrhoea  is  not  aggravated  by  the  presence  of  curds. 

Constipation  is  present  in  many  cases,  and  though  I  have  never  seen  it 
do  harm,  yet  it  is  well  every  third  or  fourth  day  to  give  an  ordinary  enema. 
If  a  laxative  is  needed  during  the  course  of  the  disease,  the  Hunyadi- 
janos  or  Friedrichshall  water  may  be  given. 

Hcemorrliage  from  the  bowels  is  best  treated  with  full  doses  of  acetate 
of  lead  and  opium.  As  absolute  rest  is  essential,  the  greatest  care  should 
be  taken  in  the  use  of  the  bed-pan.  It  is  perhaps  better  to  allow  the  pa- 
tient to  pass  the  motions  into  the  draw-sheet.  Ice  may  be  freely  given,  and 
the  amount  of  food  should  be  restricted  for  eight  or  ten  hours.  If  there 
is  a  tendency  to  collapse,  stimulants  should  be  given,  and,  if  necessary, 


TYPHOID   FEVER.  4Y 

hypodermic  injections  of  ether.  Injection  of  salt  solution  beneath  the 
skp  or  directly  into  a  vein  may  revive  a  failing  heart.  Turpentine  is 
warmly  recommended  by  certain  authors. 

Peritonitis. — In  a  majority  of  the  cases  this  is  an  inevitably  fatal  com- 
plication, though  recovery  is  possible.  If  the  peritonitis  be  due  to  perfora- 
tion, the  question  of  laparotomy  should  be  immediately  discussed.  Orders 
should  be  issued  to  the  nurse,  and  in  hospitals  to  the  house  physicians,  to 
watch  carefully  for  the  first  symptoms  of  perforation.  The  recent  re- 
sults are  most  gratifying.  Finney  (Studies  III)  has  reviewed  the  whole 
question;  of  112  cases  23  recovered.  To  January  1,  1901,  11  cases  have  been 
operated  upon  from  my  wards  with  5  recoveries.  The  danger  of  delay  is 
illustrated  by  the  following  figures:  Of  15  cases  operated  on  within  twelve 
hours,  4  recovered;  of  20  cases  operated  on  between  the  twelfth  and  twenty- 
fourth  hour,  6  recovered;  of  13  cases  operated  on  in  the  second  twenty-four 
hours  only  1  recovered.  No  case  is  so  desperate,  unless  actually  moribund, 
as  to  be  without  some  hope  in  the  hands  of  a  good  surgeon. 

Bone  Lesions. — The  typhoid  periostitis  of  the  ribs  or  of  the  tibia  does 
not  always  go  on  to  suppuration,  though,  as  a  rule,  it  requires  operation. 
Unless  the  practitioner  is  accustomed  to  do  very  thorough  surgical  work, 
he  should  hand  over  the  patient  to  a  competent  surgeon,  who  will  clear 
out  the  diseased  parts  with  the  greatest  thoroughness.  Eecurrence  is  in- 
evitable unless  the  operation  is  complete. 

For  the  progressive  heart-weakness  alcohol,  strychnine  and  ether  hypo- 
dermically  in  full  doses,  digitalis,  and  the  saline  infusions  may  be  tried. 

The  nervous  symptoms  of  typhoid  fever  are  best  treated  by  hydrother- 
apy. Special  advantages  of  this  plan  are  that  the  restlessness  is  allayed, 
the  delirium  quieted,  and  sedatives  are  rarely  needed.  In  the  cases  which 
set  in  early  with  severe  headache,  meningeal  symptoms,  and  high  fever, 
the  cold  bath,  or  in  private  practice  the  cold  pack,  should  be  employed.  An 
ice-cap  may  be  placed  on  the  head,  and  if  necessary  morphia  administered 
hypodermically.  For  the  nocturnal  restlessness,  so  distressing  in  some 
cases,  Dover's  powder  should  be  given.  As  a  rule,  if  a  hypnotic  is  indi- 
cated, it  is  best  to  give  opium  in  some  form.  Pulmonary  complications 
should,  if  severe,  receive  appropriate  treatment. 

Bacilluria. — When  bacilli  are  present,  as  demonstrated  by  cultures  or 
shown  by  the  microscope,  urotropin  may  be  given  in  ten-grain  doses  and 
kept  up,  if  necessary,  for  several  weeks. 

In  protracted  cases  very  special  care  should  be  taken  to  guard  against 
hed-sores.  Absolute  cleanliness  and  careful  drying  of  the  parts  after  an 
evacuation  should  be  enjoined.  The  patient  should  be  turned  from  side 
to  side  and  propped  with  pillows,  and  the  back  can  then  be  sponged 
with  spirits.  On  the  first  appearance  of  a  sore,  the  water-  or  air-bed  should 
be  used. 

(A)  The  Management  of  Convalescence. — Convalescents  from  typhoid 
fever  frequently  cause  greater  anxiety  than  patients  in  the  attack.  The 
question  of  food  has  to  be  met  at  once,  as  the  patient  acquires  a  ravenoue 
appetite  and  clamors  for  a  fuller  diet.  My  custom  has  been  not  to  allow 
solid  food  until  the  temperature  has  been  normal  for  ten  days.    This  is,  I 


48  SPECIFIC  INFECTIOUS  DISEASES. 

think,  a  safe  rule,  leaning  perhaps  to  the  side  of  extreme  caution;  hut, 
after  all,  with  eggs,  milk  toast,  milk  puddings,  and  jellies,  the  patient  can 
take  a  fairly  varied  diet.  Many  leading  practitioners  allow  solid  food  to  a 
patient  so  soon  as  he  desires  it.  Peabody  gives  it  on  the  disappearance  of 
the  fever;  the  late  Austin  Flint  was  also  in  favor  of  giving  solid  food 
early.  I  had  a  lesson  in  this  matter  which  I  have  never  forgotten.  A 
young  lad  in  the  Montreal  General  Hospital,  in  whose  case  I  was  much 
interested,  passed  through  a  tolerably  sharp  attack  of  typhoid  fever.  Two 
weeks  after  the  evening  temperature  had  been  normal,  and  only  a  day  or 
two  before  his  intended  discharge,  he  ate  several  mutton  chops,  and  within 
twenty-four  hours  was  in  a  state  of  collapse  from  perforation.  A  small 
transverse  rent  was  found  at  the  bottom  of  an  ulcer  which  was  in  process 
of  healing.  It  is  not  easy  to  say  why  solid  iood,  particularly  meats,  should 
disagree,  but  in  so  many  instances  an  indiscretion  in  diet  is  followed  by 
slight  fever,  the  so-called  febris  carnis,  that  it  is  in  the  best  interests  of  the 
patient  to  restrict  the  diet  for  some  time  after  the  fever  has  fallen. 
Whether  an  error  in  diet  may  cause  relapse  is  doubtful.  The  patient  may 
be  allowed  to  sit  up  for  a  short  time  about  the  end  of  the  first  week  of 
convalescence,  and  the  period  may  be  prolonged  with  a  gradual  return  of 
strength.  He  should  move  about  slowly,  and  when  the  weather  is  favor- 
able should  be  in  the  open  air  as  much  as  possible.  He  should  be  guarded 
at  this  period  against  all  unnecessary  excitement.  Emotional  disturbance 
not  infrequently  is  the  cause  of  recrudescence  of  the  fever.  Constipation  is 
not  uncommon  in  convalescence  and  is  best  treated  by  enemata.  A  pro- 
tracted diarrhoea,  which  is  usually  due  to  ulceration  in  the  colon,  may 
retard  recovery.  In  such  cases  the  diet  should  be  restricted  to  milk,  and 
the  patient  should  be  confined  to  bed;  large  doses  of  bismuth  and  astrin- 
gent injections  will  prove  useful.  The  recrudescence  of  the  fever  does  not 
require  special  measures.  The  treatment  of  the  relapse  is  essentially  that 
of  the  original  attack. 

Post-typhoid  insanity  requires  the  judicious  care  of  an  expert.  The 
cases  usually  recover.  The  swollen  leg  after  phlebitis  is  a  source  of  great 
worry.  A  bandage  should  be  worn  during  the  day  or  a  well-fitting  elastic 
stocking.  The  outlook  depends  on  the  completeness  with  which  the  col- 
lateral circulation  is  established. 

The  post-typlioid  neuritis,  a  cause  of  much  alarm  and  distress,  usually 
gets  well,  though  it  may  take  months,  or  even  a  couple  of  years,  before 
the  paralysis  disappears.  After  the  subsidence  of  the  acute  symptoms 
systematic  massage  of  the  paralyzed  and  atrophic  muscles  is  the  most  sat- 
isfactory treatment. 

The  condition  spoken  of  as  the  typhoid  spine  may  drag  on  for  months 
and  prove  very  obstinate.  The  neurotic  state  has  to  be  treated.  Separa- 
tion from  solicitous  and  sympathetic  friends,  hydrotherapy  in  the  form  of 
the  wet  pack,  and  the  Paquelin  cautery  are  the  most  efficacious  means  of 
cure.    An  encouraging  prognosis  may  be  followed  by  rapid  improvement. 


TYPHUS   FEVER.  49 

II.    TYPHUS   FEVER. 

Definition. — An  acute  infectious  disease  of  unknown  origin,  highly 
contagious,  characterized  by  sudden  onset,  maculated  rash,  marked  nervous 
symptoms,  and  a  cyclical  course  terminating  by  crisis,  usually  about  the 
end  of  the  second  week.  Post-mortem  there  are  no  special  lesions  other 
than  those  associated  with  fever. 

The  disease  is  known  by  the  names  of  hospital  fever,  spotted  fever,  jail 
fever,  camp  fever,  and  ship  fever,  and  in  Germany  is  called  exanthematic 
typhus,  in  contradistinction  to  abdominal  typhus. 

Etiology. — Typhus  fever  has  been  one  of  the  great  epidemics  of  the 
world.  Until  the  middle  of  the  nineteenth  century  it  prevailed  extensively 
in  all  the  larger  cities  of  Europe,  and  at  times  extended  to  widespread 
outbreaks.  As  Hirsch  has  remarked,  "  The  history  of  typhus  is  written 
in  those  dark  pages  of  the  world's  story  which  tell  of  the  grievous  visita- 
tions of  mankind  by  war,  famine,  and  misery  of  every  kind."  Few  coun- 
tries have  suffered  more  than  Ireland,  particularly  between  the  years  1817 
and  1819  and  in  1846.  In  England  the  disease  has  progressively  dimin- 
ished in  intensity.  In  1875  there  were  1,499  deaths,  in  1895  only  58  deaths. 
In  1897  there  were  only  3  cases  of  typhus  fever  in  the  London  Fever  Hos- 
pitals. The  last  really  great  epidemic  was  in  the  Turko-Eussian  War  in 
1877-'78. 

The  gradual  disappearance  of  typhus  fever  is  one  of  the  great  tri- 
umphs of  modern  medicine.  At  present  the  disease  lurks  in  only  a  few 
centers  in  Great  Britain  and  on  the  Continent,  and  every  few  years  slight 
outbreaks  occur  in  larger  cities,  and  sporadic  cases  appear  from  time  to  time. 
In  the  United  States  typhus  fever  has  not  prevailed  as  an  extensive  epi- 
demic for  many  years.  There  were  small  outbreaks  in  New  York  in  1881- 
'82  and  in  1892-'93,  and  in  1883  in  Philadelphia.  A  remarkable  feature  is 
the  occurrence  of  a  few  cases  at  long  intervals  of  time  from  any  other  out- 
breaks and  at  great  distances  from  any  known  foci  of  the  disease.  This 
was  one  of  the  points  which  led  Murchison  to  the  belief  that  under  favor- 
able conditions  the  disorder  might  originate  spontaneously.  But  although 
it  is  sometimes  impossible  to  explain  satisfactorily  its  importation,  such 
negative  evidence  can  not  be  regarded  as  conclusive.  Certainly,  the  analogy 
of  the  other  infectious  diseases  is  against  this  view. 

In  1877  there  occurred  a  local  outbreak  of  typhus  at  the  House  of 
Refuge,  in  Montreal,  a  city  in  which  the  disease  had  not  existed  for  many 
years.  The  overcrowding  was  so  great  in  the  basement  rooms  of  the  refuge 
that  at  night  there  were  not  more  than  88  cubic  feet  of  space  to  each  per- 
son. Eleven  individuals  were  affected.  It  was  not  possible  to  trace  the 
source  of  infection. 

In  the  spring  of  1901  from  one  house  three  cases  of  fever  were  admitted 
to  my  wards,  which  were  regarded  at  first  as  typhoid  fever,  but  the  fea- 
tures were  so  anomalous  that  our  suspicions  we're  aroused.  The  rash  was 
perfectly  characteristic  of  typhus,  the  Widal  reaction  was  negative,  blood 
cultures  were  negative,  and  a  post-mortem  on  one  fatal  case  showed  no 
typhoid  lesions,  and  no  cultures  were  obtained  from  the  spleen  or  the 


60  SPECIFIC  INFECTIOUS  DISEASES. 

blood  post-mortem.  The  other  two  cases  terminated  by  crisis,  so  that  I 
think  there  can  be  no  question  that  the  cases  were  typhus  fever.  The 
disease  has  not  prevailed  in  Baltimore  for  more  than  a  quarter  of  a  cen- 
tury. The  patients  were  Lithuanians,  they  lived  under  most  unsanitary 
conditions,  and  were  workers  at  a  suburb  frequented  by  a  great  many  for- 
eigners from  the  eastern  parts  of  Europe.  The  origin  of  the  outbreak 
could  not  be  traced,  nor  did  any  other  cases  occur. 

Typhus  is  one  of  the  most  highly  contagious  of  febrile  affections.  In 
epidemics  nurses  and  doctors  in  attendance  upon  the  sick  are  almost  inva- 
riably attacked.  There  is  no  disease  which  has  so  many  victims  in  the 
profession.  It  is  stated  that  in  a  period  of  twenty-five  years,  among  1,230 
physicians  attached  to  institutions  in  Ireland,  550  succumbed  to  this  dis- 
ease. Casual  attendance  upon  cases  in  limited  epidemics  does  not  appear 
to  be  very  risky,  but  when  the  sick  are  aggregated  in  wards  the  poison  ap- 
pears concentrated  and  the  danger  of  infection  is  much  enhanced.  Bed- 
ding and  clothes  retain  the  poison  for  a  long  time.  Murchison  thought  that 
the  virus  was  thrown  off  from  the  lungs  and  from  the  skin.  It  attaches 
itself  particularly  to  the  clothing  and  linen  and  to  the  furniture  of  the 
room,  and  appears  to  retain  its  activity  for  a  remarkably  long  time.  To 
catch  the  disease  there  apparently  must  be  fairly  intimate  contact  with  the 
patient,  more  particularly  contact  with  a  large  number  of  patients.  Thus 
in  mild  outbreaks  of  only  a  few  cases  physicians  and  nurses  are  rarely 
affected,  while  in  severe  epidemics  all  in  attendance  may  be  attacked  in 
succession. 

Bacteriology. — Hlava  in  1891  found  a  streptobacillus  in  20  cases. 
Dubieff  and  Bruhl  in  1893  described  a  diplococcus  found  in  the  blood  and 
in  the  organs  of  fatal  cases.  The  question  practically  remains  open  for 
investigation. 

Morbid  Anatomy. — The  anatomical  changes  are  those  which  result 
from  intense  fever.  The  blood  is  dark  and  fluid;  the  muscles  are  of  a  deep 
red  color,  and  often  show  a  granular  degeneration,  particularly  in  the 
heart;  the  liver  is  enlarged  and  soft  and  may  have  a  dull  clay-like  lustre; 
the  kidneys  are  swollen;  there  is  moderate  enlargement  of  the  spleen,  and 
a  general  hyperplasia  of  the  lymph-follicles.  Peyer's  glands  are  not  ulcer- 
ated. Bronchial  catarrh  is  usually,  and  hypostatic  congestion  of  the  lungs 
often,  present.    The  skin  shows  the  petechial  rash. 

Symptoms. — Incubation. — This  is  placed  at  about  twelve  days,  but 
it  may  be  less.  There  may  be  ill-defined  feelings  of  discomfort.'  As  a  rule, 
however,  the  invasion  is  abrupt  and  marked  by  chills  or  a  single  rigor, 
followed  by  fever.  The  chills  may  recur  during  the  first  few  days,  and 
there  is  headache  with  pains  in  the  back  and  legs.  There  is  early  pros- 
tration, and  the  patient  is  glad  to  take  to  his  bed  at  once.  The  tempera- 
ture is  high  at  first,  and  may  attain  its  maximum  on  the  second  or  third 
day.  The  pulse  is  full,  rapid,  and  not  so  frequently  dicrotic  as  in  typhoid. 
The  tongue  is  furred  and  white,  and  there  is  an  early  tendency  to  dry- 
ness. The  face  is  flushed,  the  eyes  congested,  and  the  expression  dull 
and  stupid.  Vomiting  may  be  a  distressing  symptom.  In  severe  cases 
mental  symptoms  are  present  from  the  outset,  either  a  mild  febrile  de- 


TYPHUS  fe\t:r.  51 

lirium  or  an  excited,  active,  almost  maniacal  condition.     Bronchial  catarrh 
is  common. 

Stage  of  Eruption. — From  the  third  to  the  fifth  day  the  eruption  ap- 
pears— first  upon  the  abdomen  and  upper  part  of  the  chest,  and  then  upon 
the  extremities  and  face ;  developing  so  rapidly  that  in  two  or  three  days 
it  is  all  out.  There  are  two  elements  in  the  eruption  :  a  subcuticular  mot- 
tling, "  a  fine,  irregular,  dusky  red  mottling,  as  if  below  the  surface  of  the 
skin  some  little  distance,  and  seen  through  a  semi-opaque  medium  "  (Bu- 
chanan) ;  and  distinct  papular  rose-spots  which  change  to  petechiae.  In 
some  instances  the  petechial  rash  comes  out  with  the  rose-spots.  Collie 
describes  the  rash  as  consisting  of  three  parts — rose-colored  spots  which 
disappear  on  pressure,  dark-red  spots  which  are  modified  by  pressure,  and 
petechias  upon  which  pressure  jDroduces  no  effect.  In  children  the  rash  at 
first  may  present  a  striking  resemblance  to  that  of  measles,  and  give  as  a 
whole  a  curiously  mottled  appearance  to  the  skin.  The  term  mulberry  rash 
is  sometimes  applied  to  it.  In  mild  cases  the  eruption  is  slight,  but  even 
then  is  largely  petechial  in  character.  As  the  rash  is  largely  hsemorrhagic, 
it  is  permanent  and  does  not  disappear  after  death.  Usually  the  skin  is 
dry,  so  that  sudaminal  vesicles  are  not  common.  It  is  stated  by  some 
authors  that  a  distinctive  odor  is  present.  During  the  second  week  the 
general  symptoms  are  much  aggravated.  The  prostration  becomes  more 
marked,  the  delirium  more  intense,  and  the  fever  rises.  The  patient  lies 
on  his  back  with  a  dull  expressionless  face,  flushed  cheeks,  injected  con- 
junctivge,  and  contracted  pupils.  The  pulse  increases  in  frequency  and  is 
feebler ;  the  face  is  dusky,  and  the  condition  becomes  more  serious.  Ee- 
tention  of  urine  is  common.  Coma-vigil  is  frequent,  a  condition  in  which 
the  patient  lies  with  open  eyes,  but  quite  unconscious ;  with  it  there  may 
be  subsultus  tendinum  and  picking  at  the  bedclothes.  The  tongue  is  dry, 
brown,  and  cracked,  and  there  are  sordes  on  the  teeth.  Eespiration  is 
accelerated,  the  heart's  action  becomes  more  and  more  enfeebled,  and  death 
takes  place  from  exhaustion.  In  favorable  cases,  about  the  end  of  the 
second  week  occurs  the  crisis,  in  which,  often  after  a  deep  sleep,  the  pa- 
tient awakes  feeling  much  better  and  with  a  clear  mind.  The  tempera- 
ture falls,  and  although  the  prostration  may  be  extreme,  convalescence  is 
rapid  and  relapse  very  rare.  This  abrupt  termination  by  crisis  is  in  strik- 
ing contrast  to  the  mode  of  termination  in  typhoid  fever. 

Fever. — The  temperature  rises  steadily  during  the  first  four  or  five 
days,  and  the  morning  remissions  are  not  marked.  The  maximum  is  usu- 
ally attained  by  the  fifth  day,  when  the  temperature  may  be  105°,  106°,  or 
107°.  In  mild  cases  it  seldom  rises  above  103°.  After  reaching  its  maxi- 
mum the  fever  generally  continues  with  slight  morning  remissions  until 
the  twelfth  or  fourteenth  day,  when  the  crisis  occurs,  during  which  the 
temperature  may  fall  below  normal  within  twelve  or  twenty-four  hours. 
Preceding  a  fatal  termination,  there  is  usually  a  rapid  rise  in  the  fever  to 
108°  or  even  109°. 

The  heart  may  early  show  signs  of  weakness.  The  first  sound  be- 
comes feeble  and  almost  inaudible,  and  a  systolic  murmur  at  the  apex  is 


52  SPECIFIC  mPECTIOUS  DISEASES. 

not  infrequent.  Hypostatic  congestion  of  the  lungs  occurs  in  all  severe 
cases.  The  brain  symptoms  are  usually  more  pronounced  than  in  typhoid, 
and  the  delirium  is  more  constant.  A  slight  leucocytosis  is  more  common 
than  in  typhoid. 

The  urine  in  typhus  shows  the  usual  febrile  increase  of  urea  and  uric 
acid.  The  chlorides  diminish  or  disappear.  Albumin  is  present  in  a  large 
proportion  of  the  cases,  but  nephritis  seldom  occurs. 

Variations  in  the  course  of  the  disease  are  naturally  common.  There 
are  malignant  cases  which  rapidly  prove  fatal  within  two  or  three  days ; 
the  so-called  typhus  siderans.  On  the  other  hand,  during  epidemics  there 
are  extremely  mild  cases  in  which  the  fever  is  slight,  the  delirium  absent, 
and  convalescence  is  established  by  the  tenth  day. 

Complications  and  Sequelae . — Broncho-pneumonia  is  perhaps  the 
most  common  complication.  It  may  pass  on  to  gangrene.  In  certain 
epidemics  gangrene  of  the  toes,  the  hands,  or  the  nose,  and  in  children 
noma  or  cancrum  oris,  have  occurred.  Meningitis  is  rare.  Paralyses, 
which  are  probably  due  to  a  post-febrile  neuritis,  are  not  very  uncom- 
mon. Septic  processes,  such  as  parotitis  and  abscesses  in  the  subcutane- 
ous tissues  and  in  the  joints,  are  occasionally  met  with.  Nephritis  is  rare. 
Hgematemesis  may  occur. 

Prognosis. — The  mortality  ranges  in  different  epidemics  from  12  to 
20  per  cent.  It  is  very  slight  in  the  young.  Children,  who  are  quite  as 
frequently  attacked  as  adults,  rarely  die.  After  middle  age  the  mortality 
is  high,  in  some  epidemics  50  per  cent.  Death  usually  occurs  toward  the 
close  of  the  second  week  and  is  due  to  the  toxaemia.  In  the  third  week  it 
more  commonly  results  from  pneumonia. 

Diagnosis. — During  an  epidemic  there  is  rarely  any  doubt,  for  the 
disease  presents  distinctive  general  characters.  Isolated  cases  may  be  very 
difficult  to  distinguish  from  typhoid  fever.  While  in  typical  instances  the 
eruption  in  the  two  affections  is  very  different,  yet  taken  alone  it  may  be 
deceptive,  since  in  typhoid  fever  a  roseolous  rash  may  be  abundant  and 
there  may  be  occasionally  a  subcuticular  mottling  and  even  petechias. 
The  difference  in  the  onset,  particularly  in  the  temperature,  is  marked ; 
but  cases  in  which  it  is  important  to  make  an  accurate  diagnosis  are  not 
usually  seen  until  the  fourth  or  fifth  day.  The  suddenness  of  the  onset, 
the  greater  frequency  of  the  chill,  and  the  early  prostration  are  the  dis- 
tinctive features  in  typhus.  The  brain  symptoms  too  are  earlier.  It  is 
easy  to  put  down  on  paper  elaborate  differential  distinctions,  which  are 
practically  useless  at  the  bedside.  The  Widal  reaction  and  blood  cultures 
are  important  aids,  but  in  sporadic  cases  the  diagnosis  is  sometimes  ex- 
tremely difficult.  I  have  seen  Murchison  himself  in  doubt,  and  more  than 
once  I  have  known  the  diagnosis  to  be  deferred  until  the  sectio  cadaveris. 
Severe  cerebro-spinal  fever  may  closely  simulate  typhus  at  the  outset,  but 
the  diagnosis  is  usually  clear  within  a  few  days.  Malignant  variola  also 
has  certain  features  in  common  with  severe  typhus,  but  the  greater  extent 
of  the  hemorrhages  and  the  bleeding  from  the  mucous  membranes  make 
the  diagnosis  clear  within  a  short  time.     The  rash  at  first  resembles  that 


TYPHUS  FEVER.  53 

of  measles,  but  in  the  latter  the  eruption  is  brighter  red  in  color,  often 
crescentic  or  irregular  in  arrangement,  and  appears  first  on  the  face. 

The  frequency  with  which  other  diseases  are  mistaken  for  typhus  is 
shown  by  the  fact  that  during  and  following  the  epidemic  of  1881  in  JSTew 
York  108  cases  were  wrongly  diagnosed — one  eighth  of  the  entire  number 
— and  sent  to  the  Riverside  Hospital  (F.  W.  Chapin). 

Treatment. — The  general  management  of  the  disease  is  like  that  of 
typhoid  fever.  Hydrotherapy  should  be  thoroughly  and  systematically 
employed.  Judging  from  the  good  results  which  we  have  obtained  by 
this  method  in  typhoid  cases  with  nervous  symptoms  much  may  be  ex- 
pected from  it.  Certain  authorities  have  spoken  against  it,  but  it  should 
be  given  a  more  extended  trial.  Medicinal  antipyretics  are  even  less  suit- 
able than  in  typhoid,  as  the  tendency  to  heart-weakness  is  often  more 
pronounced.  As  a  rule,  the  patients  require  from  the  outset  a  supporting 
treatment ;  water  should  be  freely  given,  and  alcohol  in  suitable  doses, 
according  to  the  condition  of  the  pulse. 

The  bowels  may  be  kept  open  by  mild  aperients.  The  so-called  spe- 
cific medication,  by  sulphocarbolates,  the  sulphides,  carbolic  acid,  etc.,  is 
not  commended  by  those  who  have  had  the  largest  experience.  The  spe- 
cial nervous  symptoms  and  the  pulmonary  symptoms  should  be  dealt  with 
as  in  typhoid  fever.  In  epidemics,  when  the  conditions  of  the  climate  are 
suitable,  the  cases  are  best  treated  in  tents  in  the  open  air. 

III.  RELAPSING    FEVER   {Febris  recurrens). 

Definition. — A  specific  infectious  disease  caused  by  the  spirochaete 
(spirillum)  of  Obermeier,  characterized  by  a  definite  febrile  paroxysm 
which  usually  lasts  six  days  and  is  followed  by  a  remission  of  about  the 
same  length  of  time,  then  by  a  second  paroxysm,  which  may  be  repeated 
three  or  even  four  times,  whence  the  name  relapsing  fever. 

Etiology. — This  disease,  which  has  also  the  names  "  famine  fever  " 
and  "  seven-day  fever,"  has  been  known  since  the  early  part  of  the  eight- 
eenth century,  and  has  from  time  to  time  extensively  prevailed  in  Europe 
especially  in  Ireland.  It  is  common  in  India,  where  the  conditions  for 
its  development  seem  always  to  be  present,  and  where  it  has  been  specially^ 
studied  by  Vandyke  Carter,  of  Bombay.  It  was  first  seen  in  this  country 
in  1844,  when  cases  were  admitted  to  the  Philadelphia  Hospital,  which  are 
described  by  Meredith  Clymer  in  his  work  on  fevers.  Flint  saw  cases  in 
1850-'51.  In  1869  it  prevailed  extensively  in  epidemic  form  in  New  York 
and  Philadelphia  ;  since  when  it  has  not  reappeared. 

The  special  conditions  under  which  it  develops  are  similar  to  those  of 
typhus  fever.  Overcrowding  and  deficient  food  are  the  conditions  which 
seem  to  promote  the  rapid  spread  of  the  virus.  Neither  age,  sex,  nor  sea- 
son seems  to  have  any  special  influence.  It  is  a  contagious  disease  and 
may  be  communicated  from  person  to  person,  but  is  not  so  contagious  as 
typhus.  Murchison  thinks  it  may  be  transported  by  fomites.  One  attack 
does  not  confer  immunity  from  subsequent  attacks.     In  1873  Obermeier 


54  SPECIFIC  INFECTIOUS  DISEASES. 

described  an  organism  in  the  blood  which  is  now  recognized  as  the  specific 
agent.  This  spirillum,  or  more  correctly  spirochaete,  is  from  3  to  6  times 
the  length  of  the  diameter  of  a  red  blood-corpuscle,  and  forms  a  narrow 
spiral  filament  which  is  readily  seen  moving  among  the  red  corpuscles  dur- 
ing a  paroxysm.  They  are  present  in  the  blood  only  during  the  fever. 
Shortly  before  the  crisis  and  in  the  intervals  they  are  not  found,  though 
small  glistening  bodies,  which  are  stated  to  be  their  spores,  appear  in  the 
blood.  The  disease  has  been  produced  in  human  beings  by  inoculation  with 
blood  taken  during  the  paroxysm.  It  has  also  been  produced  in  monkeys. 
Bed-bugs  may  suck  out  the  spirilla,  and  Tictin  reproduced  the  disease  by 
injecting  into  a  healthy  monkey  blood  sucked  by  a  bug  from  an  infected 
monkey.  Nothing  is  yet  known  with  reference  to  the  life  history  of  the 
spirochaete.     It  has  not  been  found  in  the  secretions  or  excretions. 

Morbid  Anatomy. — There  are  no  characteristic  anatomical  appear- 
ances in  relapsing  fever.  If  death  takes  place  during  the  paroxysm  the 
spleen  is  large  and  soft,  and  the  liver,  kidneys,  and  heart  show  cloudy 
swelling.  There  may  be  infarcts  in  the  kidneys  and  spleen.  The  bone 
marrow  has  been  found  in  a  condition  of  hyperplasia.  Ecchymoses  are 
not  uncommon. 

Symptoms. — The  inculation  appears  to  be  short,  and  in  some  in- 
stances the  attack  develops  promptly  after  exposure ;  more  frequently, 
however,  from  five  to  seven  days  elapse. 

The  invasio7i  is  abrupt,  with  chill,  fever,  and  intense  pain  in  the  back 
and  limbs.  In  young  persons  there  may  be  nausea,  vomiting,  and  convul- 
sions. The  temperature  rises  rapidly  and  may  reach  104°  on  the  evening 
of  the  first  day.  Sweats  are  common.  The  pulse  is  rapid,  ranging  from 
110  to  130.  There  may  be  delirium  if  the  fever  is  high.  Swelling  of  the 
spleen  can  be  detected  early.  Jaundice  is  common  in  some  epidemics. 
The  gastric  symptoms  may  be  severe.  There  are  seldom  intestinal  symp- 
toms. Cough  may  be  present.  Occasionally  herpes  is  noted,  and  there  may 
be  miliary  vesicles  and  petechise.  During  the  paroxysm  the  blood  inva- 
riably shows  the  spirochaete,  and  there  is  usually  a  leucocytosis  (Ouskow). 
After  the  fever  has  persisted  with  severity  or  even  with  an  increasing  in- 
tensity for  five  or  six  days  the  crisis  occurs.  In  the  course  of  a  few  hours, 
accompanied  by  profuse  sweating,  sometimes  by  diarrhoea,  the  temperature 
falls  to  normal  or  even  subnormal,  and  the  period  of  apyrexia  begins. 

The  crisis  may  occur  as  early  as  the  third  day,  or  it  may  be  delayed  to 
the  tenth ;  it  usually  comes,  however,  about  the  end  of  the  first  week.  In 
delicate  and  elderly  persons  there  may  be  collapse.  The  convalescence  is 
rapid,  and  in  a  few  days  the  patient  is  up  and  about.  Then  in  a  week, 
usually  on  the  fourteenth  day,  he  again  has  a  rigor,  or  a  series  of  chills ; 
the  fever  returns  and  the  attack  is  repeated.  A  second  crisis  occurs  from 
the  twentieth  to  the  twenty-third  day,  and  again  the  patient  recovers 
rapidly.  As  a  rule,  the  relapse  is  shorter  than  the  original  attack.  A 
second  and  a  third  may  occur,  and  there  are  instances  on  record  of  even  a 
fourth  and  a  fifth.  In  epidemics  there  are  cases  which  terminate  by  crisis 
on  the  seventh  or  eighth  day  without  the  occurrence  of  relapse.     In  pro- 


RELAPSING  FEVER. 


65 


tracted  cases  the  convalescence  is  very  tedious,  as  the  patient  is  much  ex- 
hausted. 

Eelapsing  fever  is  not  a  very  fatal  disease.  Murchison  states  that  the 
mortality  is  about  4  per  cent.  In  the  enfeebled  and  old,  death  may  occur 
at  the  height  of  the  first  paroxysm. 

Complications  are  not  frequent.  In  some  epidemics  nephritis  and 
hsematuria  have  occurred.  Pneumonia  appears  to  be  frequent  and  may 
interrupt  the  typical  course  of  the  disease.     The  acute  enlargement  of  the 


2   3  4   5 


107-6° 
105-8° 
104  0° 
102-2° 
100-4° 
98-6° 
96-8° 

gs-O" 


9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24 


W!M 


IBS 


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)Wi»'iii—gi—WWMWWW1M1M— ■■■■■■  ■■■'(■■■  ■BmBB 


Chart  V. — Relapsing  Fever  (Murchison). 

spleen  may  end  in  rupture,  and  the  haemorrhage  from  the  stomach,  which 
has  been  met  with  occasionally,  is  probably  associated  with  this  enlarge- 
ment. Post-febrile  paralyses  may  occur.  Ophthalmia  has  followed  cer- 
tain epidemics,  and  may  prove  a  very  tedious  and  serious  complication. 
Jaundice  has  already  been  mentioned.  In  pregnant  women  abortion  usu- 
ally takes  place. 

Diagnosis. — The  onset  and  general 'symptoms  may  not  at  first  be  dis- 
tinctive. At  the  beginning  of  an  epidemic  the  cases  are  usually  regarded 
as  anomalous  typhoid ;  but  once  the  typical  course  is  followed  in  a  case 
the -diagnosis  is  clear.     The  blood  examination  is  distinctive. 

Treatment. — The  paroxysm  can  neither  be  cut  short  nor  can  its 
recurrence  be  prevented.  It  might  be  thought  that  quinine,  with  its  pow- 
erful action,  would  certainly  meet  the  indications,  but  it  does  not  seem  to 
have  the  slightest  influence.  The  disease  must  be  treated  like  any  other 
continued  fever  by  careful  nursing,  a  regular  diet,  and  ordinary  hygienic 
measures.  Of  special  symptoms,  pains  in  the  back  and  in  the  limbs  and 
joints  demand  opium.  In  enfeebled  persons  the  collapse  at  the  crisis  may 
be  serious,  and  stimulants  with  ammonia  and  digitalis  should  be  given 
freely. 


56  SPECIFIC  INFECTIOUS  DISEASES. 

IV.  SMALL-POX  {Variola). 

Definition. — An  acute  infectious  disease  characterised  by  an  erup- 
tion which  passes  through  the  stages  of  papule,  vesicle,  pustule,  and 
crust.  The  mucous  membranes  in  contact  with  the  air  may  also  be 
affected.  Severe  cases  may  be  complicated  with  cutaneous  and  visceral 
hasmorrhages. 

Etiology. — It  has  not  yet  been  determined  in  what  country  small- 
pox originated.  The  disease  is  said  to  have  existed  in  China  many  centu- 
ries before  Christ.  The  pesta  magna  described  by  Galen  (and  of  which 
Marcus  Aurelius  died)  is  believed  to  be  small-pox.  In  the  sixth  century 
it  prevailed,  and  subsequently,  at  the  time  of  the  Crusades,  became  wide- 
spread. It  was  brought  to  America  by  the  Spaniards  early  in  the  sixteenth 
century.  The  first  accurate  account  was  given  by  Ehazes,  an  Arabian 
physician  who  lived  in  the  ninth  century,  and  whose  admirable  description 
is  available  in  Greenhill's  translation  for  the  Sydenham  Society.  In  the 
seventeenth  century  a  thorough  study  of  the  disease  was  made  by  the  illus- 
trious Sydenham,  who  still  remains  one  of  the  most  trustworthy  authorities 
on  the  subject. 

Special  events  in  the  history  of  the  disease  are  the  introduction  of  in- 
oculation into  Europe,  by  Lady  Mary  Wortley  Montagu,  in  1718,  and  the 
discovery  of  vaccination  by  Jenner,  in  1796. 

Small-pox  is  one  of  the  most  virulent  of  contagious  diseases,  and  per- 
sons exposed,  if  unprotected  by  vaccination,  are  almost  invariably  attacked. 
There  are  instances  on  record  of  persons  insusceptible  to  the  disease.  It  is 
said  that  Diemerbroeck,  a  celebrated  Utrecht  professor  in  the  seventeenth 
century,  was  not  only  himself  exempt,  but  likewise  many  members  of  his 
family.  One  of  the  nurses  in  the  small-pox  department  of  the  Montreal 
General  Hospital  stated  that  she  had  never  been  successfully  vaccinated, 
and  she  certainly  had  no  mark.  Such  instances,  however,  of  natural  im- 
munity are  "very  rare.  An  attack  may  not  protect  for  life.  There  are  un- 
doubted cases  of  a  second,  reputed  instances,  indeed,  of  a  third  attack. 

Age. — Small-pox  is  common  at  all  ages,  but  is  particularly  fatal  to  young 
children.  The  fceUis  in  utero  may  be  attacked,  but  only  if  the  mother 
herself  is  the  subject  of  the  disease.  The  child  may  be  born  with  the  rash 
out  or  with  the  scars.  More  commonly  the  fcetus  is  not  affected,  and 
children  born  in  a  small-pox  hospital,  if  vaccinated  immediately,,  may  escape 
the  disease ;  usually,  however,  they  die  early.  (See  Hunter's  works,  iv,  p.  74.) 

Sex. — Males  and  females  are  equally  affected. 

Race. — Among  aboriginal  races  small-pox  is  terribly  fatal.  When  the 
disease  was  first  introduced  into  America  the  Mexicans  died  by  thousands, 
and  the  North  American  Indians  have  also  been  frequently  decimated  by 
this  plague.  It  is  stated  that  the  negro  is  especially  susceptible,  and  the 
mortality  is  greater — about  42  per  cent  in  the  black,  against  39  per  cent  in 
the  white  (W.  M.  Welch). 

The  contagium  develops  in  the  system  of  the  small-pox  patient  and  is 
reproduced  in  the  pustules.     It  exists  in  the  secretions  and  excretions, 


SMALL-POX.  57 

and  in  the  exhalations  from  the  lungs  and  the  skin.  The  dried  scales  con- 
stitute by  far  the  most  important  element,  and  as  a  dust-like  powder  are 
distributed  everywhere  in  the  room  during  convalescence,  becoming  at- 
tached to  clothing  and  various  articles  of  furniture.  The  disease  is  proba- 
bly contagious  from  a  very  early  stage,  though  I  think  it  has  not  yet  been 
determined  whether  the  contagion  is  active  before  the  eruption  develops. 
The  poison  is  of  unusual  tenacity  and  clings  to  infected  localities.  It  is 
conveyed  by  persons  who  have  been  in  contact  with  the  sick  and  by  f omites. 
During  epidemics  it  is  no  doubt  widely  spread  in  street-cars  and  public 
conveyances.  It  must  not  be  forgotten  that  an  unprotected  person  may 
contract  a  very  virulent  form  of  the  disease  from  the  mild  varioloid.  Cer- 
tain facts  are  in  favor  of  aerial  transmission.  Within  a  three-quarter 
mile  radius  of  the  small-pox  ships  stationed  on  the  Thames  at  Purfieet 
(with  prevailing  winds  blowing  toward  the  village,  but  with  no  communi- 
cation between  the  ships  and  the  shore)  there  was  a  relative  great  increase 
in  the  number  of  cases.  (Thresh,  Lancet,  February  22,  1902.)  I  know  of 
no  more  striking  observation  in  favor  of  aerial  transmission. 

The  disease  smoulders  here  and  there  in  different  localities,  and  when 
conditions  are  favorable  becomes  epidemic.  There  has  been  lately  one  of 
the  periodical  revivals  of  the  disease.  According  to  the  Marine  Hospital 
Reports,  during  1899  there  were  11,136  cases  with  553  deaths,  during  1900 
there  were  20,362  cases  with  819  deaths,  and  to  May  3,  1901,  there  were 
22,344  cases  with  349  deaths.  The  disease  has  been  remarkably  mild — so 
mild,  indeed,  that  it  has  often  been  mistaken  for  chicken-pox.  In  Mont- 
real vaccination,  to  which  many  of  the  French  Canadians  were  opposed, 
had  been  neglected,  so  that  a  large  unprotected  population  grew  up  in  the 
city.  On  February  28,  1885,  a  Pullman-car  conductor,  who  had  travelled 
from  Chicago,  where  the  disease  had  been  slightly  prevalent,  was  admitted 
into  the  Hotel-Dieu,  the  civic  small-pox  hospital  being  at  the  time  closed. 
Isolation  was  not  carried  out,  and  on  the  1st  of  April  a  servant  in  the  hos- 
pital died  of  small-pox.  Following  her  decease,  with  a  negligence  abso- 
lutely criminal,  the  authorities  of  the  hospital  dismissed  all  patients  pre- 
senting no  symptoms  of  contagion,  who  could  go  home.  The  disease 
spread  like  fire  in  dry  grass,  and  within  nine  months  there  died  in  the 
city,  of  small-pox,  3,164  persons. 

The  nature  of  the  contagium  of  small-pox  is  still  doubtful.  Since  the 
issue  of  the  third  edition  of  this  work  in  1898,  Eoger  and  Weil  have  found 
special  bodies,  which  they  believe  to  be  parasites,  in  the  pus  and  blood ; 
Funck  has  found  another  protozoon,  sporidium  vaccinate,  and  Copeman 
has  obtained  zooglea  masses  made  up  of  bodies  resembling  spores,  which 
he  has  cultivated  in  collodion  capsules,  and  with  them  has  produced 
typical  vaccine  pustules  in  the  calf. 

Morbid  Anatomy. — A  section  of  a  papule  as  it  is  passing  into  the 
vesicular  stage  shows  in  the  rete  mucosum,  close  to  the  true  skin,  an  area 
in  which  the  cells  are  smooth,  granular,  and  do  not  take  the  staining  fluid. 
This  represents  a  focus  of  coagulation-necrosis  due,  according  to  Weigert, 
to  the  presence  of  micrococci.     Around  this  area  there  is  active  inflamma- 


58  SPECIFIC  INFECTIOUS  DISEASES. 

tory  reaction,  and  in  the  vesicular  stage  the  rete  mucosum  presents  re- 
ticuli,  or  spaces,  which  contain  serum,  leucocytes,  and  fibrin  filaments. 
The  central  depression  or  umbilication  corresponds  to  the  area  of  primary 
necrosis.  In  the  stage  of  maturation  the  reticular  spaces  become  filled 
with  leucocytes  and  many  of  the  cells  of  the  rete  mucosum  become  vesicu- 
lar. The  papillae  of  the  true  skin  below  the  pustule  are  swollen  and  infil- 
trated with  embryonic  cells  to  a  variable  degree.  If  the  suppuration  ex- 
tends into  this  layer,  scarring  inevitably  results ;  but  if  it  is  confined  to 
the  upper  layer,  this  does  not  necessarily  follow.  In  the  haemorrhagic  cases, 
red  corpuscles  pass  out  in  large  numbers  from  the  vessels  and  occupy  the 
vesicular  spaces.  They  infiltrate  also  the  deeper  layers  of  the  epidermis  in 
the  skin  adjacent  to  the  papules.  Frequently  a  hair-follicle  passes  through 
the  centre  of  a  papule. 

In  the  mouth  the  pustules  may  be  seen  upon  the  tongue  and  the  buccal 
mucosa,  and  on  the  palate.  The  eruption  may  be  abundant  also  in  the 
pharynx  and  the  upper  part  of  the  oesophagus.  In  exceptionally  rare  cases 
the  eruption  extends  down  the  oesophagus  and  even  into  the  stomach. 
Swelling  of  the  Peyer's  follicles  is  not  uncommon ;  the  pustules  have  been 
seen  in  the  rectum. 

In  the  larynx  the  eruption  may  be  associated  with  a  fibrinous  exudate 
and  sometimes  with  oedema.  Occasionally  the  inflammation  penetrates 
deeply  and  involves  the  cartilages.  In  the  trachea  and  bronchi  there  may 
be  ulcerative  erosions,  but  true  pocks,  such  as  are  seen  on  the  skin,  do  not 
occur.  There  are  no  special  lesions  of  the  lungs,  but  congestion  and  bron- 
cho-pneumonia are  very  common.  The  liver  is  sometimes  fatty.  A  diffuse 
hepatitis,  associated  with  intense  congestion  of  the  vessels  and  migration 
of  the  leucocytes,  has  been  described ;  Weigert  has  noted  small  areas  of 
necrosis. 

There  is  nothing  special  in  the  condition  of  the  blood,  and  even  in  the 
most  malignant  cases  there  are  no  microscopic  alterations.  In  the  blood- 
drop,  however,  it  will  be  seen  that  the  corpuscles,  instead  of  forming  rou- 
leaux, are  aggregated  into  irregular  clumps.  An  active  leucocytosis  is 
present.  The  heart  occasionally  shows  myocardial  changes,  parenchyma- 
tous and  fatty;  endocarditis  and  pericarditis  are  uncommon.  French 
writers  have  described  an  endarteritis  of  the  coronary  vessels  in  connection 
with  small-pox.  The  spleen  is  markedly  enlarged.  Apart  from  the  cloudy 
swelling  and  areas  of  coagulation-necrosis,  lesions  of  the  kidneys  are  not 
common.  Nephritis  may  occur  during  convalescence.  Chiari  has  called 
attention  to  the  frequency  of  orchitis  in  this  disease ;  there  are  scattered 
areas  of  necrosis  with  cell  infiltration. 

In  the  haemorrhagic  form  extravasations  are  found  on  the  serous  and 
mucous  surfaces,  in  the  parenchyma  of  organs,  in  the  connective  tissues, 
and  about  the  nerve-sheaths.  In  one  instance  I  found  the  entire  retro-  ^ 
peritoneal  tissue  infiltrated  with  a  large  coagulum,  and  there  were  also  ex- 
tensive extravasations  in  the  course  of  the  thoracic  aorta.  Haemorrhages 
in  the  bone-marrow  have  also  been  described  by  Golgi.  There  may  be 
haemorrhages  into  the  muscles.     Ponfick  has  described  the  spleen  as  very 


SMALL-POX.  59 

firm  and  hard  in  haemorrhagic  small-pox,  and  such  was  the  case  in  seven 
instances  which  I  examined.  The  liver  has  been  described  as  fatty  in 
these  rapid  cases,  but  in  5  of  my  7  cases  it  was  of  normal  size,  dense,  and 
firm.  In  2  it  was  large  and  fatty ;  but  one  man  had  necrosis  of  the  tibia, 
and  the  other  was  a  drunkard.  The  ecchymoses  are  scattered  over  the 
meninges  of  the  brain  and  cord,  and  in  one  case  there  was  a  clot  in  the 
right  ventricle.  In  5  of  the  cases  there  were  areas  of  haemorrhagic  infarc- 
tion of  the  lung.  In  four  instances  the  pelves  of  the  kidney  were  blocked 
with  dark  clots,  which  extended  into  the  calicos  and  down  the  ureters. 
In  one  instance  the  coats  of  the  bladder  were  uniformly  hsemorrhagic  and 
not  a  trace  of  normal  tissue  could  be  seen.  The  extravasations  in  the 
mucous  membrane  of  the  stomach  and  intestines  were  numerous  and  large. 
Peyer's  glands  were  swollen  and  prominent  in  four  instances. 
Symptoms. — Three  forms  of  small-pox  are  described : 

1.  Variola  vera ;  {a)  Discrete,  {b)  Confluent. 

2.  Variola  hmmorrhagica ;  (a)  Purpura  variolosa  or  black  small-pox; 
(b)  Hsemorrhagic  pustular  form,  variola  hgemorrhagica  pustulosa. 

3.  Varioloid,  or  small-pox  modified  by  vaccination. 

1.  Variola  Vera. — The  affection  may  be  conveniently  described  under 
various  stages :  (a)  Incubation. — "  From  nine  to  fifteen  days ;  oftenest 
twelve."  I  have  seen  it  develop  on  the  eighth  day  after  exposure  to  in- 
fection, and  there  are  well-authenticated  instances  in  which  the  stage  of 
incubation  has  been  prolonged  to  twenty  days.  It  is  unusual  for  patients 
to  complain  of  any  symptoms  in  this  stage. 

{b)  Invasion. — In  adults  a  chill  and  in  children  a  convulsion  are  com- 
mon initial  symptoms.  There  may  be  repeated  chills  within  the  first 
twenty-four  hours.  Intense  frontal  headache,  severe  lumbar  pains,  and 
vomiting  are  very  constant  features.  The  pains  in  the  back  and  in  the 
limbs  are  more  severe  in  the  initial  stage  of  this  than  of  any  other  erup- 
tive fever,  and  their  combination  with  headache  and  vomiting  is  so  sug- 
gestive that  in  epidemics  precautionary  measures  may  often  be  taken  sev- 
eral days  before  the  eruption  decides  positively  the  nature  of  the  disease. 
The  temperature  rises  quickly,  and  may  on  the  first  day  be  103°  or  104°. 
The  pulse  is  rapid  and  full,  not  often  dicrotic.  In  severe  cases  there  may 
be  marked  delirium,  particularly  if  the  fever  is  high.  The  patient  is  rest- 
less and  distressed,  the  face  is  flushed,  and  the  eyes  are  bright  and  clear. 
The  skin  is  usually  dry,  though  occasionally  there  are  profuse  sweats. 
One  can  not  judge  from  these  initial  symptoms  whether  a  case  is  likely 
to  be  discrete  or  confluent,  as  the  most  intense  backache  and  fever  may 
precede  a  very  mild  attack. 

In  this  stage  of  invasion  the  so-called  initial  rashes  may  occur,  of  which 
two  forms  can  be  distinguished — the  diffuse,  scarlatinal,  and  the  macular 
or  measly  form ;  either  of  which  may  be  associated  with  petechise  and  oc- 
cupy a  variable  extent  of  surface.  In  some  instances  they  are  general,  but 
as  a  rule  they  are  limited,  as  pointed  out  by  Simon,  either  to  the  lower 
abdominal  areas,  to  the  inner  surfaces  of  the  thighs,  and  to  the  lateral 
thoracic  region,  or  to  the  axillae.     Occasionally  they  are  found  over  the 


60 


SPECIFIC  INFECTIOUS  DISEASES. 


extensor  surf  aces,. particularly  in  the  neighborhood  of  the  knees  and  elbows. 
These  rashes,  usually  purpuric,  are  often  associated  with  an  erythematous 
or  erysipelatous  blush.  The  scarlatinal  rash  may  come  out  as  early  as  the 
second  day  and  be  as  diffuse  and  vivid  as  in  a  true  scarlatina.  The  measly 
rash  may  also  be  diffuse  and  identical  in  character  with  that  of  measles. 
Urticaria  is  only  occasionally  seen.  It  was  present  once  in  my  Montreal 
cases.    Apparently  these  initial  rashes  are  more  abundant  in  some  epidemics 


2        3        4        5         6        7 


10        11        12       13        14       15        16        17        18 


104°  F.— 40-0' 


102-2'  F— sg-o" 


100-4''  F.— 38-0' 


1-6°  F.— 37  0" 


^■■■■■H 

■■^{■■■■■■■■■■MWglBHBBWBiWMMiMMBBlMMBM 

BBilSBBniBPiSSai^KBBBBBlllBIHB 


Initial  Fever  Eruption.  Suppurative  Fever. 

Chart  VI. — True  small-pox  (Striimpell). 

than  in  others ;  thus  they  were  certainly  more  numerous  in  the  Montreal 
epidemics  between  1870  and  1875  than  they  were  in  the  more  extensive 
epidemic  in  1885.  They  occur  in  from  10  to  16  per  cent  of  cases.  In  the 
cases  under  my  care  in  the  small-pox  department  at  the  Montreal  General 
Hospital  the  percentage  was  13.*  As  will  be  subsequently  mentioned  these 
initial  rashes  have  considerable  diagnostic  value. 

(c)  Eruption. — (1)  In  the  discrete  form,  usually  on  the  fourth  day, 
small  red  spots  appear  on  the  forehead,  particularly  at  the  junction  with 
the  hair,  and  on  the  wrists.  Within  the  first  twenty-four  hours  from  their 
appearance  they  occur  on  other  parts  of  the  face  and  on  the  extremities, 
and  a  few  are  seen  on  the  trunk.  As  the  rash  comes  out  the  temperature 
falls,  the  general  symptoms  subside,  and  the  patient  feels  comfortable.  On 
the  fifth  or  sixth  day  the  papules  change  into  vesicles  with  clear  summits. 
Each  one  is  elevated,  circular,  and  presents  a  little  depression  in  the  centre, 
the  so-called  umbilication.  About  the  eighth  day  the  vesicles  change  into 
pustules,  the  umbilication  disappears,  the  flat  top  assumes  a  globular  form 
and  becomes  grayish  yellow  in  color,  owing  to  the  contained  pus.  There 
is  an  areola  of  injection  about  the  pustules  and  the  skin  between  them  is 
swollen.  This  maturation  first  takes  place  on  the  face,  and  follows  the 
order  of  the  appearance  of  the  eruption.  The  temperature  now  rises — 
secondary  fever — and  the  general  symptoms  return.  The  swelling  about 
the  pustules  is  attended  with  a  good  deal  of  tension  and  pain  in  the  face  ; 


*  The  Initial  Rashes  of  Small-pox.     Canada  Medical  and  Surgical  Journal,  1875. 


SMALL-POX.         -  Qi 

the  eyelids  become  swollen  and  closed.  There  is  a  well-marked  leucocyto- 
sis  in  the  stage  of  suppuration.  In  the  discrete  form  the  temperature  of 
maturation  does  not  usually  remain  high  for  more  than  twenty-four  or 
twenty-six  hours,  so  that  on  the  tenth  or  eleventh  day  the  fever  disappears 
and  the  stage  of  convalescence  begins.  The  pustules  rapidly  dry,  first  on 
the  face  and  then  on  the  other  parts,  and  by  the  fourteenth  or  fifteenth 
day  desquamation  may  be  far  advanced  on  the  face.  There  may  be  in 
addition  vesicles  in  the  mouth,  pharynx,  and  larynx,  causing  soreness  and 
swelling  in  these  parts,  with  loss  of  voice.  Whether  pitting  takes  place 
depends  a  good  deal  upon  the  severity  of  the  disease.  In  a  majority  of 
cases  Sydenham's  statement  holds  good,  that  "  it  is  very  rarely  the  case  that 
the  distinct  small-pox  leaves  its  mark." 

(2)  The  Confluetit  Form. — With  the  same  initial  symptoms,  though 
usually  of  greater  severity,  the  rash  appears  on  the  fourth,  or,  according  to 
Sydenham,  on  the  third  day.  The  more  the  eruption  shows  itself  before 
the  fourth  day,  the  more  sure  it  is  to  become  confluent  (Sydenham).  The 
papules  at  first  may  be  isolated  and  it  is  only  later  in  the  stage  of  matu- 
ration that  the  eruption  is  confiuent.  But  in  severer  cases  the  skin  is 
swollen  and  hyperaemic  and  the  papules  are  very  close  together.  On  the 
feet  and  hands,  too,  the  papules  are  thickly  set ;  more  scattered  on  the 
limbs;  and  quite  discrete  on  the  trunk.  With  the  appearance  of  the 
eruption  the  symptoms  subside  and  the  fever  remits,  but  not  to  the  same 
extent  as  in  the  discrete  form.  Occasionally  the  temperature  falls  to  nor- 
mal and  the  patient  may  be  very  comfortable.  Then,  usually  on  the  eighth 
day,  the  fever  again  rises,  the  vesicles  begin  to  change  to  pustules,  the 
hyperaemia  about  them  becomes  intense,  the  swelling  of  the  face  and 
hands  increases,  and  by  the  tenth  day  the  pustules  have  fully  maturated, 
many  of  them  have  coalesced,  and  the  entire  skin  of  the  head  and  extremi- 
ties is  a  superficial  abscess.  The  fever  rises  to  103°  or  104°,  the  pulse  is 
from  110  to  120,  and  there  is  often  delirium.  As  pointed  out  by  Syden- 
ham, salivation  in  adults  and  diarrhoea  in  children  are  common  symptoms 
of  this  stage.  There  is  usually  much  thirst.  The  eruption  may  also  be 
present  in  the  mouth,  and  usually  the  pharynx  and  larynx  are  involved  and 
the  voice  is  husky.  Great  swelling  of  the  cervical  lymphatic  glands  occurs. 
At  this  stage  the  patient  presents  a  terrible  picture,  unequalled  in  any 
other  disease ;  one  which  fully  justifies  the  horror  and  fright  with  which 
small-pox  is  associated  in  the  public  mind.  Even  when  the  rash  is  con- 
fluent on  the  face,  hands,  and  feet,  the  pustules  remain  discrete  on  the 
trunk.  The  danger,  as  pointed  out  by  Sydenham,  is  in  proportion  to  the 
number  upon  the  face.  "  If  upon  the  face  they  are  as  thick  as  sand  it  is 
no  advantage  to  have  them  few  and  far  between  on  the  rest  of  the  body." 
In  fatal  cases,  by  the  tenth  or  eleventh  day  the  pulse  gets  feebler  and  more 
rapid,  the  delirium  is  marked,  there  is  subsultus,  sometimes  diarrhoea,  and 
with  these  symptoms  the  patient  dies.  In  other  instances  between  the 
eighth  and  eleventh  day  hgemorrhagic  symptoms  develop.  When  recov- 
ery takes  place,  the  patient  enters  on  the  eleventh  or  twelfth  6.iiY  the 
period  of — 


62  SPECIFIC  INFECTIOUS  DISEASES. 

(fZ)  Desiccatio?i. — The  pustules  break  and  the  pus  exudes  and  forms 
crusts.  Throughout  the  third  week  the  desiccation  proceeds  and  in  cases 
of  moderate  severity  the  secondary  fever  subsides ;  but  in  others  it  may 
persist  until  the  fourth  week.  The  crusts  in  confluent  small-pox  adhere 
for  a  long  time  and  the  process  of  scarring  may  take  three  or  four  weeks. 
The  crusts  on  the  face  fall  off,  but  the  tough  epidermis  of  the  hands  and 
feet  may  be  shed  entire.  We  had  in  the  small-pox  department  of  the 
Montreal  General  Hospital  several  moulds  in  epithelium  of  the  hands  and 
feet. 

2.  HeBmorrliagic  small-pox  occurs  in  two  forms.  In  one  the  special 
symptoms  appear  early  and  death  follows  in  from  two  to  six  days.  This 
is  the  so-called  petechial  or  black  small-pox — -purpura  variolosa.  In  the 
other  form  the  case  progresses  as  one  of  ordinary  variola,  and  it  is  not 
until  the  vesicular  or  pustular  stage  that  haemorrhage  takes  place  into  the 
pocks  or  from  the  mucous  membranes.  This  is  sometimes  called  variola 
hmmorrhagica  pustulosa. 

Hfemorrhagic  small-pox  is  more  common  in  some  epidemics  than  in 
others.  It  is  less  frequent  in  children  than  in  adults.  Of  27  cases  ad- 
mitted to  the  small-pox  department  of  the  Montreal  General  Hospital 
there  were  3  under  ten  years,  4  between  fifteen  and  twenty,  9  between 
twenty  and  twenty-five,  7  between  twenty-five  and  thirty-five,  3  between 
thirty-five  and  forty-five,  and  1  above  fifty.  Young  and  vigorous  persons 
seem  more  liable  to  this  form.  Several  of  my  cases  were  above  the  aver- 
age in  muscular  development.  Men  are  more  frequently  affected  than 
women ;  thus  in  my  list  there  were  21  males  and  only  6  females.  The 
infiuence  of  vaccination  is  shown  in  the  fact  that  of  the  cases  14  were  un- 
yaccinated,  while  not  one  of  the  13  who  had  scars  had  been  revaccinated. 

The  clinical  features  of  the  forms  of  haemorrhagic  small-pox  are  some- 
what different. 

In  purpura  variolosa  the  illness  starts  with  the  usual  symptoms,  but 
with  more  intense  constitutional  disturbance.  On  the  evening  of  the 
second  or  on  the  third  day  there  is  a  diffuse  hyperaemic  rash,  particularly 
in  the  groins,  with  small  punctiform  hemorrhages.  The  rash  extends, 
becomes  more  distinctly  hsemorrhagic,  and  the  spots  increase  in  size. 
Ecchymoses  appear  on  the  conjunctivae,  and  as  early  as  the  third  day 
there  may  be  hemorrhages  from  the  mucous  membranes.  Death  may 
take  place  before  the  rash  appears.  This  is  truly  a  terrible  affection  and 
well  developed  cases  present  a  frightful  appearance.  The  skin  may  have 
a  uniformly  purplish  hue  and  the  unfortunate  victim  may  even  look  plum- 
colored.  The  face  is  swollen  and  large  conjunctival  hemorrhages  with 
the  deeply  sunken  cornee  give  a  ghastly  appearance  to  the  features.  The 
mind  may  remain  clear  to  the  end.  Death  occurs  from  the  third  to  the 
sixth  day ;  thus  in  thirteen  of  my  cases  it  took  place  between  these  dates. 
The  earliest  death  was  on  the  third  day  and  there  were  no  traces  of 
papules.  There  may  be  no  mucous  hemorrhages ;  thus  in  one  case  of  a 
most  virulent  character  death  occurred  without  bleeding  early  on  the  fourth 
day.    Haematuria  is  perhaps  most  common,  next  hematemesis,  and  melena 


SMALL-POX.  63 

■was  noticed  in  a  third  of  the  cases.  Metrorrhagia  was  present  in  one  only 
of  the  six  females  on  my  list.  Haemoptysis  occurred  in  five  cases.  The 
pulse  in  this  form  of  small-pox  is  rapid  and  often  hard  and  small.  The 
respirations  are  greatly  increased  in  frequency  and  out  of  all  proportion  to 
the  intensity  of  the  fever.  In  the  case  of  a  negro,  whose  respirations 
the  morning  after  admission  were  32  and  temperature  101°,  after  examin- 
ing the  lungs  and  finding  nothing  to  account  for  the  relatively  rapid 
breathing,  my  suspicions  were  aroused,  and  even  on  the  dark  skin  I  was 
able  on  careful  inspection  to  detect  hsemorrhages  in  and  about  the  papules. 
In  variola pushilosa  JiCBmorrhagica  the  disease  progresses  as  an  ordinary 
case  of  severe  variola,  and  the  hsemorrhages  do  not  develop  until  the  vesicu- 
lar or  pustular  stage.  The  earlier  the  hsemorrhage  the  greater  is  the  dan- 
ger. There  are  undoubtedly  instances  of  recovery  when  the  bleeding  has 
taken  place  at  the  stage  of  maturation.  Bleeding  from  the  mucous  mem- 
branes is  also  common  in  this  form,  and  the  great  majority  of  the  cases 
prove  fatal,  usually  on  the  seventh,  eighth,  or  ninth  day. 

There  is  a  form  of  haemorrhagic  small-pox  in  which  bleeding  takes 
place  into  the  pocks  in  the  vesicular  stage  and  is  followed  by  a  rapid 
abortion  of  the  rash  and  a  speedy  recovery.  Six  instances  of  this  kind 
came  under  my  observation.* 

Variations  in  the  Virulence  of  Epidemics. — Sydenham  states  that 
"  small-pox  also  has  its  peculiar  kinds,  which  take  one  form  during  one 
series  of  years,  and  another  during  another."  0.  J.  Porter  calls  attention 
to  the  fact  that  John  Mason  Good,  in  his  Study  of  Medicine,  describes 
a  number  of  very  mild  outbreaks,  some  of  which  were  mistaken  for 
chicken-pox.  Not  only  does  what  Sydenham  calls  the  epidemic  consti- 
tution vary  greatly,  but  one  sometimes  sees  the  most  extraordinary  varia- 
tions in  the  intensity  of  the  disease  in  members  of  a  family  all  exposed 
to  the  same  infection. 

3.  Varioloid. — This  term  is  applied  to  the  modified  form  of  small-pox 
which  aifects  persons  who  have  been  vaccinated.  It  may  set  in  with 
abruptness  and  severity,  the  temperature  reaching  103°.  More  commonly 
it  is  in  every  respect  milder  in  its  initial  symptoms,  though  the  headache 
and  backache  may  be  very  distressing.  The  papules  appear  on  the  even- 
ing of  the  third  or  on  the  fourth  day.  They  are  few  in  number  and  may 
be  confined  to  the  face  and  hands.  The  fever  drops  at  once  and  the  pa- 
tient feels  perfectly  comfortable.  The  vesiculation  and  maturation  of  the 
pocks  take  place  rapidly  and  there  is  no  secondary  fever.  There  is  rarely 
any  scarring.  As  a  rule,  when  small-pox  attacks  a  person  who  has  been 
vaccinated  within  five  or  six  years  the  disease  is  mild,  but  there  are  in- 
stances in  which  it  is  very  severe,  and  it  may  even  prove  fatal. 

There  are  several  forms  of  rash ;  thus  in  what  has  been  known  as  horn- 
pox,  crystalline  pox,  and  wart-pox  the  papules  come  out  in  numbers  on  the 
third  or  fourth  day,  and  by  the  fifth  or  sixth  day  have  dried  to  a  hard, 
horny  consistence. 

*  Clinical  Notes  on  Small-pox.    Montreal,  1876. 


64  SPECIFIC  INFECTIOUS  DISEASES. 

Writers  describe  a  variola  sine  eruptione,  wMcli  is  met  with  during  ejji- 
demics  in  young  persons  wlio  have  been  well  vaccinated,  and  who  present 
simply  the  initial  symptoms  of  fever,  headache,  and  backache.  In  a  some- 
what extensive  experience  in  Montreal  I  do  not  remember  to  have  met  with 
an  instance  of  this  kind,  or  indeed  to  have  heard  of  one. 

We  do  not  now  see  the  modified  form  of  small-pox,  resulting  from  in- 
oculation, in  which  by  the  seventh  or  eighth  day  a  pustule  forms  at  the 
seat  of  inoculation ;  after  this  general  fever  sets  in,  and  with  it,  about  the 
eleventh  day,  appears  a  general  eruption,  usually  limited  in  degree. 

Complications. — Considering  the  severity  of  many  of  the  cases  and 
the  general  character  of  the  disease,  associated  with  multiple  foci  of  sup- 
puration, the  complications  in  small-pox  are  remarkably  few. 

Laryngitis  is  serious  in  three  ways :  it  may  produce  a  fatal  cedema  of 
the  glottis  ;  it  is  liable  to  extend  and  involve  the  cartilages,  producing 
necrosis ;  and  by  diminishing  the  sensibility  of  the  larynx,  it  may  allow 
irritating  particles  to  reach  the  lower  air-passages,  where  they  excite 
bronchitis  or  broncho-pneumonia. 

Broncho-pneumonia  is  indeed  one  of  the  most  common  complications, 
and  is  almost  invariably  present  in  fatal  cases.  Lobar  pneumonia  is  rare. 
Pleurisy  is  common  in  some  epidemics. 

The  cardiac  complications  are  also  rare.  In  the  height  of  the  fever  a 
systolic  murmur  at  the  apex  is  not  uncommon ;  but  endocarditis,  either 
simple  or  malignant,  is  rarely  met  with.  Pericarditis  too  is  very  uncom- 
mon. Myocarditis  seems  to  be  more  frequent,  and  may  be  associated  with 
endarteritis  of  the  coronary  vessels. 

Of  complications  in  the  digestive  system,  parotitis  is  rare.  In  severe 
cases  there  is  extensive  pseudo-diphtheritic  angina.  Vomiting,  which  is 
so  marked  a  symptom  in  the  early  stage,  is  rarely  persistent.  Diarrhoea 
is  not  uncommon,  as  noted  by  Sydenham,  and  is  very  constantly  present 
in  children.  ^» 

Albuminuria  is  frequent,  but  true  nephritis  is  rare.  Inflammation  of 
the  testes  and  of  the  ovaries  may  occur. 

Among  the  most  interesting  and  serious  complications  are  those  per- 
taining to  the  nervous  system.  In  children  convulsions  are  common.  In 
adults  the  delirium  of  the  early  stage  may  persist  and  become  violent,  and 
finally  subside  into  a  fatal  coma.  Post-febrile  insanity  is  occasionally  met 
with  during  convalescence,  and  very  rarely  epilepsy.  Many  of  the  old 
writers  spoke  of  paraplegia  in  connection  with  the  intense  backache  of 
the  early  stage,  but  it  is  probably  associated  with  the  severe  agonising 
lumbar  and  crural  pains  and  is  not  a  true  paraplegia.  It  must  be  distin- 
guished from  the  form  occurring  in  convalescence,  which  may  be  due  to 
peripheral  neuritis  or  to  a  diffuse  myelitis  (Westphal).  The  neuritis  may, 
as  in  diphtheria,  involve  the  pharynx  alone,  or  it  may  be  multiple.  Of  this 
nature,  in  all  probability,  is  the  so-called  pseudo-tabes,  or  ataxie  varioUque. 
Hemiplegia  and  aphasia  have  been  met  with  in  a  fe^v  instances,  the  result 
of  encephalitis. 

Among  the  most  constant  and  troublesome  complications  of  small-pox 


SMALL-POX.  65 

are  those  involving  the  skin.  During  convalescence  boils  are  very  fre- 
quent and  may  be  severe.  Acne  and  ecthyma  are  also  met  with.  Local 
gangrene  in  various  parts  may  occur. 

Arthritis  may  develop,  usually  in  the  period  of  desquamation,  and  may 
pass  on  to  suppuration.  Acute  necrosis  of  the  bone  is  sometimes  met 
with. 

A  remarkable  secondary  eruption  (recurrent  small-pox)  occasionally 
occurs  after  desquamation. 

Special  Seiises. — The  eye  affections  which  were  formerly  so  common 
and  serious  are  not  now  so  frequent,  owing  to  the  care  which  is  given  to 
keeping  the  conjunctivae  clean.  A  catarrhal  and  purulent  conjunctivitis 
is  common  in  severe  cases.  The  secretions  cause  adhesions  of  the  eyelids, 
and  unless  great  care  is  taken  a  diffuse  keratitis  is  excited,  which  may  go 
on  to  ulceration  and  perforation.  Iritis  is  not  very  uncommon.  Otitis 
media  is  an  occasional  complication,  and  usually  results  from  an  extension 
of  the  disease  through  the  Eustachian  tubes. 

Prognosis. — In  unprotected  persons  small-pox  is  a  very  fatal  disease. 
In  different  epidemics  the  death-rate  is  from  25  to  35  per  cent.  In  Wil- 
liam M.  Welch's  report  from  the  Municipal  Hospital,  Philadelphia,  of 
2,831  cases  of  variola,  1,534 — i.  e.,  54.18  per  cent — died,  while  of  2,169 
cases  of  varioloid  only  28 — i.  e.,  1.29  per  cent — died.  Purpura  variolosa  is 
invariably  fatal,  and  a  majority  of  those  attacked  with  the  severer  confluent 
forms,  die.  In  young  children  it  is  particularly  fatal.  In  the  Montreal 
epidemic  of  1885  and  1886,  of  3,164  deaths  there  were  2,717  under  ten 
years.  The  intemperate  and  debilitated  succumb  more  readily  to  the  dis- 
ease. As  Sydenham  observed,  the  danger  is  directly  proportionate  to  the 
intensity  of  the  disease  on  the  face  and  hands.  "  When  the  fever  increases 
after  the  apjDearance  of  the  pustules,  it  is  a  bad  sign ;  but,  if  it  is  lessened 
on  their  appearance,  that  is  a  good  sign  "  (Rhazes).  Very  high  fever,  with 
delirium  and  subsultus,  are  symptoms  of  ill  omen.  The  disease  is  particu- 
larly fatal  in  pregnant  women  and  abortion  usually  takes  place.  It  is  not, 
however,  uniformly  so,  and  I  have  twice  known  severe  cases  to  recover 
after  miscarriage.  Moreover,  abortion  is  not  inevitable.  Very  severe 
pharyngitis  and  laryngitis  are  fatal  complications. 

Death  resvilts  in  the  early  stage  from  the  action  of  the  poison  upon  the 
nervous  system.  In  the  later  stages  it  usually  occurs  about  the  eleventh 
or  twelfth  day,  at  the  height  of  the  eruption.  In  children,  and  occasion- 
ally in  adults,  the  laryngeal  and  pulmonary  complications  prove  fatal. 

Diagnosis. — During  an  epidemic  the  initial  chill,  the  headache  and 
backache,  and  the  vomiting  at  once  put  the  physician  on  his  guard. 

The  initial  rashes  may  lead  to  error.  The  scarlatinal  rash  has  rarely 
the  extent  and  never  the  persistence  of  the  rash  in  true  scarlet  fever.  I 
have  known  the  rash  of  measles  to  be  mistaken  for  the  initial  rash  of- 
small-pox.  The  general  condition  of  the  patient,  and  the  presence  of 
coryza  and  conjunctivitis  and  Koplik's  sign,  may  be  better  guides  than  the 
rash  itself. 

Malignant  hjEmorrhagic  small-pox  may  prove  fatal  before  the  charac- 


QQ  SPECIFIC  INFECTIOUS  DISEASES. 

teristic  rash  appears.  In  1  of  27  cases  of  hemorrhagic  small-pox,  in  which 
death  occurred  on  the  third  day,  inspection  failed  to  show  the  papules. 
In  3  cases  dying  on  the  fourth  day  the  characteristic  papular  rash  was 
noticed.  It  may  be  diflBcult  or  impossible  to  recognize  latent  hsemorrhagic 
small-pox  from  hmmorrhagic  scarlet  fever  or  licemorrhagic  measles,  though 
in  the  latter  there  is  rarely  so  constant  involvement  of  the  mucous  mem- 
branes. K'aturally  enough,  as  they  are  allied  affections,  varicella  is  the 
disease  which  most  frequently  leads  to  error.  Particularly  has  this  been 
the  case  in  the  mild  epidemic  which  has  prevailed  throughout  the  country 
during  the  past  three  years.  A  negro  patient  was  admitted  to  my  wards 
on  the  fourth  day  of  the  disease.  Small-pox  was  not  prevalent  at  the  time, 
and  the  case  was  regarded  as  one  of  varicella.  Subsequently  eight  cases 
appeared,  several  of  exceeding  mildness,  but  our  mistake  was  forcibly 
brought  home  to  us  by  the  occurrence,  in  a  man  who  had  been  exposed  in 
the  ward,  of  a  case  of  confluent  small-pox  of  great  severity.  The  following 
points  are  to  be  borne  in  mind :  first,  the  experience  of  the  past  few  years 
has  shown  that  very  mild  epidemics  of  true  small-pox  may  occur ;  secondly, 
any  large  number  of  cases  of  a  contagious  disease  with  a  pustular  eruption 
occurring  in  adults  is  strongly  in  favor  of  small-pox.  The  characters  of 
the  rash  are  of  less  value.  Its  abundance  on  the  trunk  in  varicella  is 
important.  At  the  outset  the  papules  have  rarely  the  shotty,  hard  feel  of 
small-pox.  The  vesicles  are  more  superficial,  the  infiltrated  areola  is  not 
so  intense  nor  so  constant,  and  as  a  rule  the  pocks  may  be  seen  in  the  same 
patient  in  all  stages  of  development.  The  longer  period  of  invasion,  the 
prodromal  rashes,  the  greater  intensity  of  the  onset,  are  also  important 
points  in  small-pox.  But,  as  I  have  said,  there  are  mild  epidemics  in 
which  it  must  be  confessed  that  the  recognition  of  the  nature  of  the  out- 
break is  sometimes  only  confirmed  by  the  appearance  of  a  genuine  case  of 
the  confluent  or  of  the  hsemorrhagic  form. 

The  disease  may  be  mistaken  for  cerelro-spinal  fever,  in  which  purpuric 
symptoms  are  not  uncommon.  A  four-year-old  child  was  taken  suddenly 
ill  with  fever,  pains  in  the  back  and  head,  and  on  the  second  or  third  day 
petechise  appeared  on  the  skin.  There  were  retraction  of  the  head,  and 
marked  rigidity  of  the  limbs.  The  hsemorrhages  became  more  abundant ; 
and  finally  hsematemesis  occurred  and  the  child  died  on  the  sixth  day.  At 
the  post  mortem  there  were  no  lesions  of  cerebro-spinal  fever,  and  in  the 
deeply  hsemorrhagic  skin  the  papules  could  be  readily  seen.  The  post- 
mortem diagnosis  of  small-pox  was  unhappily  confirmed  by  the  mother 
taking  the  disease  and  dying  of  it. 

Pustular  SypMlides.—k  very  copious  pustular  rash  in  syphilis  may 
resemble  variola,  particularly  if  accompanied  by  fever,  but  the  history  and 
the  distribution,  particularly  the  slight  amount  on  the  face,  leaves  no 
question  as  to  the  diagnosis. 

Pustular  glanders  has  been  mistaken  for  small-pox.  In  a  remarkable 
instance  of  the  kind  in  Montreal  there  was  a  widespread  pustular  erup- 
tion, which  we  thought  at  first  was  small-pox,  but  the  subsequent  course 
and  the  fact  that  there  was  glanders  among  the  horses  in  the  stable  led 


SMALL-POX.  67 

to  the  correct  diagnosis.  The  eruption  resembled  exactly  that  given  in 
Bayer's  plate. 

Impetigo  contagiosa  is  stated  to  have  been  mistaken  for  variola. 

Blood  Examination. — There  is  always  a  leucocytosis,  and  several  French 
observers  have  of  late  claimed  that  there  is  a  characteristic  leucocytic 
index  in  the  disease.  The  large  mononuclears  are  increased  to  from  4  to 
10  per  cent,  the  myelocytes  to  from  2  to  10  per  cent.  The  nucleated  reds 
are  also  seen,  especially  in  the  hsemorrhagic  form. 

Treatment. — In  the  interests  of  public  health  cases  of  small-pox 
should  invariably  be  removed  to  special  hospitals,  since  it  is  impossible 
to  take  the  proper  precautions  in  private  houses.  The  general  hygienic 
arrangements  of  the  room  should  be  suitable  for  an  infectious  disease. 
All  unnecessary  furniture  and  the  curtains  and  carpets  should  be  removed. 
The  greatest  care  should  be  taken  to  keep  the  patient  thoroughly  clean, 
and  the  linen  should  be  frequently  changed.  The  bedclothing  should  be 
light.  It  is  curious  that  the  old-fashioned  notion,  which  Sydenham  tried 
so  hard  to  combat,  that  small-pox  patients  should  be  kept  hot  and  warm, 
still  prevails;  and  I  have  frequently  had  to  protest  against  the  patient 
being,  as  Sydenham  expresses  it,  stifled  in  his  bed.  Special  care  should 
be  taken  to  sterilize  thoroughly  everything  that  has  been  in  contact  with 
the  patient. 

In  the  early  stage  the  pain  in  the  back  and  limbs  requires  opium, 
which,  as  advised  by  Sydenham,  may  be  freely  given.  The  diet  should 
consist  of  milk  and  broths,  and  of  "  all  articles  which  give  no  trouble  to 
digestion."  Cold  drinks  may  be  freely  given.  Barley-water  and  the 
Scotch  borse  (oatmeal  and  water)  are  both  nutritious  and  palatable. 
After  the  preliminary  vomiting,  which  is  often  very  hard  to  check  by 
ordinary  measures,  the  appetite  is  usually  good,  and,  if  the  throat  is  not 
very  sore,  patients  with  the  confluent  form  take  nourishment  well.  In 
the  hgemorrhagic  cases  the  vomiting  is  usually  aggravated  and  persistent. 

The  fever  when  high  must  be  kept  within  limits,  and  it  is  best  to  use 
either  cold  sponging  or  the  cold  bath.  When  the  pyrexia  is  combined 
with  delirium  and  subsultus,  the  patient  should  be  placed  in  a  bath  at  70°, 
and  this  repeated  as  often  as  every  three  hours  if  the  temperature  rises 
above  103°.  When  it  is  not  practicable  to  give  the  cold  bath,  the  cold 
pack  can  be  employed.  These  measures  are  much  preferable  in  small-pox 
to  the  administration  of  medicinal  antipyretics. 

The  treatment  of  the  eruption  has  naturally  engaged  the  special  atten- 
tion of  the  profession.  The  question  of  the  preventing  of  pitting,  so  much 
discussed,  is  really  not  in  the  hands  of  the  physician.  It  depends  entirely 
upon  the  depth  to  which  the  individual  pustules  reach.  After  trying  all 
sorts  of  remedies,  such  as  puncturing  the  pustules  with  nitrate  of  silver,  or 
treating  them  with  iodine  and  various  ointments,  I  came  to  Sydenham's 
conclusion  that  in  guarding  the  face  against  being  disfigured  by  the  scars 
"the  only  effect  of  oils,  liniments,  and  the  like,  was  to  make  the  white 
scurfs  slower  in  coming  off."  There  is,  I  believe,  something  in  protecting 
the  ripening  papules  from  the  light,  and  the  constant  application  on  the 


68  SPECIFIC  INFECTIOUS  DISEASES. 

face  and  hands  of  lint  soaked  in  cold  water,  to  which  antiseptics  such  as 
carbolic  acid  or  bichloride  may  be  added,  is  perhaps  the  most  suitable 
local  treatment.  It  is  very  pleasant  to  the  patient,  and  for  the  face  it  is 
well  to  make  a  mask  of  lint,  which  can  then  be  covered  with  oiled  silk. 
When  the  crusts  begin  to  form,  the  chief  point  is  to  keep  them  thoroughly 
moist,  which  may  be  done  with  oil  or  glycerin.  This  prevents  the  desicca- 
tion and  difEusion  of  the  flakes  of  epidermis.  Vaseline  is  particularly  use- 
ful, and  at  this  stage  may  be  freely  used  upon  the  face.  It  frequently 
relieves  the  itching  also.  For  the  odor,  which  is  sometimes  so  character- 
istic and  disagreeable,  the  dilute  carbolic  solutions  are  probably  best.  If 
the  eruption  is  abundant  on  the  scalp,  the  hair  should  be  cut  short  to 
prevent  matting  and  decomposition  of  the  crusts.  During  convalescence 
frequent  bathing  is  advisable,  because  it  helps  to  soften  the  crusts.  The 
care  of  the  eyes  is  particularly  important.  The  lids  should  be  thoroughly 
cleansed  three  or  four  times  a  day,  and  the  conJunctivEe  washed  with  some 
antiseptic  solution.  In  the  confluent  cases,  when  the  eyelids  are  much 
swollen  and  the  lids  glued  together,  it  is  only  by  watchfulness  that  kerati- 
tis can  be  prevented.  The  mouth  and  throat  should  be  kept  clean,  and  if 
crusts  form  in  the  nose  they  should  be  softened  by  frequent  injections. 
Ice  can  be  given,  and  is  very  grateful  when  there  is  much  angina.  In 
moderate  cases,  so  soon  as  the  fever  subsides  the  patient  should  be  allowed 
"to  get  up,  a  practice  which  Sydenham  warmly  urged.  The  diarrhoea,  when 
severe,  should  be  checked  with  paregoric.  When  the  pulse  becomes  feeble 
and  rapid,  stimulants  may  be  freely  given.  The  delirium  is  occasionally 
maniacal  and  may  require  chloroform,  but  for  the  nervous  symptoms  the 
bath  or  cold  pack  is  the  best.  For  the  severe  hgemorrhages  of  the  malig- 
nant cases  nothing  can  be  done,  and  it  is  only  cruel  to  drench  the  unfortu- 
nate patient  with  iron,  ergot,  and  other  drugs.  Symptoms  of  obstruction 
in  the  larynx,  usually  from  oedema,  may  call  for  tracheotomy.  In  the  late 
stages  of  the  disease,  should  the  patient  b:  extremely  debilitated  and  the 
subject  of  abscesses  and  bed-sores,  he  may  be  placed  on  a  water-bed  or 
treated  by  the  continuous  warm  bath.  During  convalescence  the  patient 
should  bathe  daily  and  use  carbolic  soap  freely  in  order  to  get  rid  of  the 
crusts  and  scabs.  He  should  not  be  considered  without  danger  to  others 
until  the  skin  is  perfectly  smooth  and  clean,  and  free  from  any  trace  of 
scabs.  I  have  not  mentioned  any  of  the  so-called  specifics  or  the  inter- 
nal antiseptics,  which  have  been  advised  in  such  numbers ;  so  far  as  I 
know,  those  who  have  had  the  widest  experience  with  the  disease  do 
not  favor  their  use. 

V.  VACCINIA  {(7oM;-i?oa:)— VACCINATION. 

Definition. — An  eruptive  disease  of  the  coW;,  the  virus  of  which,  inocu- 
lated into  man  (vaccination),  produces  a  local  pock  with  constitutional 
disturbance,  Avhich  affords  protection,  more  or  less  permanent,  against 
small-pox. 

The  vaccine  is  got  either  directly  from  the  calf — animal  lymph — in 


VACCINIA— VACCINATION.  69 

which  the  disease  is  propagated  at  regular  stations,  or  is  obtained  from 
persons  vaccinated  (hnmanized  lymph). 

History. — For  centuries  it  had  been  a  popular  belief  among  farmer 
folk  that  cow-pox  protected  against  small-pox.  It  is  said  that  the  notorious 
Duchess  of  Cleveland,  replying  to  some  joker  who  suggested  that  she  would 
lose  her  occupation  if  she  was  disfigured  with  small-pox,  said  that  she  was 
not  afraid  of  the  disease,  as  she  had  had  cow-pox.  Jesty,  a  Dorsetshire 
farmer,  had  had  cow-pox,  and  in  1774  vaccinated  successfully  his  wife  and 
two  sons.  Plett,  in  Holstein,  in  1791,  also  successfully  vaccinated  three 
children.  When  Jenner  was  a  student  at  Sodbury,  a  young  girl,  who  came 
for  advice,  when  small-pox  was  mentioned,  exclaimed,  "  I  can  not  take  that 
disease,  for  I  have  had  cow-pox."  Jenner  subsequently  mentioned  the  sub- 
ject to  Hunter,  who  in  reply  gave  the  famous  piece  of  advice:  "Do  not 
think,  but  try;  be  patient,  be  accurate."  As  early  as  1780  the  idea  of  the 
protective  power  of  vaccination  was  firmly  impressed  on  Jenner's  mind. 
The  problem  which  occupied  his  attention  for  many  years  was  brought  to 
a  practical  issue  when,  on  May  14,  1796,  he  took  matter  from  the  hand  of 
a  dairy-maid,  Sarah  ISTelmes,  who  had  cow-pox,  and  inoculated  a  boy  named 
James  Phipps,  aged  eight  years.  On  July  1st  matter  was  taken  from  a 
small-pox  pustule,  and  inserted  into  the  boy,  but  no  disease  followed.  In 
1798  appeared  An  Inquiry  into  the  Causes  and  Eifects  of  the  Variola 
Vaccinge,  a  Disease  discovered  in  some  of  the  Western  Counties  of  England, 
particularly  Gloucestershire,  and  known  by  the  Name  of  Cow-pox  (pp.  iv, 
75,  four  plates,  4to.  London,  1798).  From  this  time  on  vaccination  spread 
rapidly  throughout  the  civilized  world. 

In  the  United  States  vaccination  was  introduced  by  Benjamin  Water- 
house,  Professor  of  Physic  at  Harvard,  who  on  July  8,  1800,  vaccinated 
seven  of  his  children.  President  Jefferson  was  mainly  instrumental  in 
spreading  the  practice  in  the  Southern  States,  and  John  Redman  Coxe 
introduced  it  into  Philadelphia. 

The  literature  of  vaccination  has  been  greatly  enriched  by  the  pub- 
lications in  connection  with  the  Jenner  centenary.  The  centenary  number 
of  the  British  Medical  Journal  is  particularly  valuable.  The  report  of  the 
Royal  Commission  on  vaccination,  the  exhaustive  article  in  Allbutt's  System 
by  T.  D.  Acland  and  Copeman,  and  Cory's  recent  monograph  on  the 
subject  afford  a  large  body  of  material.  To  the  public  health  officials,  who 
wish  for  distribution  in  handy  shape  Facts  about  Small-pox  and  Vaccina- 
tion, the  leaflets  issued  by  the  British  Medical  Association  (British  Medical 
Journal,  1898,  vol.  i,  p.  G32)  will  be  of  the  greatest  value. 

Nature  of  Vaccinia. — Is  cow-pox  a  separate  independent  disease, 
or  is  it  only  small-pox  modified  by  passing  through  the  cow?  In  spite  of 
a  host  of  observations,  this  question  is  not  yet  settled,  as  may  be  seen  in 
the  diametrically  opposed  views  expressed  by  Copeman  in  Allbutt's  System 
and  by  Brouardel  in  the  Twentieth  Century  Practice.  The  experiments 
may  be  divided  into  two  groups.  First,  those  in  which  the  inoculation  of 
the  small-pox  matter  in  the  heifer  produced  pocks  corresponding  in  all 
respects  to  the  vaccine  vesicles.  Lymph  from  the  first  calf  inoculated  into 
a  second  or  third  produced  the  ebaracteristic  lesions  of  cow-pox,  and  from 


YO  SPECIFIC  INFECTIOUS  DISEASES. 

the  first,  second,  or  third  animal  lymph  used  to  vaccinate  a  child  produced 
a  typical  localized  vaccine  vesicle  without  any  of  the  generalized  features 
of  small-pox.  The  experiments  of  Ceely,  of  Babcock,  and  many  other  more 
recent  workers  seem  to  leave  no  question  whatever  that  typical  vaccinia 
may  be  produced  in  the  calf  by  the  inoculation  of  variolous  matter.  A 
great  deal  of  the  vaccine  material  at  one  time  in  use  in  England  was  ob- 
tained in  this  way.  Secondly,  against  this  is  urged  Chauveau's  Lyons 
experiments.  Seventeen  young  animals  were  inoculated  with  the  virus  of 
small-pox.  Small  reddish  papules  occurred  which  disappeared  rapidly,  but 
the  animals  did  not  acquire  cow-pox.  Fifteen  of  the  seventeen  animals 
were  also  vaccinated.  Of  these  only  one  showed  a  typical  cow-pox  erup- 
tion. To  determine  the  nature  of  the  original  papules  one  was  excised  and 
inoculated  into  a  non-vaccinated  child,  which  developed  as  a  result  general- 
ized confluent  small-pox.  A  second  child  inoculated  from  the  primary 
pustule  of  the  first  child  developed  discrete  small-pox.  The  French  still 
hold  to  the  Lyons  experiments  as  demonstrating  the  duality  of  the  dis- 
eases. 

The  weight  of  evidence  favors  the  view  that  cow-pox  and  horse-pox 
are  variola  modified  by  transmission;  or,  as  has  been  suggested,  "  small-pox 
and  vaccinia  are  both  of  them  descended  from  a  common  stock — from  an 
ancestor,  for  instance — which  resembled  vaccinia  far  more  than  it  resem- 
bled small-pox  "  (Copeman). 

Bacteriology  of  Vaccinia. — This,  too,  is  still  unsettled.  Quist,  Martin, 
and  Ernst  have  described  various  micrococci.  Klein  and  Copeman  have 
independently  found  a  bacillus,  while  Pfeiffer  and  Euffer  have  met  with 
bodies  believed  to  be  of  the  nature  of  psorosperms.  Walter  Eeed  has  also 
met  with  peculiar  amoeboid  bodies  in  the  blood. 

Normal  Vaccination. — Period  of  Incubation. — At  first  there  may'^ 
be  a  little  irritation  at  the  site  of  inoculation,  which  subsides.  Period  of 
Eruption. — On  the  third  day,  as  a  rule,  a  papule  is  seen  surrounded  by  a 
reddish  zone.  This  gradually  increases,  and  on  the  fifth  or  sixth  day  shows 
a  definite  vesicle,  the  margins  of  which  are  raised  while  the  centre  is  de- 
pressed. By  the  eighth  day  the  vesicle  has  attained  its  maximum  size.  It 
is  round  and  distended  with  a  limpid  fluid,  the  margin  hard  and  prominent, 
and  the  umbilication  is  more  distinct.  By  the  tenth  day  the  vesicle  is  still 
large  and  is  surrounded  by  an  extensive  areola.  The  contents  have  now  be- 
come purulent.  The  skin  is  also  swollen,  indurated,  and  often  painful.  On 
the  eleventh  or  twelfth  day  the  hypergemia  diminishes,  the  lymph  becomes 
more  opaque  and  begins  to  dry.  By  the  end  of  the  second  week  the  vesicle 
is  converted  into  a  brownish  scab,  which  gradually  becomes  dry  and  hard, 
and  in  about  a  week  (that  is,  about  the  twenty-first  or  twenty-fifth  day  from 
the  vaccination)  separates  and  leaves  a  circular  pitted  scar.  If  the  points 
of  inoculation  have  been  close  together,  the  vesicles  fuse  and  may  form 
a  large  combined  vesicle.  Constitutional  symptoms  of  a  more  or  less 
marked  degree  follow  the  vaccination.  Usually  on  the  third  or  fourth  day 
the  temperature  rises,  and  may  persist,  increasing  until  the  eighth  or  ninth 
day.  There  is  a  marked  leucocytosis.  In  children  it  is  common  to  have 
with  the  fever  restlessness,  particularly  at  night,  and  irritability;  but  as  a 


VACCmiA— VACCINATION.  71 

rule  these  symptoms  are  trivial,  if  the  iuoculation  is  made  on  the  arm, 
the  axillary  glands  become  large  and  sore;  if  on  the  leg,  the  inguinal 
glands.  The  duration  of  the  immunity  is  extremely  variable,  differing 
in  different  individuals.  In  some  instances  it  is  permanent,  but  a  majority 
of  persons  within  ten  or  twelve  years  again  become  susceptible.' 

Eevaccination  should  be  performed  between  the  tenth  and  fifteenth 
year,  and  whenever  small-pox  is  epidemic.  The  susceptibility  to  revac- 
cination  is  curiously  variable,  and  when  small-pox  is  prevalent  it  is  not  well, 
if  unsuccessful,  to  be  content  with  a  single  attempt.  The  vesicle  in  re- 
vaccination  is  usually  smaller,  has  less  induration  and  hyperemia,  and  the 
resulting  scar  is  less  perfect.  Particular  care  should  be  taken  to  watch 
the  vesicle  of  revaccination,  as  it  not  infrequently  happens  that  a  spurious 
pock  is  formed,  which  reaches  its  height  early  and  dries  to  a  scab  by  the 
eighth  or  ninth  day.  The  constitutional  symptoms  in  revaccination  are 
sometimes  quite  severe. 

Irregular  Vaccination. — (a)  Local  Variations. — We  occasionally 
meet  with  instances  in  which  the  vesicle  develops  rapidly  with  much  itch- 
ing, has  not  the  characteristic  flattened  appearance,  the  lymph  early  be- 
comes opaque,  and  the  crust  forms  by  the  seventh  or  eighth  day.  The 
evolution  of  the  pocks  may  be  abnormally  slow.  In  such  cases  the  operation 
should  again  be  performed  with  fresh  lymph.  The  contents  of  the  vesi- 
cles may  be  watery  and  bloody.  In  the  involution  the  bruising  or  irrita- 
tion of  the  pocks  may  lead  to  ulceration  and  inflammation.  A  very  rare 
event  is  the  recurrence  of  the  pock  in  the  same  place.  Sutton  reports  four 
such  recurrences  within  six  months. 

(&)  Generalized  Vaccinia. — It  is  not  uncommon  to  see  vesicles  in  the 
vicinity  of  the  primary  sore.  Less  common  is  a  true  generalized  pustular 
rash,  developing  in  different  parts  of  the  body,  often  beginning  about  the 
wrists  and  on  the  back.  The  secondary  pocks  may  continue  to  make  their 
appearance  for  five  or  six  weeks  after  vaccination.  In  children  the  disease 
may  prove  fatal.  They  may  be  most  abundant  on  the  vaccinated  limb, 
;and  develop  usually  about  the  eighth  to  the  tenth  day. 

(c)  Complications. — In  unhealthy  subjects,  or  as  a  result  of  uncleanli- 
ness,  or  sometimes  injury,  the  vesicles  inflame  and  deep  excavated  ulcers 
resuU.  Sloughing  and  deep  cellulitis  may  follow.  In  debilitated  children 
tthere  may  be  with  this  a  purpuric  rash.  Acland  thus  arranges  the  dates  at 
which  the  possible  eruptions  and  complications  may  be  looked  for: 

1.  During  the  first  three  days:  Erythema;  urticaria;  vesicular  and 
bullous  eruptions;  invaccinated  erysipelas. 

2.  After  the  third  day  and^iuitil  the  pock  reaches  maturity:  Urticaria; 
lichen  urticatus,  erythema  multiforme;  accidental  erysipelas. 

3.  About  the  end  of  the  first  week:  Generalized  vaccinia;  impetigo;  vac- 
cinal ulceration;  glandular  abscess;  septic  infections;  gangrene. 

4.  After  the  involution  of  the  pocks:  Invaccinated  diseases — for  exam- 
ple, syphilis. 

{d)  Transmission  of  Disease  by  Vaccination. — Syphilis  has  undoubtedly 
been  transmitted  by  vaccination,  but  such  instances  are  very  rare.    A  large 
number  of  the  cases  of  alleged  vaccino-syphilis  must  Ije  thrown  out.     The 
5 


Y2  SPECIFIC  INFECTIOUS  DISEASES. 

question  has  now  become  really  of  minor  importance  since  the  widespread 
use  of  animal  lymph.  Dr.  Cory's  sad  experiment  may  here  be  referred  to. 
He  vaccinated  himself  four  times  from  syphilitic  children.  The  first  vac- 
cination followed,  but  no  syphilis.  Two  other  attempts  (negative)  were 
made.  Th*e  fourth  time  he  was  vaccinated  from  a  child  the  subject  of 
congenital  syphilis.  The  lymph  was  taken  from  the  child's  arm  with  care, 
avoiding  any  contamination  with  blood.  At  two  of  the  points  of  insertion 
red  papules  appeared  on  the  twenty-first  day.  On  the  thirty-eighth  day 
a  little  ulcer  was  found,  which  Mr.  Hutchinson  decided  was  syphilitic. 
The  diseased  parts  were  then  removed.  By  the  fiftieth  day  the  constitu- 
tional symptoms  were  well  marked.  Among  the  differences  between 
vaccino-syphilis  and  vaccination  ulcers  the  most  important  is  perhaps  that 
the  chancre  never  develops  before  the  fifteenth  day,  usually  not  until  from 
three  to  five  weeks,  whereas  the  ulceration  of  ordinary  vaccination  is  pres- 
ent by  the  twelfth  or  fifteenth  day.  The  loss  of  substance  in  the  chancre 
is  usually  quite  superficial  and  the  induration  very  parchment-like  and 
specific,  with  but  a  slight  inflammatory  areola.  The  glandular  swelling,  too, 
is  constant  and  indolent,  while  in  the  vaccination  ulcer  it  is  often  absent, 
or,  when  present,  chiefly  inflammatory. 

Tuberculosis. — "  No  undoubted  case  of  invaccinated  tubercle  was 
brought  before  the  Eoyal  Commission  on  Vaccination  "  (Acland).  The  risk 
of  transmitting  tuberculosis  from  the  calf  is  so  slight  that  it  need  not  be 
considered.    The  transmission  of  leprosy  by  vaccination  is  doubtful. 

Tetanus. — McFarland  has  collected  95  cases,  practically  all  American. 
Sixty-three  occurred  in  1901,  a  majority  of  which  could  be  traced  to  one 
source  of  supply,  in  which  E.  W.  Wilson  demonstrated  the  tetanus  bacillus. 
Most  of  the  cases  occurred  about  Philadelphia.  Of  course  there  may  be  an 
accidental  infection  of  the  sore,  but  this  is  excessively  rare.  This  outbreak 
emphasizes  the  necessity  of  governmental  control  of  the  vaccine  supply. 

(e)  Influence  of  Vaccination  upon  other  Diseases. — A  quiescent  malady 
may  be  lighted  into  activity  by  vaccination.  This  has  happened  with  con- 
genital syphilis,  occasionally  with  tuberculosis.  An  old  idea  was  preva- 
lent that  vaccination  had  a  beneficial  influence  upon  existing  diseases. 
Dr.  Archer,  the  first  medical  graduate  in  the  United  States,  recommended 
it  in  whooping-cough,  and  said  that  it  had  cured  in  his  hands  six  or  eight 
cases. 

Choice  of  Xiyrnph. — Calf  lymph  should  invariably  be  used,  and  it 
can  now  be  obtained  from  perfectly  reliable  sources.  The  practice  of  arm- 
to-arm  vaccination  with  humanized  lymph  should  be  abandoned.  If  bovine 
lymph  is  not  available,  then  the  humanizec],  lymph  should  be  taken  on  the 
eighth  day,  and  only  from  perfectly  formed,  unbroken  vesicles,  which  have 
had  a  typical  course.  Pricking  or  scratching  the  surface,  the  greatest  care 
being  taken  not  to  draw  blood,  allows  the  lymph  to  exude,  and  it  may  be 
collected  on  ivory  points  or  in  capillary  tubes.  The  child  from  which  the 
lymph  is  taken  should  be  healthy,  strong,  and  known  to  be  of  good  stock, 
free  from  tuberculous  or  syphilitic  taint.  All  possible  sources  of  contamina- 
tion with  pyogenic  organisms  are  now  obviated  by  the  use  of  the  glycerin- 
ated  calf  lymph  which  should  come  into  general  use.     The  Local  Govern- 


VACCINIA— VACCINATION.  73 

ment  Board  has  recently  issued  a  valuable  report  on  the  subject  by  Thorne 
and  Copeman,  giving  full  details  as  to  the  method  of  preparation.  In  it 
the  statement  is  made  that,  Avhereas  it  was  usual  to  make  the  lymph  from 
one  calf  serve  for  from  200  to  300  vaccinations,  the  glycerinated  lymph  will 
serve  for  from  4,000  to  5,000  vaccinations. 

Technique. — In  the  performance  of  the  operation  that  part  of  the 
arm  about  the  insertion  of  the  deltoid  is  usually  selected.  Mothers  "  in 
society  "  prefer  to  have  girl  babies  vaccinated  on  the  leg.  The  skin  should 
be  cleansed  and  put  upon  the  stretch.  Then,  with  a  lancet  or  the  ivory 
point,  cross-scratches  should  be  made  in  one  or  more  places.  When  the 
lymph  has  dried  on  the  points  it  is  best  to  moisten  it  in  warm  water.  The 
clothing  of  the  child  should  not  be  adjusted  until  the  spot  has  dried,  and 
it  should  be  protected  for  a  day  or  two  with  lint  or  a  soft  handkerchief. 
If  erysipelas  is  prevalent,  or  if  there  are  cases  of  suppuration  in  the  same 
house,  it  is  well  to  apply  a  pad  of  antiseptic  cotton.  Vaccination  is  usually 
performed  at  the  second  or  third  month.  If  unsuccessful,  it  should  be  re- 
peated from  time  to  time.  A  person  exposed  to  the  contagion  of  small- 
pox should  always  be  revaccinated.  This,  if  successful,  will  usually  pro- 
tect; but  not  always,  as  there  are  many  instances  in  which,  though  the 
vaccination  takes,  variola  also  appears. 

The  Value  of  Vaccination. — Sanitation  cannot  account  for  the 
diminution  in  small-pox  and  for  the  low  rate  of  mortality.  Isolation,  of 
course,  is  a  useful  auxiliary,  but  it  is  no  substitute.  Vaccination  is  not 
claimed  to  be  an  invariable  and  permanent  preventive  of  small-pox,  but  in 
an  immense  majority  of  cases  successful  inoculation  renders  the  person  for 
many  years  insusceptible.  Communities  in  which  vaccination  and  revac- 
cination  are  thoroughly  and  systematically  carried  out  are  those  in  which 
small-pox  has  the  fewest  victims.  On  the  other  hand,  communities  in  which 
vaccination  and  revaccination  are  persistently  neglected  are  those  in  which 
epidemics  are  most  prevalent.  In  the  German  army  the  practice  of  revac- 
cination has  stamped  out  the  disease.  Nothing  in  recent  times  has  been 
more  instructive  in  this  connection  than  the  fatal  statistics  of  Montreal. 
The  epidemic  which  started  in  1870-'71  was  severe  in  Lower  Canada,  and 
persisted  in  Montreal  until  1875.  A  great  deal  of  feeling  had  been 
aroused  among  the  French  Canadians  by  the  occurrence  of  several  serious 
cases  of  ulceration,  possibly  of  syphilitic  disease,  folloAving  vaccination; 
and  several  agitators,  among  them  a  French  physician  of  some  standing, 
aroused  a  popular  and  widespread  prejudice  against  the  practice.  There 
were  indeed  vaccination  riots.  The  introduction  of  animal  lymph  was 
distinctly  beneficial  in  extending  the  practice  among  the  lower  classes,  but 
compulsory  vaccination  could  not  be  carried  out.  Between  the  years  187G 
and  1884  a  considerable  unprotected  population  grew  up  and  the  materials 
were  ripe  for  an  extensive  epidemic.  The  soil  had  been  prepared  with  the 
greatest  care,  and  it  only  needed  the  introduction  of  the  seed,  which  in  due 
time  came,  as  already  stated,  with  the  Pullman-car  conductor  from  Chi- 
cago, on  the  28th  of  February,  1885.  Within  the  next  ten  months  thou- 
sands of  persons  were  stricken  with  the  disease,  and  3,164  died. 

Although  the  effects  of  a  single  vaccination  may  wear  out,  as  we  say, 


74  SPECIFIC  INFECTIOUS  DISEASES. 

and  the  individual  again  become  susceptible  to  small-pox,  yet  the  mortal- 
ity in  such  cases  is  very  much  lower  than  in  persons  who  have  never  been 
vaccinated.  The  mortality  in  persons  who  have  been  vaccinated  is  from 
6  to  8  per  cent,  whereas  in  the  unvaccinated  it  is  at  least  35  per  cent. 
There  is  evidence  that  the  greater  the  number  of  marks,  the  greater  the 
protection  in  relation  to  small-pox;  thus  the  English  Vaccination  Eeport 
states  that  out  of  4,754  cases  the  death-rate  with  one  mark  was  7.6  per  cent; 
with  two  marks,  7  per  cent;  with  three  marks,  4.2  per  cent;  with  four  marks, 
2.4  per  cent.  W.  M.  Welch's  statistics  of  5,000  cases  on  this  point  give  with 
good  cicatrices  8  per  cent;  with  fair  cicatrices,  14  per  cent;  with  poor  cica- 
trices, 27  per  cent;  post-vaccinal  cases,  16  per  cent;  unvaccinated  cases,  58 
per  cent. 

VI.  VARICELLA  (CMcJcen-pox). 

Definition. — An  acute  contagious  disease  of  children,  characterized 
by  an  eruption  of  vesicles  on  the  skin. 

Etiology.  — The  disease  occurs  in  epidemics,  but  sporadic  cases  are 
also  met  with.  It  may  prevail  at  the  same  time  as  small-pox  or  may  fol- 
low or  precede  epidemics  of  this  disease.  An  attack  of  chicken-pox  is  no 
protection  against  small-pox.  It  is  a  disease  of  childhood;  a  majority  of 
the  cases  occur  between  the  second  and  sixth  years.  It  is  rarely  seen  in 
adults.    The  specific  germ  has  not  yet  been  discovered. 

There  can  be  no  question  that  varicella  is  an  affection  quite  distinct 
from  variola  and  without  at  present  any  relation  whatever  to  it.  An  at- 
tack of  the  one  does  not  confer  immunity  from  an  attack  of  the  other. 
The  ease  which  Sharkey  reported  is  of  special  importance  in  this  connec- 
tion. A  boy,  aged  five,  was  admitted  to  St.  Thomas'  Hospital  with  a  vesicu- 
lar eruption,  and  was  isolated  in  a  ward  on  the  same  floor  as  the  small-pox 
ward.  The  disease  was  pronounced  chicken-pox,  however,  by  Sir  Eisdon 
Bennett  and  Dr.  Bristowe.  The  patient  was  then  removed  and  vaccinated, 
with  a  result  of  four  vesicles  which  ran  a  pretty  normal  course.  On  the 
eighth  day  from  the  vaccination  the  child  became  feverish.  On  the  fol- 
lowing day  the  papules  appeared  and  the  child  had  a  well-developed  attack 
of  small-pox  with  secondary  fever. 

Symptoms.^ After  a  period  of  incubation  of  ten  or  fifteen  days  the 
child  becomes  feverish  and  in  some  instances  has  a  slight  chill.  There 
may  be  vomiting  and  pains  in  the  back  and  legs.  Convulsions  are  rare. 
The  eruption  usually  develops  within  twenty-four  hours.  It  is  first  seen 
upon  the  trunk,  either  on  the  back  or  on  the  chest.  It  may  begin  on  the 
forehead  and  face.  At  first  in  the  form  of  raised  red  papules,  these  are  in 
a  few  hours  transformed  into  hemispherical  vesicles  containing  a  clear  or 
turbid  fluid.  As  a  rule  there  is  no  umbilication,  but  in  rare  instances  the 
pocks  are  flattened,  and  a  few  may  even  be  umbilicated.  They  are  often 
ovoid  in  shape  and  look  more  superficial  than  the  variolous  vesicles.  The 
skin  in  the  neighborhood  is  neither  infiltrated  nor  hypertemic.  At  the 
end  of  thirty-six  or  forty-eight  hours  the  contents  of  the  vesicles  are 
purulent.     They  begin  to  shrivel,  and  during  the  third  and  fourth  days 


VARICELLA.  Y5 

are  converted  into  dark  brownish  crusts,  which  fall  off  and  as  a  rule  leave 
no  scar.  Fresh  crops  appear  during  the  first  two  or  three  days  of  the  ill- 
ness, so  that  on  the  fourth  day  one  can  usually  see  pocks  in  all  stages  of 
development  and  decay.  They  are  always  discrete  and  the  number  may 
vary  from  eight  or  ten  to  several  hundreds.  As  in  variola,  a  scarlatinal 
rash  occasionally  precedes  the  development  of  the  eruption.  The  eruption 
may  occur  on  the  mucous  membrane  of  the  mouth,  and  occasionally  in  the 
larynx  (D.  H.  Hall). 

There  are  one  or  two  modifications  of  the  rash  which  are  interesting. 
The  vesicles  may  become  very  large  and  develop  into  regular  bullae,  look- 
ing not  unlike  ecthyma  or  pemphigus  (varicella  bullosa).  The  irritation 
of  the  rash  may  be  excessive,  and  if  the  child  scratches  the  pocks  ulcerat- 
ing sores  may  form,  which  on  healing  leave  ugly  scars.  Indeed,  cicatrices 
after  chicken-pox  are  more  common  than  after  varioloid.  The  fever  in 
varicella  is  slight,  but  it  does  not  as  a  rule  disappear  with  the  appear- 
ance of  the  rash.  The  course  of  the  disease  is  in  a  large  majority  of  the 
cases  favorable  and  no  ill  effects  follow.  The  disease  may  recur  in  the 
same  individual.  There  are  instances  in  which  a  person  has  had  three 
attacks. 

In  delicate  children,  particularly  the  tuberculous,  gangrene  (varicella 
escharotica)  may  occur  about  the  vesicles  (Hutchinson);  or  in  other  parts, 
as  the  scrotum. 

Cases  have  been  described  (Andrew)  of  hgemorrhagic  varicella  with 
cutaneous  ecchymoses  and  bleeding  from  the  mucous  membranes. 

Nephritis  may  occur.  Infantile  hemiplegia  has  developed  during  an 
attack  of  the  disease.  Death  has  followed  in  an  uncomplicated  case  from 
extensive  involvement  of  the  skin  (Nisbet). 

The  diagnosis  is  as  a  rule  easy,  particularly  if  the  patient  has  been  seen 
from  the  outset.  When  a  case  comes  under  observation  for  the  first  time 
with  the  rash  well  out,  there  may  be  considerable  difficulty.  The  abun- 
dance of  the  rash  on  the  trunk  in  varicella  is  most  important.  The  pocks 
in  varicella  are  more  superficial,  more  bleb-like,  have  not  so  deeply  an 
infiltrated  areola  about  them,  and  may  usually  be  seen  in  all  stages  of  de- 
velopment. They  rarely  at  the 'outset  have  the  hard,  shotty  feeling  of  those 
of  small-pox.  The  general  symptoms,  the  greater  intensity  of  the  onset,  the 
prolonged  period  of  invasion,  and  the  more  frequent  occurrence  of  prodro- 
mal rashes  in  small-pox  are  important  points  in  the  diagnosis. 

No  special  treatment  is  required.  If  the  rash  is  abundant  on  the  face 
great  care  should  be  taken  to  prevent  the  child  from  scratching  the  pus- 
tules.   A  soothing  lotion  should  be  applied  on  lint. 


VII.    SCARLET  FEVER. 

Definition. — An  infectious  disease  characterized  by  a  diffuse  exan- 
them  and  an  angina  of  variable  intensity. 

Etiology. — We  owe  the  recognition  of  scarlet  fever  as  a  distinct  dis- 
ease to  Sydenham,  before  whose  time  it  was  confounded  with  measles.    It 


76  SPECIFIC  INFECTIOUS  DISEASES. 

is  a  widespread  affection,  occurring  in  nearly  all  parts  of  the  globe  and 
attacking  all  races. 

The  disease  occurs  sporadically  from  time  to  time,  and  then  under 
unknown  conditions  becomes  widespread.     Epidemics  vary  in  severity. 

Among  predisposing  factors  age  is  most  important.  A  large  propor- 
tion of  the  cases  occur  before  the  tenth  year.  Of  an  enormous  mimber  of 
fatal  cases  tabulated  by  Murchison  over  90  per  cent  occurred  in  children 
under  this  age.  Adults,  however,  are  by  no  means  exempt.  Very  young 
infants  are  rarely  attacked.  A  certain  number  of  those  coming  in  contact 
with  the  disease  escape.  In  a  family  of  children  all  more  or  less  exposed 
one  or  two  may  not  contract  scarlet  fever,  whereas,  as  a  rule,  in  the  case 
of  measles  all  take  it.  The  susceptibility  seems  to  vary  in  families,  and  we 
meet  occasionally  with  sad  instances  in  which  three  or  more  members  of  a 
family  succumb  in  rapid  succession. 

Males  and  females  are  equally  affected. 

Epidemics  prevail  at  all  seasons,  but  perhaps  with  greater  intensity  in 
autumn  and  winter. 

The  contagion  of  scarlet  fever  is  probably  not  developed  until  the  erup- 
tion appears,  and  is  particularly  to  be  dreaded  during  desquamation.  No 
doubt  the  poison  is  spread  largely  by  the  fine  scaly  particles  which  are 
diffused  with  the  dust  throughout  the  room.  Even  late  in  the  disease, 
after  desquamation  has  been  apparently  completed,  a  patient  has  con- 
veyed the  contagion.  The  poison  clings  with  great  persistence  to  cloth- 
ing of  all  kinds  and  to  articles  of  furniture  in  the  room.  In  no  disease  is 
a  greater  tenacity  displayed.  Bedding  and  clothes  which  have  been  put 
away  for  months  or  even  for  years  may,  unless  thoroughly  disinfected, 
convey  contagion.  Physicians,  nurses,  and  others  in  contact  with  the  sick 
may  carry  the  poison  to  persons  at  a  distance.  It  is  remarkable  that  in 
the  case  of  physicians  this  does  not  more  frequently  occur.  I  know  of 
but  one  instance  in  which  I  carried  the  contagion  of  ^  this  disease.  The 
poison  probably  is  not  widely  spread  in  the  atmosphere.  Observations 
have  been  recently  made  which  indicate  that  it  may  be  conveyed  in  milk. 
The  epidemic  investigated  by  Power  and  Klein  in  London  in  1885  was 
traced  by  them  to  milk  obtained  from  a  dairy  at  Hendon,  in  which  the 
cows  were  found  to  be  suffering  from  a  vesicular  affection  of  the  udder. 
The  nature  of  this  disease  of  the  cow  is  doubtful,  however.  Crookshank 
holds  that  it  was  cow-pox,  and  had  nothing  to  do  with  scarlet  fever. 

Some  writers  maintain  that  scarlet  fever  may  be  associated  with  de- 
fective house-drainage.  Possibly  the  virus  may  occasionally  gain  entrance 
in  this  way. 

One  attack  does  not  necessarily  protect  permanently.  There  are  in- 
stances of  one  or  even  two  recurrences. 

Surgical  and  puerperal  scarlatinas,  so  called,  demand  a  word  under  this 
section.  While  scarlet  fever  may  attack  a  person  after  operation,  or  a 
woman  in  childbed,  the  majority  of  the  cases  described  as  such  are,  I  be- 
lieve, forms  of  septicemia.  In  the  cases  which  I  have  seen  the  red 
rash  was  rarely  so  widespread  as  in  scarlet  fever;  the  tongue  had  not  the 
special  features,  nor  was  the  throat  affected.    Desquamation  is  no  criterion. 


SCARLET  FEVER.  7Y 

as  it  occurs  whenever  hypergemia  of  the  skin  has  persisted  for  any  length 
of  time.  It  is  interesting  to  note  that  these  cases  have  become  rare  with 
the  gradual  disappearance  of  septicaemia.  I.  E.  Atkinson  suggests  that 
in  many  cases  these  rashes  are  due  to  quinine. 

The  specific  germ  is  still  doubtful.  Eecently  Class,  of  Chicago,  has 
found  a  diplococcus  in  300  successive  cases  in  the  blood,  in  the  throat 
secretion,  and  the  scales.  He  states  that  it  is  pathogenic  to  mice,  swine, 
and  guinea  pigs.  A  streptococcus  has  been  recently  described  by  Baginsky 
and  Sommerfeld.  These  observations  await  confirmation.  The  throat 
and  ear  lesions  are  commonly  due  to  the  streptococcus,  but  in  the  infec- 
tious pavilions  of  hospitals  the  scarlet-fever  cases  are  very  apt  to  be  com- 
plicated with  true  pharyngeal  diphtheria. 

Morbid  Anatomy. — Except  in  the  hsemorrhagic  form,  the  skin 
.after  death  shows  no  traces  of  the  rash.  There  are  no  specific  lesions. 
Those  which  occur  in  the  internal  organs  are  due  partly  to  the  fever  and 
partly  to  infection  with  pus-organisms. 

The  anatomical  changes  in  the  throat  are  those  of  simple  inflamma- 
tion, follicular  tonsillitis,  and,  in  extreme  grades,  of  pseudo-membranous 
angina.  In  severe  cases  there  is  intense  lymphadenitis  and  much  inflam- 
matory oedema  of  the  tissues  of  the  neck,  which  may  go  on  to  suppuration, 
or  even  to  gangrene.  Streptococci  are  found  abundantly  in  the  glands 
and  in  the  areas  of  suppuration.  Of  changes  in  the  digestive  organs,  a 
catarrhal  state  of  the  gastro-intestinal  mucosa  is  not  uncommon.  The 
liver  may  show  interstitial  changes  (Klein).    The  spleen  is  often  enlarged. 

Endocarditis  and  pericarditis  are  not  infrequent.  Myocardial  changes 
are  less  common.  The  renal  changes  are  the  most  important,  and  have 
been  thoroughly  studied  by  Coats,  Klebs,  Wagner,  and  others.  The  spe- 
cial nephritis  of  scarlet  fever  will  be  considered  with  the  diseases  of  the 
kidney. 

Affections  of  the  respiratory  organs  are  not  frequent.  When  death 
results  from  the  pseudo-membranous  angina,  broncho-pneumonia  is  not 
uncommon.     Cerebro-spinal  changes  are  rare. 

Symptoms. — Incubation. — "  From  one  to  seven  days,  oftenest  two  to 
four." 

Invasion. — The  onset  is  as  a  rule  sudden.  It  may  be  preceded  by  a 
slight,  scarcely  noticeable,  indisposition.  An  actual  chill  is  .rare.  Vomit- 
ing and,  in  young  children,  convulsions  are  common.  The  fever  is  in- 
tense; rising  rapidly,  it  may  on  the  first  day  reach  104°  or  even  105°. 
The  skin  is  unusually  dry  and  to  the  touch  gives  a  sensation  of  very  pun- 
gent heat.  The  tongue  is  furred,  and  as  early  as  the  first  day  there  may 
be  complaint  of  dryness  of  the  throat.  Cough  and  catarrhal  symptoms 
are  uncommon.  The  face  is  often  fluslied  and  the  patient  has  all  the  ob- 
jective features  of  an  acute  fever. 

Eruption. — Usually  on  the  second  day,  in  some  instances  within  twenty- 
four  liours,  the  rash  develops  in  the  form  of  scattered  red  points  on  a  deep 
suljcuticular  flush.  It  appears  first  on  the  neck  and  chest,  and  spreads  so 
rajMdly  that  by  the  evening  of  the  second  day  it  may  have  invaded  the 
entire  skin.    After  persisting  for  two  or  three  days  it  gradually  fades.    In 


78 


SPECIFIC  INFECTIOUS  DISEASES. 


pronounced  cases  the  rash  at  its  height  has  a  vivid  scarlet  hue,  quite  dis- 
tinctive and  unlike  that  seen  in  any  other  eruptive  disease.  It  is  entirely 
hypersemic,  and  the  ansemia  produced  hy  pressure  instantly  disappears. 
In  a  very  intense  rash  there  may  be  fine  punctiform  haemorrhages,  which 
do  not  disappear  on  pressure.  In  some  cases  the  rash  does  not  become 
Tiniform  but  remains  patchy,  and  intervals  of  normal  skin  separate  large 
hypersemic  areas.  Tiny  papular  elevations  may  sometimes  be  seen,  but 
they  are  not  so  common  as  in  measles.  At  the  height  of  the  eruption 
sudaminal  vesicles  may  develop,  the  fluid  of  which  may  become  turbid. 
The  entire  skin  may  at  the  same  time  be  covered  with  small  yellow  vesi- 
cles on  a  deep  red  background — scarlatina  miliaris.  ~  McCollom  lays  stress 
upon  the  appearance  of  a  punctate  eruption  in  the  arm-pits,  groins,  and  on 
the  roof  of  the  mouth  as  positive  proof  of  scarlet  fever. 

Occasionally  there  are  petechise,  which  in  the  malignant  type  of  the 
disease  become  widespread  and  large.  The  eruption  does  not  always  ap- 
pear upon  the  face.  There  may 
be  a  good  deal  of  swelling  of  the 
skin  which  feels  uncomfortable 
and  tense.  The  itching  is  vari- 
able; not  as  a  rule  intense  at  the 
height  of  the  eruption.  The 
rash  can  often  be  seen  on  the 
mucous  membranes  of  the  pal- 
ate, the  cheeks,  and  the  tonsils, 
giving  to  these  parts  a  vivid  red, 
punctiform  appearance.  The 
tongue  at  first  is  red  at  the  tip 
and  edges,  furred  in  the  centre; 
and  through  the  white  fur  are 
often  seen  the  swollen  red  pa- 
pillge,  which  give  the  so-called 
"  strawberry  "  appearance  to  the  tongue.  In  a  few  days  the  "  fur  "  des- 
quamates and  leaves  the  surface  red  and  rough,  and  it  is  this  condition 
which  some  writers  call  the  "  strawberry,"  or,  better,  the  "  raspberry " 
tongue.  Enlargement  of  the  papillae  was  the  only  constant  sign  in  1,000 
cases  (McCollom).  The  breath  often  has  a  very  heavy,  sweet  odor. 
The  pharyngeal  symptoms  are — 

1.  Slight  redness,  with  swelling  of  the  pillars  of  the  fauces  and  of  the 
tonsils.  2.  A  more  intense  grade  of  swelling  and  infiltration  of  these  parts 
with  a  follicular  tonsillitis.  3.  Membranous  angina  with  intense  inflam- 
'mation  of  all  the  pharyngeal  structures  and  swelling  of  the  glands  below 
the  jaw,  and  in  very  severe  cases  a  thick  brawny  induration  of  all  the  tissues 
of  the  neck. 

The  fever,  which  sets  in  with  such  suddenness  and  intensity,  may  reach 
105°  or  even  106°.  It  persists  with  slight  morning  remissions,  gradually 
declining  with  the  disappearance  of  the  rash.  In  mild  cases  the  tempera- 
ture may  not  reach  103°;  on  the  other  hand,  in  very  severe  cases  there  may  be 
hyperpyrexia,  the  thermpmeter  registering  108°  or  before  death  even  109°. 


Day 

1 

a 

3 

A 

s 

G 

7 

8 

9 

"  106'- 

loC 
loi 

100 
9S° 

A 

\J 

/\ 

A 

/ 

Y 

\J 

'] 

V 

\ 

V 

^ 

1 

V 

-A 

V 

-N 

\ 

\ 

\ 

Chart  VII. — Scarlet  fever. 


SCARLET  FEVER.  79 

The  pulse  presents  the  ordinary  febrile  characters,  ranging  in  children 
from  120  to  150,  or  even  higher.  The  respirations  show  an  increase  pro- 
portionate to  the  intensity  of  the  fever.  The  gastro-intestinal  symptoms 
are  not  marked  after  the  initial  vomiting,  and  food  is  usually  well  taken. 
In  some  instances  there  are  abdominal  pains.  The  edge  of  the  spleen  may 
be  palpable.  The  liver  is  not  often  enlarged.  With  the  initial  fever  nervous 
symptoms  are  present  in  a  majority  of  the  cases;  but  as  the  rash  comes 
out  the  headache  and  the  slight  nocturnal  wandering  disappear.  The 
urine  has  the  ordinary  febrile  characters,  being  scanty  and  high  colored. 
Slight  albuminuria  is  by  no  means  infrequent  during  the  stage  of  erup- 
tion. Careful  examination  of  the  urine  should  be  made  every  day.  There 
is  no  cause  for  alarm  in  the  trace  of  albumin  which  is  so  often  present, 
not  even  if  it  is  associated  with  a  few  tube-casts. 

Desquamation. — With  the  disappearance  of  the  rash  and  the  fever  the 
skin  looks  somewhat  stained,  is  dry,  a  little  rough,  and  gradually  the  upper 
layer  of  the  cuticle  begins  to  separate.  The  process  usually  begins  about 
the  neck  and  chest,  and  flakes  are  gradually  detached.  The  degree  and 
character  of  the  desquamation  bear  some  relation  to  the  intensity  of  the 
eruption.  When  the  latter  has  been  very  vivid  and  of  long  standing,  large 
flakes  may  be  thrown  off.  In  rare  instances  the  hair  and  even  the  nails 
have  been  shed.  It  must  not  be  forgotten  that  there  are  cases  in  which 
the  desquamation  has  been  prolonged,  according  to  Trousseau,  even  to 
the  seventh  or  eighth  week.  The  entire  process  lasts  from  ten  to  fifteen  or 
even  twenty  days. 

There  are  cases  of  exceptional  mildness  in  which  the  rash  may  be 
scarcely  perceptible.  During  epidemics,  when  several  children  of  a  house- 
hold are  affected,  it  sometimes  happens  that  a  child  sickens  as  if  of  scarlet 
fever,  and  has  a  sore  throat  and  the  "  strawberry  tongue  "  without  the  de- 
velopment of  any  rash.    This  is  the  so-called  scarlatina  sine  eruptione. 

These  mild  cases  of  scarlet  fever  may  be  followed  by  the  severest  attacks 
of  nephritis.  A  leucocytosis  is  usually  present,  which  may  be  extreme  in 
severe  cases. 

MALIGNANT  SCARLET  FEVER. 

Atactic  Form. — This  presents  all  the  characteristics  of  an  acute  intoxi- 
cation. The  patient,  overwhelmed  by  the  intensity  of  the  poison,  may  die 
within  twenty-four  or  thirty-six  hours.  The  disease  sets  in  with  great 
severity — high  fever,  extreme  restlessness,  headache,  and  delirium.  The 
temperature  may  rise  to  107°  or  even  108°,  and  rare  cases  have  been  ob- 
served in  which  the  thermometer  has  registered  even  higher.  Convulsions 
may  occur  in  children.  The  initial  delirium  rapidly  gives  place  to  coma. 
The  dyspnoea  may  be  urgent;  the  pulse  is  very  rapid  and  feeble. 

Haemorrhagic  JForm.  — In  some  instances  hEemorrhages  occur  into  the 
skin.  There  are  hsematuria  and  epistaxis.  In  the  erythematous  rash  there 
are  at  first  scattered  petechia,  which  gradually  become  more  extensive, 
and  ultimately  the  skin  may  be  universally  involved.  Death  may  take 
place  rni  the  second  or  on  the  third  day.  While  this  form  is  perhaps 
more  common  in  enfeebled  children,  I  have  twice  known  it  to  attack  per- 
sons apparently  in  full  health. 


so  SPECIFIC  INFECTIOUS  DISEASES. 

Anginose  Form. — The  throat  symptoms  may  appear  early  and  progress 
rapidly.  The  fauces  and  tonsils  are  swollen.  Membranous  exudation 
occurs.  It  may  extend  to  the  posterior  wall  of  the  pharynx,  forward  into 
the  mouth,  and  upward  into  the  nostrils.  The  glands  of  the  neck  rapidly 
enlarge.  Necrosis  occurs  in  the  tissues  of  the  throat,  the  foetor  is  extreme, 
the  constitutional  disturbance  profound,  and  the  child  dies  with  the  clin- 
ical picture  of  a  malignant  diphtheria.  Occasionally  the  membrane  ex- 
tends into  the  trachea  and  the  bronchi.  The  Eustachian  tubes  and  the 
middle  ear  are  usually  involved.  When  death  does  not  take  place  rapidly 
from  toxgemia  there  may  be  extensive  abscess  formation  in  the  tissues  of 
the  neck  and  sloughing.  In  the  separation  of  deep  sloughs  about  the  ton- 
sils the  carotid  artery  may  be  opened,  causing  fatal  hgemorrhage. 

Complications  and  Sequelae. — (a)  Nephritis. — At  the  height  of 
the  fever  there  is  often  a  slight  trace  of  albumin  in  the  urine,  which  is 
not  of  special  significance.  In  a  majority  of  cases  the  kidneys  escape  with- 
out greater  damage  than  occurs  in  other  acute  febrile  affections. 

Nephritis  is  most  common  in  the  second  or  third  week  and  may  de- 
-  velop  after  a  very  mild  attack.  It  may  be  delayed  until  the  third  or  fourth 
week.  As  a  rule,  the  earlier  it  develops  the  more  sevexe  it  is.  It  varies 
greatly  in  intensity,  and  three  grades  of  cases  may  be  recognized: 

1.  Very  severe  eases  with  suppression  of  urine  or  the  passage  of  a  small 
quantity  of  dark  bloody  urine  laden  with  albumin  and  tube-casts.  Vomit- 
ing is  constant,^-there  are  convulsions,  and  the  child  dies  with  the  symp- 
toms of  acute  uraemia. 

2.  Less  severe  cases  without  any  serious  acute  symptoms.  There  is  a 
puffy  appearance  of  the  eyelids,  with  slight  cedema  of  the  feet;  the  urine 
is  diminished  in  quantity,  smoky  in  appearance,  and  contains  albumin 
and  tube-casts.  The  kidney  symptoms  then  dominate  the  entire  case,  the 
dropsy  persists,  and  there  may  be  effusion  into  the  serous  sacs.  The  condi- 
tion may  drag  on  and  become  chronic,  or  the  patient  may  succumb  to 
uremic  accidents.  Fortunately,  in  a  majority  of  the  cases  the  disease  yields 
to  judicious  treatment  and  recovery  takes  place. 

3.  Cases  so  mild  that  they  can  scarcely  be  termed  nephritis.  The 
urine  contains  albumin  and  a  few  tube-casts,  but  rarely  blood.  The  oedema 
is  extremely  slight  or  transient,  and  the  convalescence  is  scarcely  inter- 
rupted. Occasionally,  however,  in  these  mild  attacks  serious  symptoms 
may  supervene.  OEdema  of  the  glottis  may  prove  rapidly  fatal,  and  in  one 
case  of  the  kind  a  child  under  my  care  died  of  acute  effusion  into  the 
pleural  sacs. 

Occasionally, oedema  occurs  without  albuminuria  or  signs  of  nephritis. 
Possibly  in  some  of  these  case  the  oedema  may  be  haemic  and  due  to  the 
anaemia;  but  there  are  instances  in  which  marked  changes  have  been  found 
in  the  kidney  after  death,  even  when  the  urine  did  not  show  the  features 
characteristic  of  nephritis. 

(b)  Arthritis. — During  the  subsidence  of  the  fever,  rarely  at  its  height, 
pains  and  swellings  in  the  joints  may  develop  and  present  all  the  charac- 
teristics of  acute  rheumatism.  In  all  probability  it  is  not,  howe-\>er,  true 
rheumatism,  but  is  analogous  to  gonorrhoeal  arthritis.     The  effusion  may 


SCARLET  FEVER.  81 

pass  on  to  suppuration,  in  which  case  it  most  commonly  involves  only  a 
single  joint. 

(c)  Cardiac  Complications. — Simple  endocarditis  is  not  uncommon, 
and  many  cases  of  chronic  valvular  disease  originate  probably  in  a  latent 
endocarditis  during  this  disease.  Malignant  endocarditis  is  rare.  Peri- 
carditis is  probably  not  more  frequent,  but  is  less  likely  to  be  overlooked 
than  endocarditis.  It  usually  develops  during  convalescence;  the  efEusion 
may  be  sero-fibrinous  or  purulent.  The  cardiac  complications  are  some- 
times found  in  association  with  arthritis.     Myocarditis  is  not  uncommon. 

{d)  Pleurisy  may  follow  pneumonia,  though  this  is  rare.  More  often 
it  occurs  during  convalescence,  is  insidious  in  its  course,  and  as  a  rule 
purulent.  This  serious  complication  of  scarlet  fever  is  not  sufficiently 
recognized.  It  was  one  upon  which  my  teacher,  E.  P.  Howard,*  in  Mon- 
treal, specially  insisted  in  his  lectures.  Sheriff,  in  a  number  of  the  same 
Journal,  reports  two  cases,  occurring  at  the  same  time  in  brothers,  one  of 
whom  died  suddenly  after  a  slight  exertion. 

(e)  Ear  Complications. — These  are  common  and  serious.  They  are 
due  to  extension  of  the  inflammation  from  the  throat  through  the  Eu- 
stachian tubes,  and  rank  among  the  most  frequent  causes  of  deafness.  The 
severe  forms  of  membranous  angina  are  almost  always  associated  with  in- 
flammation of  the  middle  ear,  which  goes  on  to  suppuration  and  to  per- 
foration of  the  drum.  The  suppuration  may  extend  to  the  labyrinth  and 
rapidly  produce  deafness.  In  other  instances  there  is  suppuration  in  the 
mastoid  cells.  In  the  necrosis  which  follows  the  middle-ear  disease,  the 
facial  nerve  may  be  involved  and  paralysis  follow.  Later,  still  more  seri- 
ous complications  may  follow  the  otitis,  such  as  thrombosis  of  the  lateral 
sinus,  meningitis,  or  abscess  of  the  brain. 

(/)  Adenitis. — In  comparatively  mild  cases  of  scarlet  fever  the  sub- 
maxillary lymph-glands  may  be  swollen.  In  severer  cases  the  swelling  of 
the  neck  becomes  extreme  and  extends  beyond  the  limits  of  the  glands. 
Acute  phlegmonous  inflammations  may  occur,  leading  to  widespread  de- 
struction of  tissue,  in  which  vessels  may  be  eroded  and  fatal  haemorrhage 
ensue.  The  suppurative  processes  may  also  involve  the  retro-pharyngeal 
tissues. 

The  swelling  of  the  lymph-glands  usually  subsides,  and  within  a  few 
weeks  even  the  most  extensive  enlargement  gradually  disappears.  There 
are  rare  instances,  however,  in  which  the  lymphadenitis  becomes  chronic, 
and  the  neck  remains  with  a  glandular  collar  which  almost  obliterates  its 
outline.  This  may  prove  intractable  to  all  ordinary  measures  of  treat- 
ment. A  case  came  under  my  observation  in  which,  two  years  after  scar- 
let fever,  the  neck  was  enormously  enlarged  and  surrounded  by  a  mass  of 
firm  brawny  glands. 

{())  Nervous  Complications. — Chorea  occasionally  develops  in  connec- 
tion with  the  arthritis  and  endocarditis.  Sudden  convulsions  followed  by 
hemiplegia  may  occur.  Progressive  paralysis  of  the  limbs  with  wasting 
may  develop  witli  the  features  of  a  subacute,  ascending  spinal  paralysis. 


*  Canada  Medical  and  Surgical  Journal,  December,  1872. 


82  SPECIFIC  INFECTIOUS  DISEASES. 

Thrombosis  of  the  cerebral  veins  may  occur.  Mental  symptoms,  mania  and 
melancholia^,  have  been  described. 

(h)  Other  rare  complications  and  sequelae  are  oedema  of  the  eyelids, 
without  nephritis  (S.  Philips),  symmetrical  gangrene,  enteritis,  noma,  and 
perforation  of  the  soft  palate  (Goodall).  Pearson  and  Littlewood  have 
reported  a  case  of  dry  gangrene  after  scarlet  fever  in  a  boy  of  four,  which 
developed  on  the  ninth  day  of  the  disease,  and  involved  both  legs,  neces- 
sitating amputation  at  the  upper  third  of  the  thighs.    The  child  recovered. 

Diagnosis. — The  diagnosis  of  scarlet  fever  is  not  difhcult,  but  there 
are  eases  in  which  the  true  nature  of  the  disease  is  for  a  time  doubtful. 
The  following  are  the  most  common  conditions  with  which  it  may  be 
confounded: 

1.  Acute  Exfoliating  Dermatitis. — This  pseudo-exanthem  simulates  scar- 
let fever  very  closely.  It  has  a  sudden  onset,  with  fever.  The  eruption 
spreads  rapidly,  is  uniform,  and  after  persisting  for  five  or  six  days  begins 
to  fade.  Even  before  it  has  entirely  gone,  desquamation  usually  begins. 
Some  of  these  cases  can  not  be  distinguished  from  scarlet  fever  in  the 
stage  of  eruption.  The  throat  symptoms,  however,  are  usually  absent,  and 
the  tongue  rarely  shows  the  changes  which  are  so  marked  in  scarlet  fever. 
In  the  desquamation  of  this  affection  the  hair  and  nails  are  commonly 
affected.  It  is,  too,  a  disease  liable  to  recur.  Some  of  the  instances  of 
second  and  third  attacks  of  scarlet  fever  have  been  cases  of  this  form  of 
dermatitis. 

2.  Measles,  which  is  distinguished  by  the  longer  period  of  invasion, 
the  characteristic  nature  of  the  prodromes,  and  the  later  appearance  of  the 
rash.  The  greater  intensity  of  the  measly  rash  upon  the  face,  the  more 
papular  character  and  the  irregular  crescentic  distribution  are  distinguish- 
ing features  in  a  majority  of  the  cases.  Other  points  are  the  absence  in 
measles  of  the  sore  throat,  the  peculiar  character  of  the  desquamation,  the 
absence  of  leucocytosis,  and  the  presence  of  Koplik's  sign. 

3.  Rotheln. — The  rash  of  rubella  is  sometimes  strikingly  like  that  of 
scarlet  fever,  but  in  the  great  majority  of  cases  the  mistake  could  not  arise. 
In  cases  of  doubt  the  general  symptoms  are  our  best  guide. 

4.  Septicemia. — As  already  mentioned,  the  so-called  puerperal  or  sur- 
gical scarlatina  shows  an  eruption  which  may  be  identical  in  appearance 
with  that  of  true  scarlet  fever. 

5.  Diphtheria. — The  practitioner  may  be  in  doubt  whether  he  is  deal- 
ing with  a  case  of  scarlet  fever  with  intense  membranous  angina,  a  true 
diphtheria  with  an  erythematous  rash,  or  coexisting  scarlet  fever  and 
diphtheria.  In  the  angina  occurring  early  in,  and  during  the  course  of 
scarlet  fever,  though  the  clinical  features  may  be  those  of  true  diphtheria, 
Loeffier's  bacilli  are  rarely  found.  On  the  other  hand,  in  the  membranous 
angina  occurring  during  convalescence,  the  bacilli  are  usually  present.  The 
rash  in  diphtheria  is,  after  all,  not  so  common,  is  limited  usually  to  the 
trunk,  is  not  so  persistent,  and  is  generally  darker  than  the  scarlatinal  rash. 

Scarlatina  and  diphtheria  may  coexist,  but  in  a  case  presenting  ^vdde- 
spread  erythema  and  extensive  membranous  angina  with  Loeffler's  bacilli, 
it  would  pnzzle  Hippocrates  to  say  whether  the  two  diseases  coexisted,  or 


SCARLET  FEVER.  83 

whether  it  was  only  an  intense  scarlatinal  rash  in  diphtheria.  Desquama- 
tion occurs  in  either  case.  The  streptococcus  angina  is  not  so  apt  to  ex- 
tend to  the  larynx,  nor  are  recurrences  so  common;  but  it  is  well  to  bear 
in  mind  that  general  infection  may  occur,  that  the  membrane  may  spread 
downward  with  great  rapidity,  and,  lastly,  that  all  the  nervous  sequelse  of 
the  Klebs-Loeffler  diphtheria  may  follow  the  streptococcus  form. 

6.  Drug  Rashes. — These  are  partial,  and  seldom  more  than  a  transient 
hyperemia  of  the  skin.  Occasionally  they  are  diffuse  and  intense,  and  in 
such  cases  very  deceptive.  They  are  not  associated,  however,  with  the 
characteristic  symptoms  of  invasion.  There  is  no  fever,  and  with  care  the 
distinction  can  usually  be  made.  They  are  most  apt  to  follow  the  use  of 
belladonna,  quinine,  and  iodide  of  potassium. 

Coexistence  of  other  Diseases. — Of  48,366  cases  of  scarlet  fever  in  the 
Metropolitan  Asylum  Board  Hospitals  which  were  complicated  by  some 
other  disease,  in  1,094  cases  the  secondary  infection  was  diphtheria,  in  899 
cases  chicken-pox,  in  703  measles,  in  404  whooping-cough,  in  55  erysipelas, 
in  11  enteric  fever,  and  in  1  typhus  fever  (F.  F.  Caiger). 

How  long  is  a  Child  Infective? — Usually  after  desquamation  is  com- 
plete, in  four  or  five  weeks  the  danger  is  over,  but  the  occurrence  of  so-called 
"  return  cases  "  show  that  patients  remain  infective  even  when  free  from 
desquamation.  In  1894,  with  2,593  patients  from  the  Glasgow  fever 
hospitals  sent  to  their  homes  convalescent,  fresh  cases  appeared  in  70 
of  the  houses  (Chalmers).  With  15,000  cases  submitted  to  an  average 
period  of  isolation  of  forty-nine  days  or  under,  the  percentage  of  return 
cases  was  1.86;  with  an  average  period  of  fifty  to  fifty-six  days,  the  per- 
centage was  1.12;  where  the  isolation  extended  to  between  fifty-seven  and 
sixty-five  days,  the  percentage  of  return  cases  was  1  (Neech).  This 
author  suggests  eight  weeks  as  a  minimum  and  thirteen  weeks  as  a  maxi- 
mum.   Special  care  should  be  taken  of  cases  with  rhinorrhoea  and  otorrhoea. 

Prognosis. — Epidemics  differ  in  severity  and  the  mortality  is  ex- 
tremely variable.  Among  the  better  classes  the  death-rate  is  much  lower 
than  in  hospital  practice.  There  are  physicians  who  have  treated  consecu- 
tively a  hundred  or  more  cases  without  a  death.  On  the  other  hand,  in 
hospitals  aiid  among  the  poorer  classes  the  death-rate  is  considerable, 
ranging  from  5  or  10  per  cent  in  mild  epidemics  to  20  or  30  per  cent  in  the 
very  severe.  In  1,000  cases  reported  from  the  Boston  City  Hospital  by 
McCollom,  the  death-rate  was  9.8  per  cent.  The  younger  the  child  the 
greater  the  danger.  In  infants  under  one  year  the  death-rate  is  very  high. 
The  great  proportion  of  fatal  cases  occurs  in  children  under  six  years  of 
age.  The  unfavorable  symptoms  are  very  high  fever,  early  mental  disturb- 
ance with  great  jactitation,  the  occurrence  of  haBmorrhages  (cutaneous  or 
visceral),  intense  membranous  angina  with  cervical  bubo,  and  signs  of 
laryngeal  obstruction. 

Nephritis  is  always  a  serious  complication  and  when  setting  in  with 
suppression  of  the  urine  may  quickly  prove  fatal.  It  is  noteworthy,  how- 
ever, that  a  large  majority  of  the  cases  of  scarlatinal  nephritis  recover. 

Treatment. — The  disease  can  not  be  cut  short.  In  the  presence  of 
the  severer  forms  we  are  still  too  often  helpless.    There  is  no  disease,  how- 


84  SPECIFIC  INFECTIOUS  DISEASES. 

ever^  in  which  the  successful  issue  and  the  avoidance  of  complications  de- 
pends more  upon  the  skilled  judgment  of  the  physician  and  the  care  with 
which  his  instructions  are  carried  out.    ^ 

The  child  should  be  isolated  and  placed  in  charge  of  a  competent 
nurse.  The  temperature  of  the  room  should  be  constant  and  the  ventila- 
tion thorough.  The  child  should  wear  a  light  flannel  night-gown,  and 
the  bedclothing  should  not  be  too  heavy.  The  diet  should  consist  of  milk, 
broths,  and  fresh  fruits;  water  should  be  freely  given.  With  the  fall  of 
the  temperature,  the  diet  may  be  increased  and  the  child  may  gradually 
return  to  ordinary  fare.  When  desquamation  begins  the  child  should  be 
thoroughly  rubbed  every  day,  or  every  second  day,  with  sweet  oil,  or  car- 
bolated  vaseline,  or  a  5-per-cent  hydro-naphthol  soap,  which  prevents  the 
drying  and  the  diffusion  of  the  scales.  An  occasional  warm  bath  may 
then  be  given.  At  any  time  during  the  attack  the  skin  may  be  sponged 
with  warm  water.  The  patient  may  be  allowed  to  get  up  after  the  tem- 
perature has  been  normal  for  ten  days,  but  for  at  least  three  weeks  from 
this  time  great  care  should  be  exercised  to  prevent  exposure  to  cold.  It 
must  not  be  forgotten,  also,  that  the  renal  complications  are  very  apt  to 
develop  during  the  convalescence,  and  after  all  danger  is  apparently  past. 
Ordinary  cases  do  not  require  any  medicine,  or  at  the  most  a  simple  fever 
mixture,  and  during  convalescence  a  bitter  tonic.  The  bowels  should  be 
carefully  regulated. 

Special  symptoms  in  the  severe  cases  call  for  treatment. 

When  the  fever  is  above  103°  the  extremities  may  be  sponged  with 
tepid  water.  In  severe  cases,  with  the  temperature  rapidly  rising,  this  will 
not  suffice,  and  more  thorough  measures  of  hydrotherapy  should  be  prac- 
tised. With  pronounced  delirium  and  nervous  symptoms  the  cold  pack 
should  be  used.  When  the  fever  is  rising  rapidly  but  the  child  is  not 
delirious,  he  should  be  placed  in  a  warm  bath,  the  temperature  of  which 
can  be  gradually  lowered.  The  bath  with  the  water  at  80°  is  beneficial. 
In  giving  the  cold  pack  a  rubber  sheet  and  a  thick  layer  of  blankets  should 
be  spread  upon  a  sofa  or  a  bed,  and  over  them  a  sheet,  wrung  out  of  cold 
water.  The  naked  child  is  then  laid  upon  it  and  wrapped  in  the  blankets. 
An  intense  glow  of  heat  quickly  follows  the  preliminary  chilling,  and  from 
time  to  time  the  blankets  may  be  unfolded  and  the  child  sprinkled  with 
cold  water.  The  good  effects  which  follow  this  plan  of  treatment  are 
often  striking,  particularly  in  allaying  the  delirium  and  jactitation,  and 
procuring  quiet  and  refreshing  sleep.  Parents  will  object  less,  as  a  rule, 
to  the  warm  bath  gradually  cooled  than  to  any  other  form  of  hydrotherapy. 
The  child  may  be  removed  from  the  warm  bath,  ])laced  upon  a  sheet 
wrung  out  of  tolerably  cold  water,  and  then  folded  in  Ijlankets.  The  ice- 
cap is  very  useful  and  may  be  kept  constantly  applied  in  cases  in  which 
there  is  high  fever.  Medicinal  antipyretics  are  not  of  much  service  in 
comparison  with  cold  water. 

The  throat  symptoms,  if  mild,  do  not  require  much  treatment.  If 
severe,  the  local  measures  mentioned  uuder  diphtheria  should  be  used. 
Cold  applications  to  the  neck  are  to  be  preferred  to  hot,  though  it  is  some- 
times difficult  to  get  a  child  to  submit  to  tliem.     In  connection  with  the 


MEASLES.  85 

throat,  the  ears  should  be  specially  looked  after,  and  a  careful  disinfection 
of  the  mouth  and  fauces  by  suitable  antiseptic  solutions  should  be  prac- 
tised. When  the  inflammation  extends  through  the  tubes  to  the  middle 
•ear,  the  practitioner  should  either  himself  examine  daily  the  condition  of 
the  drum,  or,  when  available,  a  specialist  should  be  called  in  to  assist  him 
in  the  case.  The  careful  watching  of  this  membrane  day  by  day  and  the 
puncturing  of  it  if  the  tension  becomes  too  great  may  save  the  hearing  of 
the  child.  With  the  aid  of  cocaine  the  drum  is  readily  punctured.  The 
operation  may  be  repeated  at  intervals  if  the  pain  and  distention  return. 
No  complication  of  the  disease  is  more  serious  than  this  extension  of  the 
inflammatory  process  to  the  ear. 

The  nephritis  should  be  dealt  with  as  in  ordinary  cases;  indications 
for  treatment  will  be  found  under  the  appropriate  section.  It  is  worth 
'nentioning,  however,  that  Jaccoud  insists  upon  the  great  value  of  milk  diet 
in  scarlet  fever  as  a  preventive  of  nephritis. 

Among  other  indications  for  treatment  in  the  disease  is  cardiac  weak- 
ness, which  is  usually  the  result  of  the  direct  action  of  the  poison,  and  is 
best  met  by  stimulants. 

Many  speciflcs  have  been  vaunted  in  scarlet  fever,  but  they  are  all 
useless. 

VIII.  MEASLES. 

Definition. — An  acute,  highly  contagious  disorder,  characterized  by    • 
an  initial  coryza  and  a  rapidly  spreading  eruption. 

Etiology. — The  infection  of  measles  is  very  intense  and  immunity 
against  attack  not  nearly  so  common  as  in  scarlet  fever.  It  is  a  disease  of 
childhood,  but  unprotected  adults  are  liable  to  the  infection.  Indeed, 
measles  is  more  frequent  in  adults  than  is  scarlet  fever.  Within  the  first 
six  months  of  life  the  liability  is  not  so  marked,  though  infants  of  a  month 
or  three  weeks  may  be  attacked.  The  sexes  are  equally  affected.  The  con- 
tagion is  communicated  by  the  breath  and  by  the  secretions,  particularly 
those  of  the  nose.    It  may  be  conveyed  by  a  third  person  and  by  fomites. 

The  disease  is  practically  endemic  in  large  centres  of  population,  and 
from  time  to  time  spreads  and  prevails  epidemically.  It  occurs  at  all  sea- 
sons, but  prevails  more  extensively  during  the  colder  months.  There  is 
no  infectious  disease  in  which  recurrence  is  more  frequent.  There  may 
be  a  second,  third,  or  even  a  fourth  attack. 

The  contagium  of  the  disease  is  unknown.  ISTo  one  of  the  various  organ- 
isms ^vhich  have  been  described  meets  the  requirements  of  Koch's  law. 

Morbid  Anatomy. — Measles  itself  rarely  kills,  but  the  complica- 
tions and  sequela}  combine  to  make  it  a  very  fatal  affection  in  children. 
There  are  no  characteristic  post-mortem  appearances.  The  skin  changes 
are  those  associated  with  an  intense  hyperemia. 

Tliere  is  a  catarrhal  condition  of  the  mucous  membranes,  particularly 
of  the  bronchi.  The  fatal  cases  show  almost  invariably  either  broncho- 
pneumonia, capillary  broncbitis  with  patches  of  colla])se,  or  less  frequently 
lobar  pneumonia.     The  bronchial  glands  are  invariably  swollen.     Pleurisy 


86 


SPECIFIC  INFECTIOUS  DISEASES. 


is  less  common.  During  convalescence  from  measles  there  is  a  special  lia- 
bility to  tuberculous  invasion,  and  tuberculous  broncho-pneumonia  claims 
a  large  number  of  victims.    The  bronchial  glands  may  also  be  aiiected. 

The  gastro-intestinal  mucosa  may  be  hypersemic.  Swelling  of  Peyer's 
glands  is  not  at  all  uncommon  and  may  reach  a  very  intense  grade  in  the 
patches. 

Symptoms. — Incubation. — "From  seven  to  eighteen  days;  oftenest 
fourteen."  The  disease  has  been  frequently  inoculated.  In  such  cases 
the  incubation  period  is  less  than  ten  days. 

Invasion. — The  disease  usually  begins  with  symptoms  of  a  feverish 
cold.  There  are  shiverings  (not  often  a  definite  chill),  marked  coryza, 
sneezing,  running  at  the  nose,  redness  of  the  eyes  and  lids,  with  photo- 
phobia, and  within  twenty-four  hours  cough.  These  early  catarrhal  s}Tnp- 
toms  are  more  marked  in  measles  than  in  any  other  infectious  disease  of 
children.  There  may  be  the  symptoms  so  commonly  associated  vrith  an 
on-coming  fever — nausea,  vomiting,  and  headache.  The  tongue  is  furred. 
Examination  of  the  throat  may  show  a  reddish  hyperemia  or  in  some  in- 
stances a  distinct  punctiform  rash. 
Occasionally  this  spreads  over  the 
whole  mucous  membrane  of  the 
mouth  with  the  exception  of  the 
tongue.  The  temperature  at  this 
stage  is  usually  high,  reaching  from 
103°  to  104°,  ascending  gradually 
through  the  second  and  third  days. 
Eruption.  —  Usually  on  the 
fourth  da}",  when  the  fever  and 
general  sjTnptoms  have  reached 
their  height,  the  rash  appears 
upon  the  cheeks  or  forehead  in 
the  form  of  small  red  papules, 
which  increase  in  size  arid  spread 
over  the  neck  and  thorax.  When 
the  eruption  becomes  well  devel- 
oped the  face  is  swollen  and  cov- 
ered with  reddish  blotches,  which 
often  have  rounded  or  crescentic  outlines.  Here  and  there  is  an  intervening 
portion  of  unaffected  skin.  At  this  stage  the  cervical  Ijonph-glands  may 
be  slightly  swollen  and  sore;  sometimes  also  the  glands  in  the  groins, 
axillae,  and  at  the  elbows.  The  papules  can  now  be  felt  with  the  finger. 
Sometimes  they  are  quite  shotty,  but  do  not  extend  deep  into  the  skin.  On 
the  trunk  and  extremities  the  swelling  of  the  skin  is  not  so  noticeable, 
the  color  of  the  rash  not  so  intense  and  often  less  uniform.  The  mottled, 
blotchy  character  of  the  rash  appears  most  clearly  on  the  chest  or  the  abdo- 
men. The  rash  is  hypersemic  and  disappears  on  pressure,  but  in  the  more 
malignant  cases  it  may  become  hgemcrrhagic.  The  general  sj-mptoms  do 
not  abate  with  the  occurrence  of  the  eruption.  They  persist  until  the  end 
of  the  fifth  or  the  sixth  day,  when  in  the  majority  of  the  cases  all  the  symp- 


Bay 

1 

S 

s 

i 

5 

e 

7 

8 

IOC 

lol 

102 

100 
98 

f 

1 

J 

\ 

\ 

/ 

\\ 

V. 

\ 

V 

' 

I 

A 

\ 

\. 

.** 

iac 

-*« 

i>^ 

^ 

Chart  VIII. — Measles. 


MEASLES.  87 

toms  become  mitigated.  Among  the  peculiarities  of  the  rash  may  be  men- 
tioned the  development  of  numerous  miliary  vesicles  and  the  occurrence  of 
petechise,  which  are  seen  occasionally  even  in  cases  of  moderate  severity. 
Preliminary  rashes  are  sometimes  seen,  chiefly  erythematous. 

Buccal  spots  were  described  by  Filatow  in  1895,  and  by  Koplik  in  1896. 
They  are  seen  on  a  level  with  the  bases  of  the  lower  milk  molars  on  either 
side,  or  at  the  line  of  Junction  of  the  molars  when  the  jaws  are  closed. 
They  are  white  or  bluish-white  specks,  surrounded  by  red  areolse.  Their 
importance  depends  upon  the  fact  of  their  remarkable  constancy  in  the  dis- 
ease, and  their  occasional  appearance  before  the  exanthem. 

After  persisting  for  two  or  three  days  the  rash  gradually  fades  and 
desquamation  occurs  in  the  form  of  very  fine  branny  scales. 

Atypical  cases  are  common.  The  rash  may  appear  early,  within 
thirty-six  hours  of  the  onset  of  the  symptoms;  or,  on  the  other  hand,  it 
may  be  delayed  until  the  sixth  day.  When  many  cases  occur  in  a  house- 
hold, one  of  the  children  may  have  all  the  initial  symptoms  and  '^  sicken 
for  the  disease,"  as  it  is  said,  but  no  eruption  appears. 

Hsemorrhagic  measles,  the  mor'billi  licemorrhagici,  is  seen  occasionally 
in  institutions,  particularly  when  the  hygienic  surroundings  are  bad,  or  one 
or  two  cases  develop  during  an  epidemic.  It  has  been  frequently  seen  in 
camps  and  when  the  disease  is  freshly  imported  into  a  native  population, 
as  in  the  Fiji  Islands. 

The  disease  sets  in  with  great  intensity,  the  rash  becomes  petechial, 
haemorrhages  occur  from  the  mucous  membranes,  the  constitutional  depres- 
sion is  very  great,  and  death  occurs  early  from  toxgemia. 

Complications  and  Sequelae. — The  existing  bronchitis  is  apt  to 
extend  into  the  smaller  tubes  and  lead  to  collapse  and  broncho-pneumonia. 
When  limited  in  extent,  this  causes  only  aggravation  of  the  cough  and  per- 
sistence of  the  fever  (symptoms  which  gradually  abate),  and  convalescence 
is  rapid;  but  in  debilitated  children,  more  particularly  in  institutions  and 
among  the  lower  classes,  this  complication  is  extremely  grave  and  is  re- 
sponsible for  the  high  death-rate  from  measles  in  the  community.  In 
some  instances  the  clinical  picture  is  that  of  a  suffocative  catarrh,  the 
result  of  a  widespread  involvement  of  the  smaller  tubes.  The  description 
of  the  condition  will  be  found  under  Broncho-pneumonia.  Lobar  pneu- 
monia is  less  common  and  perhaps  less  dangerous. 

Laryngitis  is  not  uncommon:  the  voice  becomes  husky  and  the  cough 
croupy  in  character.  CEdema  of  the  glottis  is  very  rare.  Pseudo-mem- 
branous inflammation  of  the  pharynx  and  larynx  may  occur  and  prove 
fatal.  In  debilitated  infants  severe  stomatitis,  cancrum  oris,  or  ulcerative 
vulvitis  may  develop. 

Catarrhal  inflammation  of  the  m.iddle  ear  is  not  very  uncommon,  and 
may  proceed  to  suppuration  and  to  perforation  of  the  drum.  The  con- 
junctival catarrh  rarely  leads  to  further  trouble,  though  occasionally  the 
inflammation  becomes  purulent. 

Intestinal  catarrh  is  common  in  some  epidemics,  and  there  may  be  the 
symptoms  of  acute  colitis. 
6 


88  SPECIFIC  INFECTIOUS  DISEASES. 

Nephritis  is  an  exceedingly  rare  complication. 

Of  the  sequelae  of  measles,  tuberculosis  is  the  most  important — either 
an  involvement  of  the  bronchial  glands,  a  mihary  tuberculosis,  or  a  tuber- 
culous broncho-pneumonia.  Arthritis  is  rare.  I  have  known  anchylosis  of 
the  jaw  to  follow  measles  in  a  child  of  four  years.     Eelapse  may  occur. 

Among  the  rarer  sequelse  are  paralyses.  Hemiplegia  is  very  rare,  but 
cases  of  paraplegia  have  been  described.  Thomas  Barlow  reports  a  fatal 
case  in  which  the  symptoms  occurred  early,  the  paralysis  extended  rapidly 
and  involved  the  upper  limbs,  and  death  took  place  on  the  eleventh  day. 
Marked  vascular  changes  were  found  in  the  gray  matter  of  the  spinal  cord, 
and  were  believed  to  depend  on  an  early  disseminated  myelitis.  Examina- 
tion of  the  peripheral  nerves  was  not  made.  While  some  of  these  cases  are 
due  to  an  ascending  myelitis,  others  are  probably  the  result  of  a  post- 
febrile polyneuritis. 

Diagnosis. — From  scarlet  fever,  with  which  it  is  most  likely  to  be 
confounded,  measles  is  distinguished  by  the  longer  initial  stage  with  char- 
acteristic symptoms,  and  the  blotchy  irregular  character  of  the  rash,  which 
is  so  unlike  the  diffuse  uniform  erythema  of  scarlet  fever.  Occasionally 
in  measles,  when  the  throat  is  very  sore  and  the  eruption  pretty  diffuse, 
there  may  at  first  be  difficulty  in  determining  which  disease  is  present,  but 
a  few  days  should  suffice  to  make  the  diagnosis  clear.  As  a  rule  there 
is  no  leucocytosis.  It  may  be  extremely  difficult  to  distinguish  from  rotheln. 
I  have  more  than  once  known  practitioners  of  large  experience  unable 
to  agree  upon  a  diagnosis.  The  shorter  prodromal  stage,  the  slighter  fever 
in  many  cases,  are  perhaps  the  most  important  features.  It  is  difficult  to 
speak  definitely  about  the  distinctions  in  the  rash,  though  perhaps  the 
more  uniform  distribution  and  the  absence  of  the  crescentic  arrangement 
are  more  constant  in  rotheln.  In  Africans  the  disease  is  easily  recognized, 
the  papules  stand  out  with  great  plainness,  often  in  groups;  the  hypersemia 
is  to  be  seen  on  all  but  the  very  black  skins.  The  distribution  of  the 
rash,  the  coryza,  and  the  rash  in  the  mouth  are  important  points.  The 
conditions  under  which  measles  may  be  mistaken  for  small-pox  have 
already  been  described.  Of  drug  eruptions,  that  induced  by  copaiba  is  very 
like  measles,  but  is  readily  distinguished  by  the  absence  of  fever  and 
catarrh.     Occasionally  erythema  multiforme  may  simulate  measles. 

Prognosis. — The  mortality  bills  of  large  cities  show  what  a  serious 
disease  measles  is  in  a  community.  Among  the  eruptive  fevers  it  ranks 
third  in  the  death-rate.  The  mortality  from  the  disease  itself  is'  not  high, 
but  the  pulmonary  complications  render  it  one  of  the  most  serious  of  the 
diseases  of  children. 

In  some  epidemics  the  disease  is  of  great  severity.  In  institutions  and 
in  armies  the  death-rate  is  often  high.  The  fever  itself  is  rarely  a  source 
of  danger.  The  extension  of  the  catarrhal  symptoms  to  the  finer  bronchial 
tubes  is  the  most  serious  indication. 

Treatment. — Confinement  to  bed  in  a  well-ventilated  room  and  a 
light  diet  are  the  only  measures  necessary  in  cases  of  uncomplicated  measles. 
The  fever  rarely  reaches  a  dangerous  height.    If  it  does  it  may  be  lowered 


RUBELLA.  89 

by  sponging  or  by  the  tepid  bath  gradually  reduced.  If  the  rash  does  not 
come  out  well,  warm  drinks  and  a  hot  bath  will  hasten  its  maturation. 
The  bowels  should  be  freely  opened.  If  the  cough  is  distressing,  pare- 
goric and  a  mixture  of  ipecacuanha  wine  and  squills  should  be  given.  The 
patient  should  be  kept  in  bed  for  a  few  days  after  the  fever  subsides.  Dur- 
ing desquamation  the  skin  should  be  oiled  daily,  and  warm  baths  given 
to  facilitate  the  process.  The  convalescence  from  measles  is  the  most 
important  stage  of  the  disease.  Watchfulness  and  care  may  prevent  seri- 
ous pulmonary  complications.  The  frequency  with  which  the  mothers 
of  children  with  simple  or  tuberculous  broncho-pneumonia  tell  us  that 
"  the  child  caught  cold  after  measles,"  and  the  contemplation  of  the  mor- 
tality bills  should  make  us  extremely  careful  in  our  management  of  this 
affection. 

IX.  R\J BE.L.h A  {Botheln,  German  Measles). 

This  exanthem  has  also  the  names  of  rubeola  notha,  or  epidemic  rose- 
ola, and,  as  it  is  supposed  to  present  features  common  to  both,  has  been  also 
known  as  hybrid  measles  or  h5^brid  scarlet  fever.  It  is  now  generally 
regarded,  however,  as  a  separate  and  distinct  affection. 

Etiology. — It  is  propagated  by  contagion  and  spreads  with  great 
];apidity.  It  frequently  attacks  adults,  and  the  occurrence  of  either  measles 
or  scarlet  fever  in  childhood  is  no  protection  against  it.  The  epidemics 
of  it  are  often  very  extensive. 

Symptoms. — These  are  usually  mild,  and  it  is  altogether  a  less  seri- 
ous affection  than  measles.  Very  exceptionally,  as  in  the  epidemics  studied 
by  Cheadle,  the  symptoms  are  severe. 

The  stage  of  incubation  ranges  from  ten  to  twelve  days. 

In  the  stage  of  invasion  there  are  chilliness,  headache,  pains  in  the 
back  and  legs,  and  coryza.  A  macular,  rose-red  eruption  on  the  throat  is 
a  constant  symptom,  on  which  account,  indeed,  it  was  that  it  was  originally 
regarded  as  a  hybrid,  having  the  sore  throat  of  scarlet  fever  and  the  rash 
of  measles.  There  may  be  very  slight  fever.  In  30  per  cent  of  Edwards's 
cases  the  temperature  did  not  rise  above  100°.  The  duration  of  this  stage 
is  somewhat  variable.  The  rash  usually  appears  on  the  first  day,  some 
writers  say  on  the  second,  and  others  again  give  the  duration  of  the  stage 
of  invasion  as  three  days.  Griffith  places  it  at  two  days.  The  eruption 
comes  out  first  on  the  face,  then  on  the  chest,  and  gradually  extends  so 
that  within  twenty-four  hours  it  is  scattered  over  the  whole  body.  It  may 
be  the  first  symptom  noted  by  the  mother.  The  eruption  consists  of  a 
number  of  round  or  oval,  slightly  raised  spots,  pinkish-red  in  color,  usually 
discrete,  but  sometimes  confluent. 

The  color  of  the  rash  is  somewhat  brighter  than  in  measles.  The 
patches  are  less^distinctly  crescentic.  After  persisting  for  two  or  three 
days  (sometimes  longer),  it  gradually  fades  and  there  is  a  slight  furfura- 
ceous  desquamation.  The  rash  persists  as  a  rule  longer  than  in  scarlet 
fever  or  measles,  and  the  skin  is  slightly  stained  after  it.  The  lymphatic 
glands  of  the  neck  are  frequently  swollen,  and,  when  the  eruption  is  very 
intense  and  diffuse,  the  lymph-glands  in  the  other  parts  of  the  body. 


90  SPECIFIC  INFECTIOUS  DISEASES. 

There  are  no  special  complications.  The  disease  usually  progresses 
-favorably;  but  in  rare  instances,  as  in  those  reported  by  Cheadle,  the 
symptoms  are  of  greater  severity.  Albuminuria  may  occur  and  even 
nephritis.  Pneumonia  and  colitis  have  been  present  in  some  epidemics. 
Icterus  has  been  seen. 

Diagnosis. — The  slightness  of  the  prodromal  symptoms,  the  mild- 
ness, or  the  absence  of  the  fever,  the  more  diffuse  character  of  the  rash, 
its  rose-red  color,  and  the  early  enlargement  of  the  cervical  glands,  are  the 
chief  points  of  distinction  between  rotheln  and  measles.  Dukes  has  de- 
scribed a  "  fourth  disease,"  distinguished  from  rotheln  chiefly  by  a  more 
diffuse  rash  and  a  longer  period  of  incubation. 

The  treatment  is  that  of  a  simple  febrile  affection. 

X.    EPIDEMIC    PAROTITIS  {Mumps). 

Definition. — An  infectious  disease,  characterized  by  inflammation  of 
the  parotid  gland.  The  testes  in  males  and  the  ovaries  and  breasts  in 
females  are  sometimes  involved. 

Etiology. — The  nature  of  the  virus  is  unknown. 

The  affection  has  all  the  characters  of  an  epidemic  disease.  It  is  said 
to  be  endemic  in  certain  localities,  and  probably  is  so  in  large  centres  of 
population.  At  certain  seasons,  particularly  in  the  spring  and  autumn 
months,  the  number  of  cases  increases  rapidly.  It  is  met  most  frequently 
in  childhood  and  adolescence.  Very  young  infants  and  adults  are  seldom 
attacked.  Males  are  somewhat  more  frequently  affected  than  females.  In 
institutions  and  schools  the  disease  has  been  known  to  attack  over  90  per 
cent  of  all  the  children.  It  may  be  curiously  localized  in  a  city  or  district. 
The  disease  is  contagious  and  spreads  from  patient  to  patient. 

A  remarkable  idiopathic,  non-specific  parotitis  may  follow  injury  or 
disease  of  the  abdominal  or  pelvic  organs  (see  Diseases  of  the  Salivary 
Glands). 

Symptoms. — The  period  of  incubation  is  from  two  to  three  weeks, 
and  there  are  rarely  any  symptoms  during  this  stage.  The  invasion  is 
marked  by  fever,  which  is  usually  slight,  rarely  rising  above  101°,  but  in 
exceptionally  severe  cases  going  up  to  103°  or  104°.  The  child  complains 
of  pain  just  below  the  ear  on  one  side.  Here  a  slight  swelling  is  noticed, 
which  increases  gradually,  until,  within  forty-eight  hours,  there  is  great 
enlargement  of  the  neck  and  side  of  the  cheek.  The  swelling  passes  for- 
ward in  front  of  the  ear,  and  back  beneath  the  sterno-mastoid  muscle.  The 
other  side  usually  becomes  affected  within  a  day  or  two.  The  other  sali- 
vary glands  are  rarely  involved.  The  greatest  inconvenience  is  experi- 
enced in  taking  food,  for  the  patient  is  unable  to  open  the  mouth,  and 
even  speech  and  deglutition  become  difficult.  There  may  be  an  increase 
in  the  secretion  of  the  saliva,  but  the  reverse  is  sometimes  the  case.  There 
is  seldom  great  pain,  but,  instead,  an  unpleasant  feeling  of  tension  and 
tightness.  There  may  be  earache,  even  otitis  media,  and  slight  impairment 
of  hearing. 

After  persisting  for  from  seven  to  ten  days,  the  swelling  gradually 


EPIDEMIC  PAROTITIS.  91 

subsides  and  the  child  rapidly  regains  his  strength  and  health  and  is  none 
the  worse  for  the  attack. 

Occasionally  the  disease  is  very  severe  and  characterized  by  high  fever, 
delirium,  and  great  prostration.  The  patient  may  even  lapse  into  a  typhoid 
condition. 

Orchitis. — Excessively  rare  before  puberty,  it  develops  usually  as  the 
parotitis  subsides,  or  indeed  a  week  or  ten  days  later.  One  or  both  testicles 
may  be  involved.  The  swelling  may  be  great,  and  occasionally  effusion 
takes  place  into  the  tunica  vaginalis.  The  orchitis  may  develop  before 
the  parotitis,  or  in  rare  instances  may  be  the  only  manifestation  of  the 
infection  (orchitis  paroticlea).  The  inflammation  increases  for  three  or  four 
days,  and  resolution  takes  place  gradually.  There  may  be  a  muco-purulent 
discharge  from  the  urethra.  In  severe  cases  atrophy  may  follow,  fortunately 
as  a  rule  only  in  one  organ;  occurring  in  both  before  puberty  the  natural 
development  is  usually  checked.  Even  when  both  testicles  are  atrophied 
and  small,  sexual  vigor  may  be  retained.  The  proportion  of  cases  of  orchitis 
varies  in  different  epidemics;  211  cases  occurred  in  699  cases,  and  103  cases 
of  atrophy  followed  163  instances  of  orchitis  (Comby). 

A  vulvo-vaginitis  sometimes  occurs  in  girls,  and  the  breasts  may  be- 
come enlarged  and  tender.  Mastitis  has  been  seen  in  boys.  Involvement 
of  the  ovaries  is  rare. 

Complications  and  Sequelae. — Of  these  the  cerebral  affections 
are  perhaps  the  most  serious.  As  already  mentioned,  there  may  be  de- 
lirium and  high  fever.  In  rare  instances  meningitis  has  been  found. 
Hemiplegia  and  coma  may  also  occur.  A  majority  of  the  fatal  cases  are 
associated  with  meningeal  symptoms.  These,  of  course,  are  very  rare  in 
comparison  with  the  frequency  of  the  disease;  yet,  in  the  Index  Catalogue, 
under  this  caption,  there  are  six  fatal  cases  mentioned.  In  some  epi- 
demics the  cerebral  complications  are  much  more  marked  than  in  others. 
Acute  mania  has  occurred,  and  there  are  instances  on  record  of  insanity 
following  the  disease. 

Arthritis,  albuminuria,  even  acute  ursemia  with  convulsions,  endocar- 
ditis, facial  paralysis,  hemiplegia,  and  peripheral  neuritae  are  occasional 
complications. 

Suppuration  of  the  gland  is  an  extremely  rare  complication  in  genuine 
idiopathic  mumps.  Gangrene  has  occasionally  occurred.  The  special 
senses  may  be  seriously  involved.  Many  cases  of  deafness  have  been  de- 
scribed in  connection  with  or  following  mumps.  It,  unfortunately,  may 
be  permanent.  Affections  of  the  eye  are  rare,  but  atrophy  of  the  optic 
nerve  has  been  described.     The  lachrymal  glands  may  be  involved. 

Eelapse  may  occur,  even  two  or  three,  and  chronic  hypertrophy  of  the 
gland  may  follow. 

The  diagnosis  of  the  disease  is  usually  easy.  The  position  of  the 
swelling  in  front  of  and  below  the  ear  and  the  elevation  of  the  lobe  on  the 
affected  side  definitely  fix  the  locality  of  the  swelling.  In  children  in- 
flammation of  the  parotid,  apart  from  ordinary  mumps,  is  excessively  rare. 

Treatment. — It  is  well  to  keep  the  patient  in  bed  during  tlie  height 
of  the  disease.    The  bowels  should  be  freely  opened,  and  the  patient  given 


92  SPECIFIC  INFECTIOUS  DISEASES. 

a  light  liquid  diet.  No  medicine  is  required  unless  the  fever  is  high,  in 
which  case  aconite  may  be  given.  Cold  compresses  may  be  placed  on  the 
gland,  but  children,  as  a  rule,  prefer  hot  applications.  A  pad  of  cotton 
wadding  covered  with  oiled  silk  is  the  best  application.  Suppuration  is 
hardly  ever  to  be  dreaded,  even  though  the  gland  become  very  tense.  Should 
redness  and  tenderness  develop,  leeches  may  be  used.  With  delirium  and 
head  symptoms  the  ice-cap  may  be  applied.  In  a  robust  subject,  unless 
the  signs  of  constitutional  depression  are  extreme,  a  free  venesection  may 
do  good.  For  the  orchitis,  rest,  with  support  and  protection  of  the  swollen 
gland  with  cotton-wool,  is  usually  sufficient. 


XI.  WHOOPING  COUGH. 

Definition. — A  specific  affection  characterized  by  convulsive  cough 
and  a  long-drawn  inspiration,  during  which  the  "  whoop  "  is  produced. 

Etiology. — The  disease  occurs  in  epidemic  form,  but  sporadic  cases 
appear  in  a  community  from  time  to  time.  It  is  directly  contagious  from 
person  to  person;  but  dwelling-rooms,  houses,  school-rooms,  and  other 
localities  may  be  infected  by  a  sick  child.  It  is,  however,  in  this  way  less 
contagious  than  other  diseases,  and  is  probably  most  often  taken  by  direct 
contact.  Koplik,  Czaplewski,  and  Hensel  have  described  a  bacillus  in  the 
sputum,  which  is  probably  the  specific  organism.  The  bacilli  are  pres- 
ent in  the  mucous  clumps,  with  other  forms  as  a  rule,  but  they  can  be  sepa- 
rated by  proper  means.  Koplik  found  them  in  13  of  16  cases  of  whooping- 
cough.  It  is  a  small  bacillus  with  rounded  ends,  a  little  larger  than  the 
influenza  bacillus.  It  is  a  facultative  anaerobe,  and  is  pathogenic  for  mice. 
There  are  still  doubtful  points  regarding  the  organism.  Epidemics  prevail 
for  two  or  three  months,  usually  during  the  winter  and  spring,  and  have 
a  curious  relation  to  other  diseases,  often  preceding  or  following  epidemics 
of  measles,  less  frequently  of  scarlet  fever. 

Children  between  the  first  and  second  dentitions  are  commonly  affected. 
Sucklings  are,  kowever,  not  exempt,  and  I  have  seen  very  severe  attacks 
in  infants  under  six  weeks.  It  is  stated  that  girls  are  more  subject  to  the 
disease  than  boys.  Adults  and  old  people  are  sometimes  attacked,  and  in 
the  aged  it  may  be  a  very  serious  affection.  Many  persons  possess  immu- 
nity against  the  disease,  and,  though  frequently  exposed,  escape.  As  a 
rule,  one  attack  protects.  Delicate  anaemic  children  with  nasal  or  bron- 
chial catarrh  are  more  subject  to  the  disease  than  others.  According  to 
the  United  States  Census  Eeports,  the  disease  is  more  than  twice  as  fatal 
in  the  negro  race  than  in  others. 

Morbid  Anatomy. — Whooping-cough  itself  has  no  special  patho- 
logical changes.  In  fatal  cases  pulmonary  complications,  particularly 
broncho-pneumonia,  are  usually  present.  Collapse  and  compensatory  em- 
physema, vesicular  and  interstitial,  are  found,  and  the  tracheal  and  bron- 
chial glands  are  enlarged. 

Symptoms. — Catarrhal  and  paroxysmal  stages  can  be  recognized. 
There  is  a  variable  period  of  incubation  of  from  seven  to  ten  days.     In 


WHOOPING-COUaH.  ^  93 

the  catarrhal  stage  the  child  has  the  symptoms  of  an  ordinary  cold,  which 
may  begin  with  slight  fever,  running  at  the  nose,  injection  of  the  eyes, 
and  a  bronchial  cough,  usually  dry,  and  sometimes  giving  indications  of  a 
spasmodic  character.  The  fever  is  usually  not  high,  and  slight  attention 
is  paid  to  the  symptoms,  which  are  thought  to  be  those  of  a  simple  catarrh. 
After  lasting  for  a  week  or  ten  days,  instead  of  subsiding,  the  cough  be- 
comes worse  and  more  convulsive  in  character. 

The  paroxysmal  stage,  marked  by  the  characteristic  cough,  dates  from 
the  first  appearance  of  the  "  whoop."  The  fit  begins  with  a  series  of  from 
fifteen  to  twenty  short  coughs  of  increasing  intensity,  and  then  with  a 
deep  inspiration  the  air  is  drawn  into  the  lungs,  making  the  "  whoop," 
which  may  be  heard  at  a  distance  and  from  which  the  disease  takes  its 
name.  This  loud  inspiratory  sound  may  sometimes  precede  the  series  of 
spasmodic  expiratory  efforts.  Several  coughing-fits  may  succeed  each  other 
until  a  tenacious  mucus  is  ejected.  This  may  be  small  in  amount,  but 
after  a  series  of  coughing-fits  a  considerable  quantity  may  be  expec- 
torated. Not  infrequently  it  is  brought  up  by  vomiting  or  by  a  combina- 
tion of  cough  and  regurgitation.  There  may  be  only  four  or  five  of  these 
attacks  in  the  day,  or  in  severe  cases  they  may  recur  every  half-hour.  Dur- 
ing the  paroxysm  the  thorax  is  very  strongly  compressed  by  the  powerful 
expiratory  efforts,  and,  as  very  little  air  passes  in  through  the  glottis,  there 
are  signs  of  defective  aeration  of  the  blood;  the  face  becomes  swollen  and 
congested,  the  veins  are  prominent,  the  eyeballs  protrude,  and  the  con- 
junctivae become  deeply  engorged.  Suffocation  indeed  seems  imminent, 
when  with  a  deep,  crowing  inspiration  air  enters  the  lungs  and  the  color 
is  quickly  restored.  Children  are  usually  terrified  at  the  onset,  and  run 
at  once  to  the  mother  or  nurse  to  be  supported  during  the  attack.  Few 
diseases  are  more  painful  to  witness.  In  severe  paroxysms  vomiting  is 
frequent  and  the  sphincters  may  be  opened.  The  urine  is  said  to  be  of 
high  specific  gravity  (1022-1032),  pale  yellow,  and  to  contain  much  uric 
acid. 

An  ulcer  under  the  tongue  is  a  very  common  event,  and  was  thought 
at  one  time  to  be  the  cause  of  the  disease. 

During  the  attack,  if  the  chest  be  examined,  the  resonance  is  defective 
in  the  expiratory  stage,  full  and  clear  during  the  deep,  crowing  inspiration; 
but  on  auscultation  during  the  latter  there  may  be  no  vesicular  murmur 
heard,  owing  to  the  slowness  with  which  the  air  passes  the  narrowed  glot- 
tis.   Bronchial  rales  are  occasionally  heard. 

Among  circumstances  which  precipitate  a  paroxysm  are  emotion,  such 
as  crying,  and  any  irritation  about  the  throat.  Even  the  act  of  swallowing 
sometimes  seems  sufficient.  In  a  close  dusty  atmosphere  the  coughing- 
fits  are  more  frequent.  After  lasting  for  three  or  four  weeks  the  attacks 
become  lighter  and  finally  cease.  In  cases  of  ordinary  severity  the  course 
of  the  disease  is  rarely  under  six  weeks. 

The  complications  and  sequelae  of  whooping-cough  are  important.  Dur- 
ing the  extensive  venous  congestion  haemorrhages  are  very  apt  to  occur 
in  the  form  of  petechife,  particularly  about  the  forehead,  ecehymosis  of 
the   conjunctivae,   epistaxis,   and   occasionally   hfemoptysis.      Haemorrhage 


94  SPECIFIC  INFECTIOUS  DISEASES. 

from  the  bowels  is  rare.  Convulsions  are  not  very  uncommon,  due  perhaps 
to  the  extreme  engorgement  of  the  cerebral  cortex.  Very  rarely  hemiplegia 
or  monoplegia  follows.  Sudden  death  has  been  caused  by  extensive  sub- 
dural haemorrhage.  Whooping-cough  must  be  regarded  as  a  very  unusual 
cause  of  cerebral  palsy  in  children.  It  was  associated  with  3  of  my  series 
of  120  cases,  but  in  none  of  them  did  the  hemiplegia  come  on  during  the 
paroxysm,  as  in  a  case  reported  by  S.  West.  Bernhardt  has  described  an 
acutely  developing  spastic  paraplegia. 

The  persistent  vomiting  may  induce  marked  ansemia  and  wasting.  The 
pulmonary  complications  which  follow  whooping-cough  are  extremely  seri- 
ous. During  the  severe  coughing-spells  interstitial  emphysema  may  be 
induced,  more  rarely  pneumothorax.  I  saw  one  instance  in  which  rupture 
occurred,  evidently  near  the  root  of  the  lung,  and  the  air  passed  along  the 
trachea  and  reached  the  subcutaneous  tissues  of  the  neck,  a  condition 
which  has  been  known  to  become  general.  Broncho-pneumonia,  with  its 
accompanying  collapse,  is  the  most  frequent  pulmonary  complication  and 
carries  ofE  a  large  number  of  children.  It  may  be  simple,  but  in  a  con- 
siderable proportion  of  the  cases  the  process  is  tuberculous.  Pleurisy  is 
sometimes  met  with  and  occasionally  lobar  pneumonia.  Enlargement  of 
the  bronchial  glands  is  very  common  in  whooping-cough  and  has  been 
thought  to  cause  the  disease.  It  may  sometimes  be  sufficient  to  produce 
dulness  over  the  manubrium.  During  the  spasm  the  radial  pulse  is  small, 
the  right  heart  engorged,  and  during  and  after  the  attack  the  cardiac  action 
is  very  much  disturbed.  Serious  damage  may  result,  and  possibly  some 
of  the  cases  of  severe  valvular  disease  in  children  who  have  had  neither 
rheumatism  nor  scarlet  fever  may  be  attributed  to  the  terrible  heart  strain 
during  a  prolonged  attack  of  whooping-cough.  Koplik  regards  the  swelling 
about  the  face  and  eyes  as  an  important  sign  of  the  heart  strain.  Serious 
renal  complications  are  very  uncommon,  but  albumin  sometimes  and  sugar 
frequently  are  found  in  the  urine.  An  unusually  marked  leucocytosis 
appears  early,  chiefly  of  the  lymphocytes  (Meunier). 

Diagnosis.^ — So  distinctive  is  the  "  whoop ''  of  the  disease  that  the 
diagnosis  is  very  easy;  but  occasionally  there  are  doubtful  cases,  particu- 
larly during  epidemics,  in  which  a  series  of  expiratory  coughs  occurs  with- 
out any  inspiratory  crow. 

Prognosis. — Taken  with  its  complications,  whooping-cough  must  be 
regarded  as  a  very  fatal  affection.  According  to  Dolan,  it  ranks  third 
among  the  fatal  diseases  of  children  in  England,  where  the  death-rate  per 
1,000,000  from  this  disease  is  5,000  annually.  The  younger  the  infant 
the  greater  is  the  probability  of  serious  complications.  The  deaths  are 
chiefly  among  children  of  the  poor  and  among  delicate  infants. 

Treatment. — Parents  should  be  warned  of  the  serious  nature  of 
whooping-cough,  the  gravity  of  which  is  scarcely  appreciated  by  the  pub- 
lic. Particular  care  should  be  taken  that  children  suspected  of  the  disease 
are  not  sent  to  the  public  schools  or  exposed  in  any  way  so  that  other  chil- 
dren can  become  contaminated.  There  is  more  reprehensible  neglect  in 
connection  with  this  than  with  any  other  disease.  The  patient  should  be 
isolated,  and  if  the  paroxysms  are  at  all  severe,  at  rest  in  bed.    Fresh  air. 


INFLUENZA.  95 

night  and  day,  is  a  most  essential  element  in  the  treatment  of  the  disease. 
The  medicinal  treatment  of  whooping-cough  is  most  unsatisfactory.  In 
the  catarrhal  stage  when  there  is  fever  the  child  should  be  in  bed  and  a 
saline  fever  mixture  administered.  If  the  cough  is  distressing,  ipecacuanha 
wine  and  paregoric  may  be  given.  For  the  paroxysmal  stage  a  suspiciously 
long  list  of  remedies  has  been  recommended,  twenty-two  in  one  popular 
text-book  on  therapeutics.  If  the  disease  is  due,  as  seems  probable,  to  a 
germ  growing  upon  and  irritating  the  bronchial  mucosa,  a  germicidal  plan 
of  treatment  seems  highly  rational,  and  persistent  attempts  should  be  made 
to  discover  a  suitable  remedy.  Quinine  is  one  of  the  best  drugs.  One 
sixth  of  a  grain  may  be  given  three  times  a  day  for  each  month  of  age, 
and  1-|  grain  for  each  year  in  children  under  five  years.  Resorcin 
in  a  1-per-cent  solution,  swabbed  frequently  on  the  throat;  3  or  3  grains 
of  iodoform  to  an  ounce  of  starch  powder;  a  spray  of  carbolic  acid 
— have  all  been  warmly  recommended.  J.  Lewis  Smith  advises  the  use  of 
the  steam  atomizer  with  a  solution  of  carbolic  acid,  chlorate  of  potassium, 
and  bromide  of  potassium  in  glycerin.  Bromoform,  in  doses  of  1  to  5 
minims  suspended  in  syrup,  has  been  warmly  recommended  of  late.  Jacobi 
regards  belladonna  as  the  most  satisfactory  remedy.  He  gives  it  in  full 
doses,  as  much  as  one  sixth  of  a  grain  of  the  extract  to  a  child  of  six  or 
eight  months  three  times  a  day.  It  should  be  given  in  sufficient  doses  to 
produce  the  cutaneous  flush.  Good  results  have  been  obtained  by  the  use 
of  antipyrin  or  a  combination  of  it  with  bromine  (Kerley.) 

After  the  severity  of  the  attack  has  passed  and  convalescence  has 
begun,  the  child  should  be  watched  with  the  greatest  care.  It  is  just  at 
this  period  that  the  fatal  broncho-pneumonias  are  apt  to  develop.  The 
cough  sometimes  persists  for  months  and  the  child  remains  Aveak  and  deli- 
cate. Change  of  air  should  be  tried.  Such  a  patient  should  be  fed  with 
care,  and  given  tonics  and  cod-liver  oil. 

XII.    INFLUENZA  {La  Grippe). 

Definition. — A  pandemic  disease,  appearing  at  irregular  intervals, 
characterized  by  extraordinary  rapidity  of  extension  and  the  large  number 
of  people  attacked.  Following  the  pandemic  there  are,  as  a  rule,  for  sev- 
eral years  endemic  or  epidemic  outbreaks  in  different  regions.  Clinically, 
the  disease  has  protean  aspects,  but  with  a  special  tendency  to  attack  the 
respiratory  mucous  membranes. 

History. — Great  pandemics  have  been  recognized  since  the  sixteenth 
century.  There  were  four  with  their  succeeding  epidemics  during  the 
last  century— 1830-'33,  1836-'37,  1847-'48,  and  1889-'90.  The  last  pan- 
demic began,  as  others  had  done  before,  in  some  of  the  distant  prov- 
inces of  Eussia  (hence  the  name  Eussian  fever)  in  October,  and  by  the 
beginning  of  IS'ovcmber  it  had  reached  Moscow.  By  the  middle  of  Xovom- 
ber  Berlin  was  attacked.  By  the  middle  of  December  it  was  in  London, 
and  by  the  end  of  the  month  it  had  invaded  New  York,  and  was  widely 
distributed  over  the  entire  continent.  Within  a  year  it  had  visited  nearly 
all  parts  of  the  earth. 


96  SPECIFIC  INFECTIOUS  DISEASES. 

The  duration  of  an  epidemic  in  any  one  locality  is  from  six  to  eight 
weeks.  With  the  exception,  perhaps^,  of  dengue,  there  is  no  disease  which 
attacks  indiscriminately  so  large  a  proportion  of  the  inhabitants.  For- 
tunately, as  in  dengue,  the  rate  of  mortality  is  very  low,  but  the  last  epi- 
demic taught  us  to  recognize  in  influenza,  particularly  its  sequels  and  com- 
plications, one  of  the  most  serious  of  all  specific  diseases.  The  opportunity 
for  studying  the  disease  in  the  last  epidemic  has  thrown  much  light  upon 
many  problems.  Among  the  most  notable  productions  were  the  work  of 
Pfeiifer  in  discovering  the  specific  germ,  the  elaborate  Berlin  report  by  von 
Leyden  and  Senator,  and  the  Local  Government  Board's  report  by  Parsons. 
Leichtenstern's  article  in  ISTothnagel's  Handbuch  is  the  most  masterly  and 
systematic  consideration  of  the  disease  in  the  literature. 

Etiology. — What  relation  has  the  epidemic  influenza  to  the  ordinary 
influenza  cold  or  catarrhal  fever  (commonly  also  called  the  grippe),  which 
is  constantly  present  in  the  community?  Leichtenstern  answers  this  ques- 
tion by  making  the  following  divisions:  (1)  Epidemic  in-fiuenza  vera,  caused 
by  Pfeiffer's  bacillus;  (2)  endemic-epidemic  in-fiuenza  vera,  which  often 
develops  for  several  years  in  succession  after  a  pandemic,  also  caused  by  the 
same  bacillus;  (3)  endemic  influenza  nostras,  pseudo-influenza  or  catarrhal 
fever,  commonly  called  the  grippe,  which  is  a  special  disease,  still  of  un- 
known etiology,  and  which  bears  the  same  relation  to  the  true  influenza  as 
cholera  nostras  does  to  Asiatic  cholera. 

During  the  past  ten  years,  since  the  great  pandemic  of  1889-'90,  there 
have  been  epidemics  in  different  localities,  varying  in  extent  and  intensity. 

The  disease  is  highly  contagious;  it  spreads  with  remarkable  rapidity, 
which,  however,  is  not  greater  than  modern  methods  of  conveyance.  In 
the  great  pandemic  of  1889-'90  some  of  the  large  prisons  escaped  entirely. 
The  outbreak  of  epidemics  is  independent  of  all  seasonal  and  meteorological 
conditions,  though  the  worst  have  been  in  the  colder  seasons  of  the  year. 
One  attack  does  not  necessarily  protect  from  a  subsequent  one.  A  few 
persons  appear  not  to  be  liable  to  the  disease. 

Bacteriology. — In  1892  Pfeiffer  isolated  a  bacillus  from  the  nasal 
and  bronchial  secretions,  which  is  recognized  as  the  cause  of  the  disease. 
It  is  a  small,  non-motile  organism,  which  stains  well  in  Loeffier's  methylene 
blue,  or  in  a  dilute,  pale-red  solution  of  carbol-fuchsin  in  water.  On  cul- 
ture media  it  grows  only  in  the  presence  of  hgemoglobin.  The  bacilli  are 
present  in  enormous  numbers  in  the  nasal  and>  bronchial  secretions  of 
patients,  in  the  latter  almost  in  pure  cultures.  They  persist  often  after 
the  severe  symptoms  have  subsided. 

The  much-discussed  question  whether  during  the  presence  of  an  epi- 
demic human  influenza  attacks  animals  must  be  answered  in  the  negative. 
In  great  pandemics  of  influenza  the  general  rule  holds  good  that  other 
diseases  do  not  prevail  to  the  same  extent.  Anders  has  brought  forward 
statistics  to  indicate  that  the  outbreaks  of  malaria  are  very  much  dimin- 
ished during  the  prevalence  of  influenza. 

Symptoms. — The  incubation  period  is  "  from  one  to  four  days;  often- 
est  three  to  four  days."  The  onset  is  usually  abrupt,  with  fever  and  its 
associated  phenomena. 


INFLUENZA.  97 

Types  of  the  Disease. — The  manifestations  are  so  extraordinarily 
complex  that  it  is  best  to  describe  them  under  types  of  the  disease. 

1.  Respiratory. — The  mucous  membrane  of  the  respiratory  tract  from 
the  nose  to  the  air-cells  of  the  lungs  may  be  regarded  as  the  seat  of  election 
of  the  influenza  bacilli.  In  the  simple  forms  the  disease  sets  in  with  coryza, 
and  presents  the  features  of  an  acute  catarrhal  fever,  with  perhaps  rather 
more  prostration  and  debility  than  is  usual.  In  other  cases  the  catarrhal 
symptoms  persist,  bronchitis  develops,  the  fever  continues,  there  is  de- 
lirium and  much  prostration,  and  the  picture  may  even  be  that  of  severe 
typhoid.  The  graver  respiratory  conditions  are  bronchitis,  pleurisy,  and 
pneumonia.  The  bronchitis  has  really  no  special  peculiarities.  The  sputum 
is  supposed  by  many  to  be  distinctive.  Sometimes  it  is  in  extraordinary 
amounts,  very  thin,  and  containing  purulent  masses.  Pfeiffer  regards 
sputum  of  a  greenish-yellow  color  and  in  coin-like  lumps  as  almost  char- 
acteristic of  influenza.  In  other  cases  there  may  be  a  dark  red,  bloody 
sputum.  One  of  the  most  distressing  sequels  of  the  influenza  bronchitis 
is  difEuse  bronchiectasis,  of  which  I  have  seen  several  instances.  It 
occasionally  happens  that  the  bronchitis  is  of  great  intensity  and  reaches 
the  finer  tubes,  so  that  the  patient  becomes  cyanosed  or  even  asphyxiated. 

Influenza  pneumonia  is  one  of  the  most  serious  manifestations,  and  may 
depend  upon  PfeifEer's  bacillus  itself,  or  is  the  result  of  a  mixed  infection. 
The  true  influenza  pneumonia  is  most  commonly  lobular  or  catarrhal,  less 
often  croupous.  Much  of  the  mortality  of  the  disease  depends  upon  the 
fatal  character  of  this  complication.  The  clinical  course  of  the  cases  is 
often  irregular  and  the  symptoms  are  obscure  or  masked. 

Influenza  pleurisy  is  more  rare,  but  cases  of  primary  involvement  of  the 
pleura  are  reported.  It  is  very  apt  to  lead  to  empyema.  Pulmonary 
tuberculosis  is  usually  much  aggravated  by  an  attack  of  influenza. 

2.  Nervous  Form. — Without  any  catarrhal  symptoms  there  may  be 
severe  headache,  pain  in  the  back  and  joints,  with  profound  prostration. 
Many  remarkable  nervous  manifestations  were  noted  during  the  last  epi- 
demic. Among  the  more  serious  may  be  mentioned  meningitis  and  en- 
cephalitis, the  latter  leading  to  hemiplegia  or  monoplegia.  Abscess  of  the 
brain  has  followed  in  acute  cases.  All  forms  of  neuritis  are  not  uncom- 
mon, and  in  some  cases  are  characterized  by  marked  disturbance  of  motion 
and  sensation.  Judging  from  the  accounts  in  the  literature,  almost  every 
form  of  disease  of  the  nervous  system  may  follow  influenza. 

To  involvement  of  the  nerves  may  be  ascribed  some  of  the  common 
cardiac  symptoms,  such  as  persistent  irregularity,  tachycardia  or  brady- 
cardia, and  attacks  of  angina  pectoris.  Among  the  most  important  of  the 
nervous  sequelae  are  depression  of  spirits,  melancholia,  and  in  some  cases 
dementia. 

3.  Gastro-intestinal  Form. — With  the  onset  of  the  fever  there  may  be 
nausea  and  vomiting,  or  the  attack  may  set  in  with  abdominal  pain,  profuse 
diarrhoea,  and  collapse.  In  some  epidemics  jaundice  has  been  a  common 
symptom.  In  a  considerable  number  of  the  cases  there  is  enlargement  of 
the  spleen,  depending  chiefly  upon  the  inteusity  of  the  fever. 

4.  Febrile  Form. — The  fever  in  influenza  is  very  variable,  but  it  is 


98  SPECIFIC  INFECTIOUS  DISEASES. 

important  to  recognize  that  it  may  be  the  only  manifestation  of  the  dis- 
ease. It  is  sometimes  markedly  remittent,  with  chills;  or  in  rare  cases 
there  is  a  protracted,  continued  fever  of  several  weeks  duration,  which 
simulates  typhoid  closely  (W.  W.  Johnston). 

While  these  are  perhaps  the  most  common  forms  with  their  complica- 
itions,  there  are  many  others,  among  which  may  be  mentioned  the  follow- 
ing: Various  renal  affections  have  been  noted.  G.  Baumgarten  has  called 
attention  to  the  frequency  of  nephritis  in  the  recent  epidemic.  Orchitis 
has  been  also  seen.  Endocarditis  and  pericarditis,  phlebitis  and  thrombosis 
of  the  various  vessels  are  reported.  Herpes  is  common.  A  diffuse  erythema 
sometimes  occurs,  occasionally  purpura.  Catarrhal  conjunctivitis  is  a  fre- 
quent event.  Iritis,  and  in  rare  instances  optic  neuritis,  have  been  met 
with.  Acute  otitis  media  was  a  common  complication.  I  have  seen  severe 
and  persistent  vertigo  follow  influenza,  probably  from  involvement  of  the 
labyrinth. 

Since  the  late  severe  epidemics  it  has  been  the  fashion  to  date  various 
ailments  or  chronic  ill-health  from  influenza.  In  many  cases  this  is  cor- 
rect. It  is  astonishing  the  number  of  people  who  have  been  crippled  in 
health  for  years  after  an  attack. 

Diagnosis. — During  a  pandemic  the  cases  offer  but  slight  difficulty. 
The  profoundness  of  the  prostration,  out  of  all  proportion  to  the  intensity 
of  the  disease,  is  one  of  the  most  characteristic  features.  In  the  respiratory 
form  the  diagnosis  may  be  made  by  the  bacteriological  examination  of  the 
sputum,  a  procedure  which  should  be  resorted  to  early  in  a  suspected  epi- 
demic. The  differentiation  of  the  various  forms  has  been  already  suffi- 
ciently considered. 

Treatment. — Isolation  should  be  practised  when  possible,  and  old 
people  should  be  guarded  against  all  possible  sources  of  infection.  The 
secretions,  nasal  and  bronchial,  should  be  thoroughly  disinfected.  In  every 
case  the  disease  should  be  regarded  as  serious,  and  the  patient  should  be 
confined  to  bed  until  the  fever  has  completely  disappeared.  In  this- way 
alone  can  serious  complications  be  avoided.  From  the  outset  the  treatment 
should  be  supporting,  and  the  patient  should  be  carefully  fed  and  well 
nursed.  The  bowels  should  be  opened  by  a  dose  of  calomel  or  a  saline 
draught.  At  night  10  grains  of  Dover's  powder  may  be  given.  At  the 
onset  a  warm  bath  is  sometimes  grateful  in  relieving  the  pain  in  the  back 
and  limbs,  but  great  care  should  be  taken  to  have  the  bed  well  warmed, 
and  the  patient  should  be  given  after  it  a  drink  of  hot  lemonade-.  If  the 
fever  is  high  and  there  is  delirium,  small  doses  of  antipyrin  may  be  given 
and  an  ice-cap  applied  to  the  head.  The  medicinal  antipyretics  should  be 
used  with  caution,  as  profound  prostration  sometimes  develops  in  these 
cases.  Too  much  stress  should  not  be  laid  upon  the  meiital  features.  De- 
lirium may  be  marked  even  with  slight  fever.  In  the  cases  with  great  car- 
diac weakness  stimulants  should  be  given  freely,  and  during  convalescence 
strychnia  in  full  doses. 

The  intense  bronchitis,  pneumonia,  and  other  complications  should 
receive  their  appropriate  treatment.  The  convalescence  requires  careful 
management,  and  it  may  be  weeks  or  months  before  the  patient  is  restored 


DENGUE.  -  99 


to  full  health.  A  good  nutritious  diet,  change  of  air,  and  pleasant  sur- 
roundings are  essential.  The  depression  of  spirits  following  this  disease 
is  one  of  its  most  unpleasant  and  obstinate  features. 


XIII.   DENGUE. 

Definition. — An  acute  infectious  disease  of  tropical  and  subtropical 
regions,  characterized  by  febrile  paroxysms,  pains  in  the  Joints  and  mus- 
cles, an  initial  erythematous,  and  a  terminal  polymorphous  eruption. 

It  is  known  as  breaJc-bone  fever  from  the  atrocious  character  of  the  pain, 
and  dandy  fever  from  the  stiff,  dandified  gait.  The  word  dengue  is  sup- 
posed to  be  derived  from  a  Spanish,  or  possibly  Hindoostanee,  equivalent  of 
the  word  dandy. 

History  and  Geographical  Distribution. — The  disease  was  first 
recognized  in  1779  in  Cairo  and  in  Java,  where  Brylon  described  the  out- 
break in  Batavia.  The  description  by  Benjamin  Rush  of  the  epidemic 
in  Philadelphia  in  1780  is  one  of  the  first,  and  one  of  the  very  best  ac- 
*  counts  of  the  disease.  Between  1824  and  1828  it  was  prevalent  at  intervals 
in  India  and  in  the  Southern  States.  S.  H.  Dickson  gives  a  graphic  de- 
scription of  the  disease  as  it  appeared  in  Charleston  in  1828.  Since  that 
date  there  have  been  four  or  five  widespread  epidemics  in  tropical  coun- 
tries and  on  this  continent  along  the  Gulf  States,  the  last  in  the  summer 
of  1897.  None  of  the  recent  epidemics  have  extended  into  the  JSTorthern 
States,  but  in  1888  it  prevailed  as  far  north  as  Virginia. 

!ptiology. — The  rapidity  of  diffusion  and  the  pandemic  character  are 
the  two  most  important  features  of  dengue.  There  is  no  disease,  not  even 
influenza,  which  attacks  so  large  a  proportion  of  the  population.  In  Galves- 
ton, in  1897,  20,000  people  were  attacked  within  two  months.  It  appears 
to  belong  to  the  group  of  exanthematic  fevers,  and  has  their  highly  infec- 
tious characters.  A  micrococcus  has  been  found  in  the  blood  of  patients  by 
McLaughlin,  of  Texas. 

As  the  disease  is  rarely  fatal,  no  observations  have  been  made  upon  its 
pathological  anatomy. 

Symptoms. — The  period  of  incubation  is  from  three  to  five  days, 
during  which  the  patient  feels  well.  The  attack  sets  in  suddenly  with 
headache,  chilly  feelings,  and  intense  aching  pains  in  the  joints  and  mus- 
cles. The  temperature  rises  gradually,  and  may  reach  106°  or  107°.  The 
pulse  is  rapid,  and  there  are  the  other  phenomena  associated  with  acute 
fever — loss  of  appetite,  coated  tongue,  slight  nocturnal  delirium,  and  con- 
centrated urine.  The  face  has  a  suffused,  bloated  appearance,  the  eyes  are 
injected,  and  the  visible  mucous  membranes  are  flushed.  There  is  a  con- 
gested, erythematous  state  of  the  skin.  Rush's  description  of  the  pains  is 
worth  quoting,  as  in  it  the  epithet  break -bone  occurs  in  the  literature  for 
the  first  time.  "  The  pains  which  accompanied  this  fever  were  exquisitely 
severe  in  the  head,  back,  and  limbs.  The  pains  in  the  head  were  sometimes 
in  the  back  parts  of  it,  and  at  other  times  they  occupied  only  the  eyeballs. 
In  some  people  the  pains  were  so  acute  in  their  backs  and  hips  that  they 
could  not  lie  in  bed.    In  others,  the  pains  affected  the  neck  and  arms,  so 


100  SPECIFIC  INFECTIOUS  DISEASES. 

as  to  produce  in  one  instance  a  difiiculty  of  moving  the  fingers  of  the  right 
hand.  They  all  complained  more  or  less  of  a  soreness  in  the  seats  of  these 
pains,  particularly  when  they  occupied  the  head  and  eyeballs.  A  few  com- 
plained of  their  flesh  being  sore  to  the  touch  in  every  part  of  the  body. 
From  these  circumstances  the  disease  was  sometimes  believed  to  be  a  rheu- 
matism, but  its  more  general  name  among  all  classes  of  people  was  the  break- 
bone  fever?^  The  large  and  small  joints  are  affected,  sometimes  in  suc- 
cession, and  become  swollen,  red,  and  painful.  In  some  cases  cutaneous  hy- 
perEesthesia  has  been  noted.  Haemorrhage  from  the  mucous  membranes  was 
noted  by  Eush.    Black  vomit  has  also  been  described  by  several  observers. 

The  fever  gradually  reaches  its  maximum  by  the  third  or  fourth  day; 
the  patient  then  enters  upon  the  apyretic  period,  which  may  last  from  two 
to  four  days,  and  in  which  he  feels  prostrated  and  stiff.  A  second  paroxysm 
of  fever  then  occurs,  and  the  pains  return.  In  a  large  number  of  cases  an 
eruption  is  common,  which.  Judging  from  the  description,  has  nothing 
distinctive,  being  sometimes  macular,  like  that  of  measles,  sometimes  dif- 
fuse and  scarlatiniform,  or  papular,  or  lichen-like.  In  other  instances  the 
rash  has  been  described  as  urticarial,  or  even  vesicular.  Certain  writers 
describe  inflammation  and  hypersemia  of  the  mucous  membrane  of  the 
nose,  mouth,  and  pharynx.  Enlargement  of  the  lymph-glands  is  not  un- 
common, and  may  persist  for  weeks  after  the  disappearance  of  the  fever. 
Convalescence  is  often  protracted,  and  there  is  a  degree  of  mental  and 
physical  prostration  out  of  all  proportion  to  the  severity  of  the  primary 
attack.  The  pams  in  the  joints  or  muscles,  sometimes  very  local,  may  per- 
sist for  weeks.  Eush  refers  to  the  former,  stating  that  a  young  lady  after 
recovery  said  it  should  be  called  break-heart,  not  break-bone,  fever.  The 
average  duration  of  a  moderate  attack  is  from  seven  to  eight  days.  Dengue 
is  very  seldom  fatal.    Dickson  saw  three  deaths  in  the  Charleston  epidemic. 

Complications  are  rare.  Insomnia  and  occasionally  delirium,  resem- 
bling somewhat  the  alcoholic  form,  have  been  observed,  and  convulsions 
in  children.    A  relapse  may  occur  even  as  late  as  two  weeks. 

The  diagnosis  of  the  disease,  prevailing  as  it  does  in  epidemic  form 
and  attacking  all  classes  indiscriminately,  rarely  offers  any  special  difficulty. 
Isolated  cases  might  be  mistaken  at  first  for  acute  rheumatism.  The  im- 
portant question  of  the  differentiation  between  yellow  fever  and  dengue 
will  be  considered  later. 

Treatment. — This  is  entirely  symptomatic.  Quinine  is  stated  to  be 
a  prophylactic,  but  on  insufficient  grounds.  Hydrotherapy  may  be  em- 
ployed to  reduce  the  fever.  The  salicylates  or  antipyrin  may  be  tried  for 
the  pains,  which  usually,  however,  require  opium.  During  convalescence 
iodide  of  potassium  is  recommended  for  the  arthritic  pains,  and  tonics  are 
indicated. 

XIV.    CEREBRO-SPINAL    FEVER. 

Definition. — An  infectious  disease,  occurring  sporadically  and  in 
epidemics,  caused  by  the  diplococcus  intracellularis,  characterized  by  in- 
fiammation  of  the  cerebro-spinal  meninges  and  a  clinical  course  of  great 
irregularity. 


CEREBRO-SPINAL  FEVER.  101 

The  affection  is  also  known  by  the  names  of  malignant  purpuric  fever, 
petechial  fever,  and  spotted  fever. 

History. — Vieusseux  first  described  a  small  outbreak  in  Geneva  in 
1805.  In  1806  L.  Danielson  and  E.  Mann  (Medical  and  Agricultural 
Eegister,  Boston)  gave  an  account  of  "  a  singular  and  very  mortal  disease 
which  lately  made  its  appearance  in  Medford,  Mass." 

The  disease  attracted  much  attention  and  was  the  subject  of  several 
very  careful  studies.  The  Massachusetts  Medical  Society,  in  1809,  ap- 
pointed James  Jackson,  Thomas  Welch,  and  J.  C.  Warren  to  investigate  it. 
Elisha  North's  little  book  (1811)  gives  a  full  account  of  the  early  epi- 
demics. Stille's  monograph  (1867)  and  the  elaborate  section  in  vol.  i  of 
Joseph  Jones'  works  contain  details  of  the  later  American  outbreaks. 
Hirsch's  Geographical  Pathology,  the  appendix  by  Ormerod  to  his  article 
in  Allbutt's  System,  and  Netter's  comprehensive  article  in  the  Twentieth 
Century  Practice,  vol.  xvi,  give  full  details  of  the  epidemics  in  different 
countries.  Hirsch  divides  the  outbreaks  into  four  periods:  From  1805 
to  1830,  in  which  the  disease  was  most  prevalent  throughout  the  United 
States;  a  second  period,  from  1837  to  1850,  when  the  disease  prevailed  ex- 
tensively in  Prance,  and  there  were  a  few  outbreaks  in  the  United  States; 
a  third  period,  from  1854  to  1874,  when  there  were  outbreaks  in  Europe 
and  several  extensive  epidemics  in  this  country.  During  the  civil  war 
there  were  comparatively  few  cases  of  the  disease.  It  prevailed  extensively 
in  the  Ottawa  Valley  early  in  the  seventies.  In  the  fourth  period,  from 
1875  to  the  present  time,  the  disease  has  broken  out  in  a  great  many 
regions.  During  the  past  decade  there  have  been  localized  outbreaks  in 
many  lands.  In  this  country,  during  1898-'99,  it  prevailed  in  mild  form 
in  27  States.  The  outbreak  in  Boston  has  been  described  by  Councilman, 
Mallory,  and  Wright,  in  Chicago  by  Class,  and  in  Baltimore  by  the  writer 
(Cavendish  Lecture,  Philadelphia  Medical  Journal,  1899).  It  is  a  rare 
disease  in  Great  Britain.  In  Ireland  there  have  been  a  few  outbreaks, 
a  mild  one  last  year. 

Etiology. — Cerebro-spinal  fever  occurs  in  epidemic  and  in  sporadic 
forms.  The  epidemics  are  localized,  occurring  in  certain  regions,  and  are 
rarely  very  widespread.  As  a  rule,  country  districts  have  been  more 
afflicted  than  cities.  The  outbreaks  have  occurred  most  frequently  in  the 
winter  and  spring.  The  concentration  of  individuals,  as  of  troops  in  large 
barracks,  seems  to  be  a  special  factor,  and  epidemics  on  the  Continent 
show  how  liable  recruits  and  young  soldiers  are  to  the  disease.  In  civil 
life  children  and  young  adults  are  most  susceptible.  Over-exertion,  long 
marches  in  the  heat,  depressing  mental  and  bodily  surroundings,  and  the 
misery  and  squalor  of  the  large  tenement  houses  in  cities  are  predisposing 
causes.  The  disease  seems  not  to  be  directly  contagious,  and  is  probably 
not  transmitted  by  clothing  or  the  excretions.  It  is  very  rare  to  have 
more  than  one  or  two  cases  in  a  house,  and  in  a  city  epidemic  the  distribu- 
tion of  the  cases  is  very  irregular.  Councilman  has  found  five  instances 
in  which  the  same  individual  is  reported  to  have  had  the  disease  twice. 

Sporadic  cerebrospinal  fever  occurs  in  all  the  larger  cities  and  in  the 
country  districts  of  this  continent.    The  disease  lingers  in  a  city  indefinitely 


102  SPECIFIC  INFECTIOUS  DISEASES. 

after  an  outbreak,  and  in  Boston,  Philadelphia,  and  Baltimore  a  moderate 
number  of  eases  occur  every  year.  It  seems  probable  that  the  form  of 
meningitis  known  as  the  posterior  lasic  is  of  this  nature,  and  Still  at  the 
Great  Ormond  Street  Hospital  and  Hunter  and  Nuttall  have  isolated  an 
organism  similar  to  the  diplococcus  intracellularis.  The  clinical  and  ana- 
tomical features  of  this  form  are  very  fully  discussed  by  Barlow  and  Lees 
in  Allbutt's  System.  It  is  very  desirable  that  these  sporadic  forms  of 
meningitis,  both  in  adults  and  in  children,  should  be  carefully  studied 
by  the  newer  methods  to  determine  the  relative  incidence  of  the  forms 
due  to  the  pneumococcus  and  to  the  diplococcus  intracellularis.  The 
clinical  features,  too,  of  the  sporadic  forms  present  interesting  variations 
which  are  worthy  of  additional  study. 

Bacteriology. — In  1887  Weichselbaum  described  an  organism,  the 
Diplococcus  intracellularis  meningitidis,  which  was  probably  the  same  as 
one  previously  found  by  Leiehtenstern.  In  the  tissues  the  organism  is 
almost  constantly  within  the  polynuclear  leucocytes.  In  cultures  it  has 
well-characterized  features,  and  is  distinguishable  from  the  pneumococcus. 
Since  Weichselbaum's  observations  this  organism  has  been  met  with  in 
all  carefully  studied  epidemics  of  the  disease.  In  the  Boston  outbreak, 
in  35  of  the  cases  on  which  post-mortem  examinations  were  made,  the 
diplococei  were  demonstrated  in  all  but  4,  in  one  of  which  they  had  pre- 
viously been  found  in  fluid  withdrawn  by  spinal  puncture.  The  other 
3  cases  were  chronic.  Since  the  appearance  of  the  last  edition  (1898)  we 
have  had  an  opportunity  of  observing  a  small  outbreak,  and  we  have 
found  the  diplococcus  intracellularis  in  all  of  the  acute  cases.  The  recent 
studies,  too,  in  Paris  and  Germany  have  all  been  confirmatory  of  the 
constant  association  of  this  organism  with  the  disease. 

Morbid  Anatomy. — In  malignant  cases  there  may  be  no  characteris- 
tic changes,  the  brain  and  spinal  cord  showing  only  extreme  congestion, 
which  was  the  lesion  described  by  Vieusseux.  In  a  majority  of  the  acutely 
fatal  cases  death  occurs  within  the  first  week.  There  is  intense  injection  of 
the  pia-arachnoid.  The  exudate  is  usually  fibrino-purulent,  most  marked 
at  the  base  of  the  brain,  where  the  meninges  may  be  greatly  thickened  and 
plastered  over  with  it.  On  the  cortex  there  may  be  much  lymph  along 
the  larger  fissures  and  in  the  sulci;  sometimes  the  entire  cortex  is  covered 
with  a  thick,  purulent  exudate.  It  deserves  to  be  recorded  that  Danielson 
and  Mann  made  five  autopsies  and  were  the  first  to  describe  "  a  fluid  resem- 
bling pus  between  the  dura  and  pia  mater."  The  cord  is  always  involved 
with  the  brain.  The  exudate  is  more  abundant  on  the  posterior  surface, 
and  involves,  as  a  rule,  the  dorsal  and  lumbar  regions  more  than  the  cervical 
portion. 

In  the  more  chronic  cases  there  is  general  thickening  of  the  meninges 
and  scattered  yellow  patches  mark  where  the  exudate  has  been.  The  ven- 
tricles in  the  acute  cases  are  dilated  and  contain  a  turbid  fluid,  or  in  the 
posterior  cornua  pure  pus.  In  the  chronic  cases  the  dilatation  may  be  very 
great.  The  brain  substance  is  usually  a  little  softer  than  normal  and  has 
a  pinkish  tinge;  foci  of  hemorrhage  and  of  encephalitis  may  be  found. 
The  cranial  nerves  are  usually  involved,  particularly  the  second,  fifth,  sev- 


CEREBRO-SPINAL   FEVER.  103 

enth,  and  eighth.  The  spinal  nerve  roots  are  also  found  imbedded  in  the 
exudate. 

Microscopically,  the  exudate  consists  largely  of  polynuclear  leucocytes 
closely  packed  in  a  fibrinous  material.  Flexner  and  Barker  describe  larger 
cells,  from  two  to  eight  times  the  diameter  of  a  leucocyte.  The  lesions  in 
the  tissue  of  the  brain  and  cord,  according  to  Councilman,  are  more  marked 
in  this  than  in  other  forms.  They  consist  chiefly  in  infiltration  of  the 
tissue  with  pus  cells,  which  extend  downward  in  the  perivascular  spaces.  In 
some  instances  there  are  foci  of  purulent  infiltration  and  haemorrhage. 
The  neuroglia  cells  are  swollen,  with  large,  clear,  and  vesicular  nuclei. 
The  ganglion  cells  show  less  marked  changes.  Diplococci  are  found  in 
variable  numbers  in  the  exudate,  being  more  numerous  in  the  brain  than  in 
the  cord. 

Lesions  in  Other  Parts. — In  one  of  the  Boston  cases,  examination 
of  the  nasal  secretion  during  life  showed  diplococci,  and  in  this  instance 
there  was  found  post  mortem  a  purulent  infiltration  of  the  mucous  mem- 
brane.   In  two  other  cases  this  membrane  was  normal. 

Lungs. — Pneumonia  and  pleurisy  have  been  described  in  the  disease. 
Councilman  reports  that  in  the  recent  epidemic  in  13  cases  there  was  con- 
gestion with  oedema,  in  7  broncho-pneumonia,  in  2  characteristic  croupous 
pneumonia  with  pneumococci;  in  8  pneumonia  due  to  the  diplococcus  intra- 
cellularis  was  present. 

Spleen. — The  organ  varies  a  good  deal  in  size.  In  only  three  of  the 
Boston  fatal  cases  was  it  found  much  enlarged.  The  liver  is  rarely  abnormal. 
Acute  nephritis  is  sometimes  present.  The  intestines  show  sometimes  swell- 
ing of  the  follicles,  but  this  was  not  present  in  any  of  the  Boston  cases. 

Symptoms. — Cases  differ  remarkably  in  their  characters.  Many  dif- 
ferent forms  have  been  described.  These  are  perhaps  best  grouped  into 
three  classes: 

1.  Malignant  Form. — This  fulminant  or  apoplectic  type  is  found  with 
variable  frequency  in  epidemics.  It  may  occur  sporadically.  The  onset 
is  sudden,  usually  with  violent  chills,  headache,  somnolence,  spasms  in  the 
muscles,  great  depression,  moderate  elevation  of  temperature,  and  feeble 
pulse,  which  may  fall  to  fifty  or  sixty  in  the  minute.  Usually  a  purpuric 
rash  develops.  In  a  Philadelphia  case,  in  1888,  a  young  girl,  apparently 
quite  well,  died  within  twenty  hours  of  this  form.  There  are  cases  on 
record  in  which  death  has  occurred  within  a  shorter  time.  Stille  tells  of 
a  child  of  five  years,  in  whom  death  occurred  after  an  illness  of  ten  hours; 
and  refers  to  a  case  reported  by  Gordon,  in  which  the  entire  duration  of 
the  illness  was  only  five  hours.  Two  of  Vieusseux's  cases  died  within 
twenty-four  hours. 

2.  Ordinary  Form. — The  stage  of  incubation  is  not  known.  The  dis- 
ease usually  sets  in  suddenly.  There  may  be  premonitory  symptoms: 
headache,  pains  in  the  back,  and  loss  of  appetite.  More  commonly,  the 
onset  is  with  headache,  severe  chill,  and  vomiting.  The  temperature  rises 
to  101°  or  102°.  The  pulse  is  full  and  strong.  An  early  and  important 
symptom  is  a  painful  stiffness  of  the  muscles  of  the  neck.  The  headache 
increases,  and  there  are  photophobia  and  great  sensitiveness  to  noises. 

7 


104  SPECIFIC  INFECTIOUS  DISEASES. 

Children  become  very  irritable  and  restless.  In  severe  cases  the  contrac- 
tion of  the  muscles  of  the  neck  sets  in  early,  the  head  is  drawn  back,  and, 
when  the  muscles  of  the  back  are  also  involved,  there  is  orthotonos,  which 
is  more  common  than  opisthotonos.  The  pains  in  the  back  and  in  the 
limbs  may  be  very  severe.  The  motor  symptoms  are  most  characteristic. 
Tremor  of  the  muscles  may  be  present,  with  tonic  or  clonic  spasms  in  the 
arms  or  legs.  Eigidity  of  the  muscles  of  the  back  or  neck  is  very  com- 
mon, and  the  patient  lies  with  the  body  stiff  and  the  head  drawn  so  far 
back  that  the  occiput  may  be  between  the  shoulder-blades.  Except  in 
early  childhood  convulsions  are  not  common.  Strabismus  is  a  frequent 
and  important  symptom.  Spasm  of  the  muscles  of  the  face  may  also 
occur.  Cases  have  been  described  in  which  the  general  rigidity  and  stiff- 
ness was  such  that  the  body  could  be  moved  like  a  statue.  Paralysis  of 
the  trunk  muscles  is  rare,  but  paralysis  of  the  muscles  of  the  eye  and  the 
face  is  not  uncommon. 

Of  sensory  symptoms,  headache  is  the  most  dominant  and  persists  from 
the  outset.  It  is  chiefly  in  the  back  of  the  head,  and  the  pain  extends 
into  the  neck  and  back.  There  may  be  great  sensitiveness  along  the  spine, 
and  in  many  cases  there  is  marked  hypersesthesia. 

The  psychical  symptoms  are  pronounced.  Delirium  occurs  at  the  onset, 
occasionally  of  a  furious  and  maniacal  kind.  The  patient  may  display  at 
the  start  marked  erotic  symptoms.  The  delirium  gives  place  in  a  few  days 
to  stupor,  which,  as  the  effusion  increases,  deepens  to  coma. 

The  temperature  is  irregular  and  variable.  Eemissions  occur  frequently, 
and  there  is  no  uniform  or  typical  curve  during  the  disease.  In  some  in- 
stances there  has  been  little  or  no  fever.  In  others  the  temperature  may 
reach  105°  or  106°,  or,  before  death,  108°.  The  pulse  may  be  very  rapid 
in  children;  in  adults  it  is  at  first  usually  full  and  strong.  In  some  cases 
it  is  remarkably  slow,  and  may  not  be  more  than  fifty  or  sixty  in  the  minute. 
Sighing  respirations  and  Cheyne-Stokes  breathing  are  met  with  in  some 
instances.  Unless  there  is  pneumonia  the  respirations  are  not  often  in- 
creased in  frequency. 

The  cutaneous  symptoms  of  the  disease  are  important.  Herpes  occurs 
with  a  frequency  almost  equal  to  that  in  pneumonia  or  intermittent  fever. 
The  petechial  rash,  which  has  given  the  name  spotted  fever  to  the  dis- 
ease, is  very  variable.  Stille  states  that  of  98  cases  in  the  Philadel- 
phia Hospital,  no  eruption  was  observed  in  37.  In  the  Montreal 
cases  petechias  and  purple  spots  were  common.  They  appear  to  have  been 
more  frequent  in  the  epidemics  on  this  continent  than  in  Europe.  The 
petechise  may  be  numerous  and  cover  the  entire  skin.  An  erythema  or 
dusky  mottling  may  be  present.  In  some  instances  there  have  been  rose- 
colored  hypersemic  spots  like  the  typhoid  rash.  Urticaria  or  erythema  no- 
dosum, ecthyma,  pemphigus,  and  in  rare  instances  gangrene  of  the  skin 
have  been  noted. 

Leucocytosis  is  an  early  and  constant  feature,  and  ranges  from  25,000 
to  40,000  per  cubic  millimetre.  It  persists  even  in  the  most  protracted 
cases.  In  one  of  our  cases  the  diplococcus  intracellularis  was  isolated 
from  the  blood  during  life. 


CEREBRO-SPINAL  FEVER.  106 

As  already  stated,  vomiting  may  be  a  special  feature  at  the  onset;  but, 
as  a  rule,  it  gradually  subsides.  In  some  instances,  however,  it  persists 
and  becomes  the  most  serious  and  distressing  of  the  symptoms.  Diarrhoea 
is  not  common.  The  bowels  are  usually  confined.  The  abdomen  is  not 
tender.    In  the  acute  form  the  spleen  is  usually  enlarged. 

The  urine  is  sometimes  albuminous  and  the  quantity  may  be  increased. 
Glycosuria  has  been  noted  in  some  instances,  and  in  the  malignant  types 
heematuria. 

The  course  of  the  disease  is  extremely  variable.  Hirsch  rightly  states 
that  it  may  range  between  a  few  hours  and  several  months.  More  than 
half  of  the  deaths  occur  within  the  first  five  days.  In  favorable  cases, 
after  the  symptoms  have  persisted  for  five  or  six  days,  improvement  is  in- 
dicated by  a  lessening  of  the  spasm,  reduction  of  the  fever,  and  a  return 
of  the  intelligence.  A  sudden  fall  in  the  temperature  is  of  bad  omen.  Con- 
valescence is  extremely  tedious,  and  may  be  interrupted  by  complications 
and  sequelae  to  be  noted. 

3.  Anomalous  Forms. 

(a)  Abortive  Type. — The  attack  sets  in  with  great  severity,  but  in  a 
day  or  two  the  symptoms  subside  and  convalescence  is  rapid.  Strlimpell 
would  distinguish  between  this  abortive  variety,  which  begins  with  such 
intensity,  and  the  mild  ambulant  cases  described  by  certain  writers.  He 
reports  a  case  in  which  the  meningeal  symptoms  set  in  with  the  greatest 
intensity  and  persisted  for  four  days,  the  temperature  rising  to  105.6°  F. 
On  the  fifth  day  the  patient  entered  upon  a  rapid  and  satisfactory  con- 
valescence. In  the  mild  cases,  as  distinguished  from  the  abortive,  the  pa- 
tients complain  of  headache,  nausea,  sensations  of  discomfort  in  the  back 
and  limbs,  and  stiffness  in  the  neck.  There  is  little  or  no  fever,  and  only 
moderate  vomiting.  These  cases  could  be  recognized  only  during  the 
prevalence  of  an  epidemic. 

(h)  An  Intermittent  Type  has  been  observed  in  many  epidemics,  and  is 
recognized  by  von  Ziemssen  and  Stille.  It  is  characterized  by  exacerba- 
tions of  fever,  which  may  recur  daily  or  every  second  day,  or  follow  a  curve 
of  an  intermittent  or  remittent  character.  The  pyrexia  resembles  that  of 
pyaemia  rather  than  malaria. 

(c)  Chronic  Form. — Heubner  states  that  this  is  a  relatively  frequent 
form,  though  it  does  not  seem  to  be  recognized  by  many  writers  on  the 
subject.  An  attack  may  be  protracted  for  from  two  to  five  or  even  six 
months,  and  may  cause  the  most  intense  marasmus.  It  is  characterized  by 
a  series  of  recurrences  of  the  fever,  and  may  present  the  most  complex 
symptomatology.  It  is  not  improbable  that  these  protracted  cases  depend 
upon  chronic  hydrocephalus  or  abscesses  of  the  brain.  This  form  differs 
distinctly  from  the  intermittent  type.  Three  cases  in  our  recent  series 
were  of  this  chronic  form;  in  one  patient  the  disease  persisted  for  ninety 
days. 

Complications. — Pleurisy,  pericarditis,  and  parotitis  are  not  un- 
common. 

Pneumonia  is  described  as  frequent  in  certain  outbreaks.  Immermann 
found,  during  the  Erlangen  epidemic,  many  instances  of  the  combination 
of  pneumonia  with  meningitis,  but  it  does  not  seem  possible  to  determine 


106  SPECIFIC  INFECTIOUS  DISEASES. 

whether^  in  such  cases,  pneumonia  is  the  primary  disease  and  the  meningitis 
secondary,  or  vice  versa.  The  frequency  Avith  which  inflammation  of  the 
meninges  of  the  brain  complicates  pneumonia  is  well  known.  Council- 
man suggests  that  the  pneumonia  of  the  disease  is  not  the  true  croupous 
form,  hut  due  to  the  diplococcus  meningitidis.  This  was  found  in  eight 
of  the  Boston  cases,  and  in  one  it  was  so  extensive  that  it  could  have  been 
mistaken  for  the  ordinary  croupous  pneumonia.  Arthritis  has  been  the 
most  frequent  complication  in  certain  epidemics.  Many  joints  are  affected 
simultaneously,  and  there  are  swelling,  pain,  and  exudation,  sometimes 
serous,  sometimes  purulent.  This  was  first  observed  by  James  Jackson,  Sr., 
in  the  epidemic  which  he  described.    Enteritis  is  rare. 

Headache  may  persist  for  months  or  years  after  an  attack.  Chronic 
hydrocephalus  develops  in  certain  instances  in  children.  The  symptoms 
of  this  are  "  jDaroxysms  of  severe  headache,  pains  in  the  neck  and  extremi- 
ties, vomiting,  loss  of  consciousness,  convulsions,  and  involuntary  discharges 
of  fseces  and  urine  "  (von  Ziemssen).  Von  Ziemssen  regards  chronic  hydro- 
cephalus as  by  no  means  a  rare  sequela.  Mental  feebleness  and  aphasia 
have  occasionally  been  noted. 

Paralysis  of  individual  cranial  nerves  or  of  the  lower  extremities  may 
persist  for  some  time.  In  some  of  these  cases  there  may  be  peripheral 
neuritis,  as  Mills  suggested. 

Special  Senses. — Eye. — These  are  due  to  three  causes:  First,  neuritis 
following  involvement  of  the  nerve  in  the  exudation  at  the  base.  This  may 
affect  the  third  nerve  or  the  optic  nerves,  leading  to  acute  papillitis,  which 
was  found  in  6  out  of  40  cases  examined  by  Randolph.  Secondly,  the 
inflammation  may  extend  directly  into  the  eye  along  the  pia-arachnoid  of 
the  optic  nerve,  causing  purulent  choroido-iritis  or  even  keratitis.  Thirdly, 
a  neuritis  of  the  fifth  nerve  may  be  followed  by  keratitis  and  purulent 
conjunctivitis. 

Ear. — Deafness  very  often  follows  inflammation  of  the  labyrinth.  Otitis 
media,  with  mastoiditis,  may  develop  from  direct  extension.  In  6-i  cases 
of  meningitis  which  recovered.  Moos  found  that  55  per  cent  were  deaf.  He 
suggests  that  the  abortive  form  of  the  disease  may  be  responsible  for  many 
cases  of  early  acquired  deafness.  In  children  this  not  infrequently  leads 
to  deaf -mutism.  Von  Ziemssen  vstates  that  in  the  deaf  and  dumb  institutions 
of  Bamberg  and  jSTuremberg,  in  1874,  a  majority  of  the  pupils  had  become 
deaf  from  epidemic  cerebro-spinal  meningitis. 

Nose. — Coryza  is  not  infrequent  early  in  the  disease,  and  Striimpell  says 
that  in  many  of  his  cases  nasal  catarrh  preceded  the  meningitis.  He  sug- 
gests that  the  latter  may  be  caused  by  infection  from  the  nose.  Certainly 
the  nasal  secretion  appears  frequently  to  contain  the  diplococci — in  18  cases 
examined  by  Scherrer,  and  in  10  out  of  15  of  the  Boston  cases. 

Diagnosis. — Much  has  been  done  of  late  to  enable  the  practitioner 
to  recognize  definitely  the  existence  of  meningitis  and  of  the  various 
forms. 

(a)  The  fever,  headache,  delirium,  retraction  of  the  neck,  tremor,  and 
rigidity  of  the  muscles  are  most  important  signs.  As  already  mentioned,  in 
the  meningitis  of  cerebro-spinal  fever  the  spinal  symptoms  are  very  much 


CEREBRO-SPINAL   FEVER.  107 

more  marked  than  in  the  other  forms.  One  has  constantly  to  hear  in 
mind  that  certain  cases  of  typhoid  fever  and  of  pneumonia  closely  simulate 
cerebro-spinal  meningitis.  Long  ago  Stokes  made  the  wise  observation 
that  "  there  is  no  single  nervous  symptom  which  may  not  and  does  not 
occur  independently  of  any  appreciable  lesion  of  the  brain,  nerves,  or 
spinal  cord." 

Q))  Among  the  special  diagnostic  features  may  be  mentioned: 

Kernig's  Sign. — When  the  thigh  is  flexed  at  right  angles  to  the  abdo- 
men, the  leg  can  be  extended  upon  the  thigh  nearly  in  a  straight  line. 
If  meningitis  be  present,  strong  contractures  of  the  flexors  prevent  the 
full  extension  of  the  leg  on  the  thigh.  This  is  a  valuable  sign,  and  has 
been  present  in  all  of  our  recent  cases. 

Lumbar  Puncture. — The  procedure  is  quite  harmless,  and  in  a  majority 
of  the  cases  can  be  done  without  general  ansesthesia,  with  the  aid  of  a 
local  freezing  mixture.  As  a  rule,  it  is  best  in  children  to  give  a  whifE 
or  two  of  chloroform.  The  patient  is  turned  on  the  right  side  with  the 
back  bowed,  the  knees  drawn  up,  and  the  left  shoulder  forward.  As  a 
rule,  there  is  no  difficulty  in  finding  the  spinal  processes,  and  with  the 
thumb  or  index  finger  of  the  left  hand  as  a  guide,  a  small  aspirator  needle 
or  that  of  the  antitoxin  syringe  is  inserted  to  one  side  of  the  median  line 
and  thrust  deeply  into  the  third  interspace  in  an  upward  and  inward 
direction.  At  a  variable  distance,  according  to  the  age  and  musculature, 
the  needle  enters  the  spinal  cord, — about  two  and  a  half  centimetres  in 
infants  and  from  four  to  six  centimetres  in  adults. 

The  fluid  runs,  as  a  rule,  drop  by  drop,  and  when  meningitis  is  present 
it  is  usually  turbid,  sometimes  purulent,  occasionally  bloody.  Meningitis 
may  be  present  with  a  clear  fluid.  Cover-glass  preparations  should  be 
made  and  studied,  and  the  character  of  the  organisms  carefully  noted. 
The  cover-slip  preparations  may  give  the  diagnosis  at  once.  In  acute 
cases  of  cerebro-spinal  fever  the  organisms  may  be  present  in  large  num- 
bers. There  is  rarely  any  difficulty  in  determining  between  the  pneumo- 
coccus  and  the  diplococcus  intracellularis.  Should  the  fluid  be  sterile 
and  tuberculosis  suspected,  a  guinea-pig  may  be  inoculated. 

Cyto-diagnosis. — Eecent  French  writers  claim  that  in  tuberculous  men- 
ingitis the  exudate  obtained  by  lumbar  puncture  contains  only  lymphocytes, 
while  in  the  pneumococcus  meningitis  and  in  cerebro-spinal  fever  the  pol}'- 
nuclear  leucocytes  predominate.  They  claim  too  that  the  meninges  are 
impermeable  to  potassium  iodide  in  cerebroTspinal  fever,  and  the  iodine 
can  not  be  detected  in  the  fluid  obtained  by  lumbar  puncture;  while  in  tu- 
berculous meningitis  it  is  present.  In  recent  cases  we  have  not  been  able 
to  confirm  either  of  these  observations. 

Prognosis. — Ilirsch  states  that  the  mortality  has  ranged  in  various 
epidemics  from  20  to  75  per  cent.  In  children  the  death-rate  is  much 
higher  than  in  adults.  Cases  with  deep  coma,  repeated  convulsions,  and 
high  fever  rarely  recover.  The  outlook  in  the  protracted  cases  is  not  good, 
though  Ileubner  gives  an  instance  of  a  lad  of  seven,  who  was  ill  from  the 
end  of  February  until  the  end  of  June,  with  repeated  recurrences,  was 
"worn  to  a  skeleton,  and  yet  completely  recovered. 


108  SPECIFIC  INFECTIOUS  DISEASES. 

Treatment. — The  high  rate  of  mortality  which  has  existed  in  most 
epidemics  indicates  the  futility  of  the  various  therapeutical  agents  which 
have  been  recommended.  When  we  consider  the  nature  of  the  local  dis- 
ease and  the  fact  that,  so  far  as  we  know,  simple  and  tuberculous  cerebro- 
spinal meningitis  are  invariably  fatal,  we  may  wonder  rather  that  recovery 
follows  in  any  well-developed  case. 

In  strong  robust  patients  the  local  abstraction  of  blood  by  wet  cups 
on  the  nape  of  the  neck  relieves  the  pain.  General  bloodletting  is  rarely 
indicated.  Cold  to  the  head  and  spine,  which  was  used  in  the  first  epi- 
demics by  New  England  physicians,  is  of  great  service.  A  bladder  of  ice 
to  the  head,  or  an  ice-cap,  and  the  spinal  ice-bag  may  be  continuously  em- 
ployed. The  latter  is  very  beneficial.  Hydrotherapy  should  be  systematic- 
ally used,  in  the  form  of  the  tub  bath,  at  98°,  as  recommended  by  Aufrecht. 
Netter  speaks  highly  of  its  good  effects,  and  we  have  also  seen  it  do  good. 
It  may  be  given  every  third  hour.  If  any  counter-irritation  is  thought 
necessary,  the  skin  of  the  back  of  the  neck  may  be  lightly  touched  with 
the  Paquelin  thermocautery.  Blisters,  which  have  been  used  so  much,  are 
of  doubtful  benefit.  The  lumbar  puncture  seems  helpful  in  cases  with 
coma  or  convulsions,  and  in  any  case  it  does  no  harm.  Of  internal  reme- 
dies opium  may  be  given  freely,  best  as  morphia  hypodermically.  Von 
Ziemssen  advises  the  hypodermic  injection  of  morphia,  from  one  third 
to  one  half  grain  in  adults.  Mercury  has  no  special  influence  on  menin- 
geal inflammation.  Iodide  of  potassium  is  warmly  recommended  by  some 
writers.  Quinine  in  large  doses,  ergot,  belladonna  and  Calabar  bean  have 
had  advocates.  Bromide  of  potassium  may  be  employed  in  the  milder 
cases,  but  it  is  not  so  useful  as  morphia  to  control  the  spasms. 

The  diet  should  be  nutritious,  consisting  of  milk  and  strong  broths 
while  the  fever  persists.  Many  cases  are  very  difficult  to  feed,  and  Heubner 
recommends  forced  alimentation  with  the  stomach-tube.  The  cases  seem 
to  bear  stimulants  well,  and  whisky  or  brandy  may  be  given  freely  when 
there  are  signs  of  a  failing  heart. 


XV.    LOBAR    PNEUMONIA. 

{Croupous  or  Fibrinous  Pneumonia ;  Pneumonitis;  Lung  Fever.) 

Definition. — An  infectious  disease  characterized  by  inflammation  of 
the  lungs,  toxsemia  of  varying  intensity,  and  a  fever  that  terminates  ab- 
ruptly by  crisis.  Secondary  infective  processes  are  common.  The  micro- 
coccus lanceolatus  of  Fraenkel  is  present  in  a  large  proportion  of  the  cases. 

Incidence. — The  most  widespread  and  fatal  of  all  acute  diseases, 
pneumonia  is  now  the  "  Captain  of  the  Men  of  Death,"  to  use  the  phrase 
applied  by  John  Bunyan  to  consumption.  In  the  United  States  during 
the  census  year  1890  there  died  of  it  76,496,  a  death-rate  per  100,000 
of  population  of  186.94.  In  Chicago  during  the  past  ten  years  it  has 
gradually  replaced  consumption  as  the  principal  cause  of  death,  which 
A.  R.  Eeynolds  attributes  to  the  predisposing  influence  of  influenza.    In 


LOBAR  PNEUMONIA.  109 

the  last  decade  the  death-rate  was  18.03  per  10,000  of  population,  against 
12.36  per  10,000  in  the  previous  decade.  There  has  been  a  marked  in- 
crease in  the  disease  in  Baltimore,  and  Folsom  has  brought  forward  evi- 
dence to  show  that  there  has  been  a  progressive  increase  in  the  death-rate 
from  pneumonia  in  the  State  of  Massachusetts.  The  admission  of  pneu- 
monia cases  to  hospitals  during  the  past  few  years  has  in  some  places  almost 
doubled. 

Etiology. — Age- — To  the  sixth  year  the  predisposition  to  pneumonia 
is  marked;  it  diminishes  to  the  fifteenth  year,  but  then  for  each  subsequent 
decade  it  increases.  For  children  Holt's  statistics  of  500  cases  give:  First 
year,  15  per  cent;  from  the  second  to  the  sixth  year,  62  per  cent;  from  the 
seventh  to  the  eleventh  year,  21  per  cent;  from  the  twelfth  to  the  four- 
teenth year,  2  per  cent.  Lobar  pneumonia  has  been  met  with  in  the  new- 
born. The  relation  to  age  is  well  shown  in  the  last  Census  Eeport.  The 
death-rate  in  persons  from  fifteen  to  forty-five  years  was  100.05  per  100,000 
of  population;  from  forty-five  to  sixty-five  years  it  was  263.12;  and  in  per- 
sons sixty-five  years  of  age  and  over  it  was  733.77.  Pneumonia  may  well 
be  called  the  friend  of  the  aged.  Taken  off  by  it  in  an  acute,  short,  not 
often  painful  illness,  the  old  man  escapes  those  "  cold  gradations  of  decay  " 
so  distressing  to  himself  and  to  his  friends. 

Sex. — Males  are  more  frequently  affected  than  females.  The  Census 
Eeport  for  1890  gives  42,739  males  against  33,757  females. 

Race. — In  this  country  pneumonia  is  more  fatal  in  the  colored  race  than 
among  the  whites,  the  death-rate  being  278.97  against  182.24. 

Social  Condition. — The  disease  is  more  common  in  the  cities.  The 
census  figures  give  234.07  deaths  per  100,000  of  population  for  the  cities 
against  141.09  for  rural  districts.  Individuals  who  are  much  exposed  to 
hardship  and  cold  are  particularly  liable  to  the  disease.  New-comers  and 
immigrants  are  stated  to  be  less  susceptible  than  native  inhabitants. 

Personal  Condition. — Debilitating  causes  of  all  sorts  render  individuals 
more  susceptible.  Alcoholism  is  perhaps  the  most  potent  predisposing 
factor.     Eobust,  healthy  men  are,  however,  often  attacked. 

Previous  Attach . — No  other  acute  disease  recurs  in  the  same  individual 
with  such  frequency.  Instances  are  on  record  of  individuals  who  have  had 
ten  or  more  attacks.  The  percentage  of  recurrences  has  been  placed  as 
high  as  50.  Netter  gives  it  as  31,  and  he  has  collected  \ie  statistics 
of  eleven  observers  who  place  the  percentage  at  26.8.  Among  the 
highest  figures  for  recurrences  are  those  of  Benjamin  Eush,  28,  and 
Andral,  16. 

Trauma — C ontusion- pneumonia. — Pneumonia  may  follow  directly  upon 
injury,  particularly  of  the  chest,  without  necessarily  any  lesion  of  the 
lung.  Litten  gives  4.4  per  cent,  Stern  2.8  per  cent.  There  has  been  but 
one  well-marked  case  in  twelve  years  at  the  Johns  Hopkins  Hospital. 
Stern  describes  three  clinical  varieties:  first,  the  ordinary  lobar  pneu- 
monia following  a  contusion  of  the  chest  wall;  second,  atypical  cases, 
with  slight  fever  and  not  very  characteristic  physical  signs;  third,  cases 
with  the  physical  signs  and  features  of  broncho-pneumonia.  The  last 
two  varieties  have  a  favorable  prognosis.    According  to  Ballard,  workers  in 


110  SPECIFIC  INFECTIOUS  DISEASES. 

certain  phosphate  factories,  where  they  breathe  a  very  dusty  atmosphere, 
are  particularly  prone  to  pneumonia. 

Cold  has  been  for  years  regarded  as  an  important  etiological  factor. 
The  frequent  occurrence  of  an  initial  chill  has  been  one  reason  for  this 
widespread  belief.  As  to  the  close  association  of  pneumonia  with  exposure 
there  can  be  no  question.  We  see  the  disease  occur  either  promptly  after 
a  wetting  or  a  chilling  due  to  some  unusual  exposure,  or  come  on  after 
an  ordinary  catarrh  of  one  or  two  days'  duration.  Cold  is  now  regarded 
simply  as  a  factor  in  lowering  the  resistance  of  the  bronchial  and  pul- 
monary tissues. 

Climate  and  Season. — Climate  does  not  appear  to  have  very  much  in- 
fluence, as  pneumonia  prevails  equally  in  hot  and  cold  countries.  It  is 
stated  to  be  more  prevalent  in  the  Southern  than  in  the  Northern  States, 
but  an  examination  of  the  last  Census  Eeport  shows  that  there  is  very  little 
difference  in  the  various  State  groups. 

Much  more  important  is  the  influence  of  season.  Statistics  are  almost 
unanimous  in  placing  the  highest  incidence  of  the  disease  in  the  winter 
and  spring  months.  In  Montreal  January,  the  coldest  month  of  the  year, 
but  with  steady  temperature,  has  usually  a  comparatively  low  death-rate 
from  pneumonia.  The  large  statistics  of  Seitz  from  Munich  and  of  Seibert 
of  New  York  give  the  highest  percentage  in  February  and  March. 

Bacteriology  of  Acute  Lobar  Pheiunonia. — (a)  Micrococcus 
lanceolatus,  Pneumococcus  or  Diplococcus  pneumonice  of  Fraenlcel  and 
Weichselbaum. — In  September,  1880,  Sternberg  inoculated  rabbits  with  his 
own  saliva  and  isolated  a  micrococcus.  The  publication  was  not  made  until 
April  30,  1881.  Pasteur  discovered  the  same  organism  in  the  saliva  of  a 
child  dead  of  hydrophobia  in  December,  1880,  and  the  priority  of  the 
discovery  belongs  to  him,  as  his  publication  is  dated  January  18,  1881. 
There  was,  however,  no  suspicion  that  this  organism  was  concerned  in 
the  etiology  of  lobar  pneumonia,  and  it  was  not  really  until  April,  1884, 
that  A.  Fraenkel  determined  that  the  organism  found  by  Sternberg  and 
Pasteur  in  the  saliva,  and  known  as  the  coccus  of  sputum  septicsemia,  was 
the  most  frequent  organism  in  acute  pneumonia.  At  first  there  was  a 
good  deal  of  confusion  between  this  and  the  organism  described  by  Fried- 
lander,  November,  1883,  and  which  is  now  known  as  the  pneumo-bacillus. 
Fraenkel  and  Weichselbaum,  in  1886,  demonstrated  the  diplococcus  in 
most  cases  of  croupous  pneumonia,  and  later  studies  have  made  it 
probable  that  this  organism  is  the  sole  cause  of  genuine  acute  lobar 
pneumonia. 

The  organism  is  a  somewhat  elliptical,  lance-shaped  coccus,  usually 
occurring  in  pairs;  hence  the  term  diplococcus.  It  is  readily  demon- 
strated in  cover-glass  preparations  with  the  usual  dyes  and  by  the  Gram 
method.  About  the  organism  in  the  sputum  a  capsule  can  always  be 
demonstrated.  Its  cultural  and  biological  properties  present  many  vari- 
ations, for  a  consideration  of  which  the  student  is  referred  to  the  text- 
books on  bacteriology.  Scarcely  any  peculiarity  is  constant.  A  large 
number  of  varieties  have  been  cultivated.  Its  kinship  to  streptococcus 
pyogenes  is  regarded  by  many  as  very  close. 


LOBAR  PNEUMONIA.  Ill 

Distribution  in  the  Body. — In  the  bronchial  secretions  and  in  the  af- 
fected lung  it  is  readily  demonstrated  in  cover-slips,  and  in  the  latter  in 
sections.  The  organism  was  isolated  from  the  blood  by  Cole  in  9  of  64 
cases  at  my  clinic  in  the  session  of  1900-1901. 

Micrococcus  lanceolatus  under  other  Conditions. — In  this  connection  a 
very  important  point  is  the  presence  of  the  virulent  organism  in  the  mouth 
and  bronchial  secretions  of  healthy  individuals — 20  per  cent,  according 
to  Netter's  observations.  It  occurs  also  in  a  non-virulent  state,  and  may 
be  regarded  as  a  regular  inhabitant  of  the  mouth  and  pharynx. 

In  other  Diseases. — The  organism  is  very  widely  distributed,  and  is 
found  in  many  other  conditions  besides  croupous  pneumonia.  It  is  a 
common  cause  of  primary  and  secondary  broncho-pneumonias,  and  has 
been  found  also  in  pleurisy,  pericarditis,  meningitis,  peritonitis,  acute 
synovitis,  otitis,  endocarditis,  etc. 

An  acute  general  infection  with  micrococcus  lanceolatus  without  local- 
ized foci  may  prove  rapidly  fatal,  constituting  a  pneumococcus  septicwniia 
comparable  to  the  typhoid  septicaemia  already  described.  Townsend  has 
reported  a  remarkable  case  of  a  girl  aged  six,  who  had  pain  in  the  abdo- 
men, vomiting,  and  a  temperature  of  104.2°.  There  was  no  exudate  in  the 
throat.  Twenty-four  hours  from  the  beginning  of  the  symptoms  she  had 
a  convulsion  and  died  six  hours  later.  There  was  found  a  general  infection 
with  the  pneumococcus,  which  occurred  in  the  blood,  lungs,  spleen,  and 
kidneys.  In  Flexner's  study  of  terminal  infections  micrococcus  lanceo- 
latus was  found  four  times  in  acute  peritonitis,  eleven  times  in  acute  peri- 
carditis, five  times  in  acute  endocarditis,  three  times  in  acute  pleurisy, 
and  three  times  in  acute  meningitis. 

Outside  the  body  the  organism  has  been  found  in  the  dust  and  sweepings 
of  rooms. 

(h)  Bacillus  pneumonice  of  Friedldnder. — This  is  a  larger  organism  than 
the  pneumococcus,  and  appears  in  the  form  of  plump,  short  rods.  It  also 
shows  a  capsule,  but  presents  marked  biological  and  cultural  differences 
from  Fraenkel's  pneumococcus.  It  occurred  in  9  of  Weichselbaum's  129 
cases.  It  may  cause  broncho-pneumonia  and  other  affections,  but  probably 
is  not  a  cause  of  genuine  lobar  pneumonia. 

(c)  Other  Organisms. — Various  bacteria  may  be  associated  with  the 
pneumococcus  in  lobar  pneumonia,  the  most  common  of  these  being  strep- 
tococcus pyogenes,  the  pyogenic  staphylococci,  and  Friedlander's  pneumo- 
bacillus;  but  while  these  latter  may  cause  broncho-pneumonias,  they  have 
not  been  satisfactorily  demonstrated  to  be  other  than  secondary  invaders 
in  lobar  pneumonia.  Likewise  the  pneumonias  caused  by  bacillus  typho- 
sus, bacillus  diphtherise,  and  the  influenza  bacillus  are  not  to  be  identified 
with  true  lobar  pneumonia. 

Clinically,  the  infectious  nature  of  pneumonia  was  recognized  long  be^ 
fore  we  knew  anything  of  the  pneumococcus.  Among  the  features  which 
favored  this  view  were  the  following:  First,  the  disease  is  similar  to  other 
infections  in  its  mode  of  outbreak.  It  may  occur  in  endemic  form,  local- 
ized in  certain  houses,  in  barracks,  jails,  and  schools.  As  many  as  ten 
occupants  of  one  house  have  been  attacked,  and  in  hospital  practice  it  is 


112  SPECIFIC  INFECTIOUS  DISEASES. 

not  infrequent  to  have  2  or  3  cases  admitted  from  the  same  house.  I  have 
seen  three  members  of  a  family  consecutively  attacked  with  a  most  malig- 
nant type  of  pneumonia.  Among  the  more  remarkable  endemic  outbreaks 
is  that  reported  by  W.  B.  Eodman,  of  Frankfort,  Ky.  In  a  prison  with 
a  population  of  735  there  occurred  in  one  year  118  cases  of  pneumonia 
with  35  deaths.  At  the  penitentiary  at  Amberg  during  a  period  of  five 
months  there  were  161  cases,  with  a  mortality  above  28  per  cent.  The 
disease  may  assume  epidemic  proportions.  In  the  Middlesborough  epi- 
demic, so  carefully  studied  by  Ballard,  there  were  682  persons  attacked 
with  a  mortality  of  21  per  cent.  During  some  years  pneumonia  is  so  preva- 
lent that  it  is  practically  pandemic.  Direct  contagion  is  suggested  by  the 
fact  that  a  patient  in  the  next  bed  to  a  pneumonia  case  may  take  the  dis- 
ease, or  2  or  3  cases  may  follow  in  rapid  succession  in  a  ward.  It  is  very 
exceptional,  however,  for  nurses  or  doctors  to  be  attacked. 

Secondly,  the  clinical  course  of  the  disease  is  that  of  an  acute  infection. 
It  is  the  very  type  of  a  self-limited  disease,  running  a  definite  cycle  in  a 
way  seen  only  in  infectious  disorders. 

Thirdly,  as  in  other  acute  infections,  the  constitutional  symptoms  may 
bear  no  proportion  whatever  to  the  severity  of  the  local  lesion.  As  is  well 
known,  a  patient  may  have  a  very  small  apex  pneumonia  which  does  not 
seriously  impair  the  breathing  capacity,  but  which  may  be  accompanied 
with  the  most  intense  toxic  features. 

Immunity  and  Serum  Therapy. ^-The  pneumococcus  does  not  produce 
in  artificial  cultures  any  strong,  soluble  toxin  analogous  to  the  diphtheria 
toxin  or  the  tetanus  toxin,  but  its  poison  is  contained  within  the  bac- 
terial cells,  from  which  it  may  be  extracted  in  various  ways,  or  it  may 
be  set  free  from  the  dead  or  degenerated  cocci.  The  possibility  that  the 
pneumococcus  may  secrete  a  soluble  toxin  in  the  infected  human  or  animal 
body  may  be  admitted,  but  of  this  there  is  no  conclusive  demonstration. 
By  the  use  of  living  or  dead  pneumococci  or  their  extracts,  animals  may 
be  vaccinated  against  this  organism,  so  that  their  blood-serum  is  capable 
of  protecting  susceptible  animals  against  many  times  the  minimal  fatal 
dose  of  the  virulent  pneumococcus.  Strong  protective  serum  has  thus  been 
obtained  from  rabbits,  horses,  asses,  cows,  and  other  animals  subjected 
to  repeated  inoculations  with  dead  and  living  cultures  of  the  pneumococcus. 
This  specific  serum  is  not,  as  was  at  first  supposed  by  the  Klemperers,  an 
antitoxic  serum.  The  exact  mode  of  its  action  has  not  been  satisfactorily 
determined.  It  is  considered  by  A.  and  M.  Wassermann  to  belong  to  the 
class  of  bactericidal  or  bacteriolytic  sera,  like  the  anti-cholera  and  the 
anti-typhoid  sera,  whereas  MetschnikofE  and  his  school  believe  that  it  acts 
by  stimulating  the  leucocytes  to  ingest  and  destroy  the  pneumococci.  M. 
Wassermann  finds  that  the  specific  protective  substances  are  formed  in 
the  bone-marrow,  and  thence  distributed  to  the  blood.  There  is  evidence 
that  similar  specific  substances  antagonistic  to  the  pneumococcus  are  pro- 
duced in  human  beings  infected  with  this  organism,  and  the  crisis  of 
pneumonia  is  explained  by  the  formation  and  accumulation  of  these  sub- 
stances in  the  body. 

Many  trials  have  been  made  of  the  curative  value  of  antipneumococcic 


LOBAR  PNEUMONIA.  113 

serum  in  the  treatment  of  pneumonia,  the  serum  made  by  Pane  having 
been  most  extensively  employed.  Thus  far  it  has  not  been  shown  that 
this  serum  influences  in  any  marked  degree  the  course  of  the  disease 
in  man. 

Morbid  Anatomy. — Since  the  time  of  Laennec,  pathologists  have 
recognized  three  stages  in  the  inflamed  lung — engorgement,  red  hepatiza- 
tion, and  gray  hepatization. 

In  the  stage  of  engorgement  the  lung  tissue  is  deep  red  in  color,  firmer 
to  the  touch,  and  more  solid,  and  on  section  the  surface  is  bathed  with 
blood  and  serum.  It  still  crepitates,  though  not  so  distinctly  as  healthy 
lung,  and  excised  portions  float.  The  air-cells  can  be  dilated  by  insuffla- 
tion from  the  bronchus.  Microscopical  examination  shows  the  capillary 
vessels  to  be  greatly  distended,  the  alveolar  epithelium  swollen,  and  the 
air-cells  occupied  by  a  variable  number  of  blood-corpuscles  and  detached 
alveolar  cells.  In  the  stage  of  red  hepatization  the  lung  tissue  is  solid,  firm, 
and  airless.  If  the  entire  lobe  is  involved  it  looks  voluminous,  and  shows 
indentations  of  the  ribs.  On  section  the  surface  is  dry,  reddish  brown  in 
color,  and  has  lost  the  deeply  congested  appearance  of  the  first  stage.  One 
of  the  most  remarkable  features  is  the  friability;  in  striking  contrast  to 
the  healthy  lung,  which  is  torn  with  difficulty,  a  hepatized  organ  can  be 
readily  broken  by  the  finger.  Careful  inspection  shows  that  the  surface 
is  distinctly  granular,  the  granulations  representing  fibrinous  plugs  filling 
the  air-cells.  The  distinctness  of  this  appearance  varies  greatly  with  the 
size  of  the  alveoli,  which  are  about  0.10  mm.  in  diameter  in  the  infant, 
0.15  or  0.16  in  the  adult,  and  from  0.20  to  0.25  in  old  age.  On  scraping 
the  surface  with  a  knife  a  reddish  viscid  serum  is  removed,  containing  small 
granular  masses.  The  smaller  bronchi  often  contain  fibrinous  plugs.  If 
the  lung  has  been  removed  before  the  heart,  it  is  not  uncommon  to  find 
solid  moulds  of  clot  filling  the  blood-vessels.  Microscopically,  the  air-cells 
are  seen  to  be  occupied  by  coagulated  fibrin  in  the  meshes  of  which  are  red 
blood-corpuscles,  polynuclear  leucocytes,  and  alveolar  epithelium.  The 
alveolar  walls  are  infiltrated  and  leucocytes  are  seen  in  the  interlobular 
tissues.  Cover-glass  preparations  from  the  exudate,  and  thin  sections  show, 
as  a  rule,  the  diplococci  already  referred  to,  many  of  which  are  contained 
within  cells.  Staphylococci  and  streptococci  may  also  be  seen  in  some 
cases.  In  the  stage  of  gray  hepatization  the  tissue  has  changed  from  a 
reddish-brown  to  a  grayish-white  color.  The  surface  is  moister,  the  exudate 
obtained  on  scraping  is  more  turbid,  the  granules  in  the  acini  are  less  dis- 
tinct, and  the  lung  tissue  is  still  more  friable.  Histologically,  in  gray 
hepatization,  it  is  seen  that  the  air-cells  are  densely  filled  with  leucocytes, 
the  fibrin  network  and  the  red  blood-corpuscles  have  disappeared.  A  more 
advanced  condition  of  gray  hepatization  is  that  known  as  purnlent 
infiUration,  in  which  the  lung  tissue  is  softer  and  bathed  with  a  purulent 
fluid. 

The  stage  of  gray  hepatization  appears  to  be  the  first  step  in  the  process 
of  resolution.  The  exudate  is  softened,  the  cell  elements  are  disintegrated 
and  rendered  capable  of  absorption.  When  the  purulent  infiltration  of 
the  lung  tissue  reaches  the  grade  sometimes  seen  post  mortem,  it  is  prob- 


114  SPECIFIC  INFECTIOUS  DISEASES. 

able  that  resolution  could  not  take  place.  Small  abscess  cavities  may  arise, 
and  by  their  fusion  larger  ones.  Often  in  one  lung^  or  even  in  one  lobe, 
the  various  stages  of  the  process  may  be  seen,  and  the  passage  of  the  en- 
gorgement into  red  hepatization  and  of  the  latter  into  the  gray  stage  can 
be  readily  traced. 

The  general  details  of  the  morbid  anatomy  of  pneumonia  may  be 
gathered  from  the  following  facts,  based  on  100  autopsies,  made  by  me  at 
the  General  Hospital,  Montreal:  In  51  cases  the  right  lung  was  affected; 
in  33,  tlie  left;  in  17,  both  organs.  In  27  cases  the  entire  lung,  with  the 
exception,  perhaps,  of  a  narrow  margin  at  the  apex  and  anterior  border, 
was  consolidated.  In  34  cases,  the  lower  lobe  alone  was  involved;  in  13 
cases,  the  upper  lobe  alone.  When  double,  the  lower  lobes  were  usually 
affected  together,  but  in  three  instances  the  lower  lobe  of  one  and  the 
upper  lobe  of  the  other  were  attacked.  In  three  cases  also,  both  upper 
lobes  were  affected.  Occasionally  the  disease  involves  the  greater  part  of 
both  lungs;  thus,  in  one  instance  the  left  organ  with  the  exception  of  the 
anterior  border  was  uniformly  hepatized,  while  the  right  was  in  the  stage 
of  gray  hepatization,  except  a  still  smaller  portion  in  the  corresponding 
region.  In  a  third  of  the  cases,  red  and  gray  hepatization  existed  together. 
In  22  instances  there  was  gray  hepatization.  As  a  rule  the  unaffected  por- 
tion of  the  lung  is  congested  or  oedematous.  When  the  greater  portion  of 
a  lobe  is  attacked,  the  uninvolved  part  may  be  in  a  state  of  almost  gelati- 
nous oedema.  The  unaffected  lung  is  usually  congested,  particularly  at 
the  posterior  part.  This,  it  must  be  remembered,  may  be  largely  due  to 
post-mortem  subsidence.  The  uninfiamed  portions  are  not  always  con- 
gested and  oedematous.  The  upper  lobe  may  be  dry  and  bloodless  when 
the  lower  lobe  is  uniformly  consolidated.  The  average  weight  of  a  normal 
lung  is  about  600  grammes,  while  that  of  an  inflamed  organ  may  be  1,500, 
2,000,  or  even  2,500  grammes. 

The  bronchi  contain,  as  a  rule,  at  the  time  of  death  a  frothy  serous 
fluid,  rarely  the  tenacious  mucus  so  characteristic  of  pneumonic  sputum. 
The  mucous  membrane  is  usually  reddened,  rarely  swollen.  In  the  affected 
areas  the  smaller  bronchi  often  contain  fibrinous  plugs,  which  may  extend 
into  the  larger  tubes,  forming  perfect  casts.  The  bronchial  glands  are 
swollen  and  may  even  be  soft  and  pulpy.  The  pleural  surface  of  the  in- 
flamed lung  is  invariably  involved  when  the  process  becomes  superficial. 
Commonly,  there  is  only  a  thin  sheeting  of  exudate,  producing  slight 
turbidity  of  the  membrane.  In  only  two  of  the  hundred  instances  the 
pleura  was  not  involved.  In  some  cases  the  fibrinous  exudate  may  form  a 
creamy  layer  an  inch  in  thickness.  A  serous  exudation  of  variable  amount 
is  not  uncommon. 

Lesions  in  other  Organs. — The  heart  is  distended  with  firm,  tenacious 
coagula,  which  can  be  withdrawn  from  the  vessels  as  dendritic  moulds. 
In  no  other  acute  disease  do  we  meet  with  coagula  of  such  solidity  and 
firmness.  The  distention  of  the  right  chambers  of  the  heart  is  particu- 
larly marked.  The  left  chambers  are  rarely  distended  to  the  same  degree. 
The  spleen  is  often  enlarged,  though  in  only  35  of  the  100  cases  was  the 
weight  above  200  grammes.    The  kidneys  show  parenchymatous  swelling, 


LOBAR  PNEUMONIA.  115 

turbidity  of  the  cortex,  and,  in  a  very  considerable  proportion  of  the  cases 
— 25  per  cent — chronic  interstitial  changes. 

Pericarditis  is  not  infrequent,  and  occurs  more  particularly  with  pneu- 
monia of  the  left  side  and  with  double  pneumonia.  In  5  of  the  100  autop- 
sies it  was  present,  and  in  4  of  them  the  lappet  of  lung  overlying  the  peri- 
cardium with  its  pleura  was  involved.  Endocarditis  is  more  frequent  and 
occurred  in  16  of  the  100  cases.  In  5  of  these  the  endocarditis  was  of  the 
simple  character;  in  11  the  lesions  were  ulcerative.  Fatty  degeneration 
of  the  heart  is  not  common  except  in  protracted  cases. 

Me7iingitis  is  not  infrequently  found,  and  in  many  cases  is  associated 
with  malignant  endocarditis.  It  was  present  in  8  of  the  100  autopsies. 
Of  20  cases  of  meningitis  in  ulcerative  endocarditis  15  occurred  in  pneu- 
monia.    The  meningeal  inflammation  in  these  cases  is  usually  cortical. 

Croupous  or  diphtheritic  inflammation  may  occur  in  other  parts.  A 
croupous  colitis,  as  pointed  out  by  Bristowe,  is  not  very  uncommon.  It 
occurred  in  5  of  my  100  post-mortems.  It  is  usually  a  thin,  flaky  exuda- 
tion, most  marked  on  the  tops  of  the  folds  of  the  mucous  membrane.  In 
1  case  there  was  a  patch  of  croupous  gastritis,  covering  an  area  of  12  by 
8  cm.,  situated  to  the  left  of  the  cardiac  orifice. 

The  liver  shows  parenchymatous  changes  and  often  extreme  engorge- 
ment of' the  hepatic  veins. 

Symptoms. — Course  of  the  Disease  in  Typical  Cases. — We  know  but 
little  of  the  incubation  period  in  lobar  pneumonia.  It  is  probably  very 
short.  There  are  sometimes  slight  catarrhal  symptoms  for  a  day  or  two. 
As  a  rule,  the  disease  sets  in  abruptly  with  a  severe  chill,  which  lasts  from 
fifteen  to  thirty  minutes  or  longer.  In  no  acute  disease  is  an  initial  chill 
so  constant  or  so  severe.  The  patient  may  be  taken  abruptly  in  the  midst 
of  his  work,  or  may  awaken  out  of  a  sound  sleep  in  a  rigor.  The  tempera- 
ture taken  during  the  chill  shows  that  the  fever  has  already  begun.  If 
seen  shortly  after  the  onset,  the  patient  has  usually  features  of  an  acute 
fever,  and  complains  of  headache  and  general  pains.  Within  a  few  hours 
pain  in  the  side  develops,  often  of  an  agonizing  character;  a  short,  dry, 
painful  cough  begins,  and  the  respirations  are  increased  in  frequency. 
When  seen  on  the  second  or  third  day,  the  picture  in  typical  pneumonia 
is  quite  pathognomonic;  more  so,  perhaps,  than  that  presented  by  any 
other  acute  disease.  The  patient  lies  flat  in  bed,  often  on  the  affected 
side;  the  face  is  flushed,  particularly  one  or  both  cheeks;  the  breathing  is 
hurried,  accompanied  often  with  a  short  expiratory  grunt;  the  alje  nasi 
dilate  with  each  inspiration;  herpes  is  usually  present  on  the  lips  or  nose; 
the  eyes  are  bright,  the  expression  is  anxious,  and  there  is  a  frequent  short 
cough  which  makes  the  patient  wince  and  hold  his  side.  The  expectora- 
tion is  blood-tinged  and  extremely  tenacious.  The  temperature  may  be 
104°  or  105°.  The  pulse  is  full  and  bounding  and  the  pulse-respiration 
ratio  much  disturbed.  Examination  of  the  lung  shows  the  physical  signs 
of  consolidation — ^blowing  breathing  and  fine  rales.  After  persisting  for 
from  seven  to  ten  days  the  crisis  occurs,  and  with  a  fall  in  the  temperature 
the  patient  passes  from  the  condition  of  extreme  distress  and  anxiety  to  one 
of  comparative  comfort. 


116 


SPECIFIC  INFECTIOUS  DISEASES. 


Special  Features.  — The  fever  rises  rapidly^,  and  the  height  may  be 
104°  or  105°  within  twelve  hours.     Having  reached  the  fastiginm,  it  is 


Jan.  40  11  i2  is  u  IS  16 


R«sp. 


Pnlse 
190 


Temp 
109 


96 
Temp, 


Resp, 
Stools 


3ay  of 
iscase 


BLACK,  temperature;  red,  pulse;  blue,  respiration. 

Chart  IX. — Fever,  pulse,  and  respirations  in  lobar  pneumonia. 

remarkably  constant.     Often  the  two-hour  temperature  chart  will  not  show 
ior  two  days  more  than  a  degree  of  variation.     In  children  and  in  cases 


LOBAR  PNEUMONIA.  117 

without  chill  the  rise  is  more  gradual.  In  old  persons  and  in  drunkards 
the  temperature  range  is  lower  than  in  children  and  in  healthy  individuals; 
indeed,  one  occasionally  meets  with  an  afebrile  pneumonia. 

The  Crisis. — After  the  fever  has  persisted  for  from  five  to  nine  or  ten 
days  there  is  an  abrupt  drop,  known  as  the  crisis,  which  is  perhaps  the 
most  characteristic  feature  of  lobar  pneumonia.  The  day  of  the  crisis  is 
variable.  It  is  very  uncommon  before  the  third  day,  and  rare  after  the 
twelfth.  I  have  twice  seen  it  as  early  as  the  third  day.  From  the  time  of 
Hippocrates  it  has  been  thought  to  be  more  frequent  on  the  uneven  days, 
particularly  the  fifth  and  seventh.  A  precritical  rise  of  a  degree  or  two 
may  occur.  In  one  case  the  temperature  rose  from  105°  to  nearly  107°,  and 
then  in  a  few  hours  fell  to  normal.  Not  even  after  the  chill  in  malarial 
fever  do  we  see  such  a  prom|)t  and  rapid  drop  in  the  temperature.  The 
usual  time  is  from  five  to  twelve  hours,  but  often  in  an  hour  there  may 
occur  a  fall  of  six  or  eight  degrees  (S.  West).  The  temperature  may  be 
subnormal  after  the  crisis,  as  low  as  96°  or  97°.  Usually  with  the  crisis 
there  is  an  abundant  sweat,  and  the  patient  sinks  into  a  comfortable 
sleep.  The  day  after  the  crisis  there  may  be  a  slight  post-critical  rise. 
A  pseudo-crisis  is  not  very  uncommon,  in  which  on  the  fifth  or  sixth  day 
the  temperature  drops  from  104°  or  105°  to  103°,  and  then  rises  again. 
When  the  fall  takes  place  gradually  within  twenty-four  hours  it  is  called 
a  protracted  crisis.  If  the  fever  persists  beyond  the  twelfth  day,  the  fall 
is  likely  to  be  by  lysis.  In  children  this  mode  of  termination  is  common, 
and  occurred  in  one  third  of  a  series  of  183  cases  reported  by  Morrill. 
Occasionally  in  debilitated  individuals  the  temperature  drops  rapidly  just 
before  death;  more  frequently  there  is  an  ante-mortem  elevation.  In  cases 
of  delayed  resolution  the  fever  may  persist  for  weeks.  The  crisis  is  the 
most  remarkable  single  phenomenon  of  pneumonia.  With  the  fall  in  the 
fever  the  respirations  become  reduced  almost  to  normal,  the  pulse  slows,  and 
the  patient  passes  from  perhaps  a  state  of  extreme  hazard  and  distress  to  one 
of  safety  and  comfort,  and  yet,  so  far  as  the  physical  examination  indicates, 
there  is  with  the  crisis  no  special  change  in  the  local  condition  in  the  lung. 

Pain. — There  is  early  a  sharp,  agonizing  pain,  generally  referred  to  the 
region  of  the  nipple  or  lower  axilla  of  the  affected  side,  and  much  aggra- 
vated on  deep  inspiration  and  on  coughing.  It  is  associated,  as  Aretreus 
remarks,  with  involvement  of  the  pleura.  It  is  absent  in  central  pneu- 
monia, and  much  less  frequent  in  apex  pneumonia.  In  exceptional  cases 
the  pain  is  in  the  abdomen,  and  I  have  twice  known  the  suspicion  of 
appendicitis  raised  by  the  sudden  acute  onset  of  the  pain,  once  in  the 
region  of  the  navel  and  once  low  on  the  right  side.  The  pain  may  be 
severe  enough  to  require  a  hypodermic  injection  of  morphia. 

Dyspnoea  is  an  almost  constant  feature.  Even  early  in  the  disease  the 
respirations  may  be  30  in  the  minute,  and  on  the  second  or  third  day  be- 
tween 40  and  50.  The  movements  are  shallow,  evidently  restrained,  and 
if  the  patient  is  asked  to  draw  a  deep  breath  he  cries  out  with  the  pain. 
Expiration  is  frequently  interrupted  by  an  audible  grunt.  At  first  with  the 
increased  respiration  there  may  be  no  sensation  of  distress.  Later  this 
may  be  present  in  a  marked  degree.    In  children  the  respirations  may  be 


118  SPECIFIC  INFECTIOUS  DISEASES. 

80  or  even  100.  Many  factors  combine  to  produce  the  shortness  of  breath — 
the  pain  in  the  side,  the  toxgemia,  the  fever,  and  the  loss  of  function  in  a 
considerable  area  of  the  lung  tissue.  Sometimes  there  appear  to  be  nerv- 
ous factors  at  work.  That  it  does  not  depend  upon  the  consolidation  is 
shown  by  the  fact  that  after  the  crisis,  without  any  change  in  the  local 
condition  of  the  lung,  the  number  of  respirations  may  drop  to  normal. 
The  ratio  between  the  respirations  and  the  pulse  may  be  1  to  3  or  even  1  to 
1.5,  a  disturbance  rarely  so  marked  in  any  other  disease. 

Cough. — This  usually  comes  on  with  the  pain  in  the  side,  and  at  first  is 
dry,  hard,  and  without  any  expectoration.  Later  it  becomes  very  charac- 
teristic— frequent,  short,  restrained,  and  associated  with  great  pain  in  the 
side.  In  old  persons,  in  drunkards,  in  the  terminal  pneumonias,  and  some- 
times in  young  children  there  may  be  no  cough.  After  the  crisis  the  cough 
usually  becomes  much  easier  and  the  expectoration  more  easily  expelled. 
The  cough  is  sometimes  persistent,  continuous,  and  by  far  the  most  aggra- 
vated and  distressing  symptom  of  the  disease.  Paroxysms  of  coughing  of 
great  intensity  after  the  crisis  suggest  a  pleural  exudate. 

Sputum. — A  brisk  hsemoptysis  may  be  the  initial  symptom.  At  first 
the  sputum  may  be  mucoid,  but  usually  after  twenty-four  hours  it  becomes 
blood-tinged,  viscid,  and  very  tenacious.  At  first  quite  red  from  the  un- 
changed blood,  it  gradually  becomes  rusty  or  of  an  orange  yellow.  The 
tenacious  viscidity  of  the  sputum  is  remarkable;  it  often  has  to  be  wiped 
from  the  lips  of  the  patient.  When  jaundice  is  present  it  may  be  green  or 
yellow.  In  low  types  of  the  disease  the  sputum  may  be  fluid  and  of  a 
dark  brown  color,  resembling  prune  juice.  The  amount  is  very  variable. 
In  children  and  in  old  people  there  may  be  none,  and  even  in  adults  cases 
are  not  very  uncommon  in  which  from  beginning  to  close  there  is  no  ex- 
pectoration. A  common  amount  is  from  150  to  300  cc.  daily.  After  the 
crisis  the  quantity  is  variable,  abundant  in  some  cases,  absent  in  others. 

Microscopically,  the  sputum  consists  of  leucocytes,  mucus  corpuscles, 
-red  blood-corpuscles  in  all  stages  of  degeneration,  and  bronchial  and  alve- 
olar epithelium.  Hsematoidin  crystals  are  occasionally  met  with.  Of  micro- 
organisms the  pneumococcus  is  usually  present,  and  sometimes  Friedlander's 
bacillus.  Very  interesting  constituents  are  small  cell  moulds  of  the  alveoli 
and  the  fibrinous  casts  of  the  bronchioles;  the  latter  may  be  very  plainly 
visible  to  the  naked  eye,  and  sometimes  may  form  good-sized  dendritic  casts. 
Chemically,  the  expectoration  is  particularly  rich  in  calcium  chloride. 

Physical  Signs. — Inspection. — The  position  of  the  patient  is  not 
constant.  He  usually  rests  more  comfortably  on  the  affected  side,  or  he 
is  propped  up  with  the  spine  curved  toward  it.  Orthopncea  is  not  nearly 
so  frequent  as  in  heart-disease. 

In  a  small  lesion  no  differences  may  be  noted  between  the  sides;  as 
a  rule,  movement  is  much  less  on  the  affected  side,  which  may  look 
larger.  With  involvement  of  a  lower  lobe,  the  apex  on  the  same  side  may 
show  greater  movement.  The  compensatory  increased  movement  on  the 
sound  side  is  sometimes  very  noticeable  even  before  the  patient's  chest 
is  bared.  The  intercostal  spaces  are  not  usually  obliterated.  Wlien  the 
cardiac  lappet  of  the  left  upper  lobe  is  involved  there  may  be  a  marked 


LOBAR  PNEUMONIA.  119 

increase  in  the  area  of  visible  cardiac  pulsation.  Pulsation  of  the  aSected 
lung  may  cause  a  marked  movement  of  the  chest  wall  (Graves).  Other 
points  to  be  noticed  in  the  inspection  are  the  frequency  of  the  respiration, 
the  action  of  the  accessory  muscles,  such  as  the  sterno-cleido-mastoids  and 
scaleni,  and  the  dilatation  of  the  nostrils  with  each  inspiration. 

Mensuration  may  show  a  definite  increase  in  the  volume  of  the  side 
affected,  rarely  more,  however,  than  1  or  1-|  cm. 

Palpation. — The  lack  of  expansion  on  the  affected  side  is  sometimes 
more  readily  perceived  by  touch  than  by  sight.  The  pleural  friction  may 
be  felt.  On  asking  the  patient  to  count,  the  voice  fremitus  is  greatly  in- 
creased in  comparison  with  the  corresponding  point  on  the  healthy  side. 
It  is  to  be  remembered  that  if  the  bronchi  are  filled  with  thick  secretion, 
or  if,  in  what  is  known  as  massive  pneumonia,  they  are  filled  with  fibrinous 
exudate,  the  tactile  fremitus  may  be  diminished.  It  is  always  well  to  ask 
the  patient  to  cough  before  testing  the  fremitus. 

Percussion. — In  the  stage  of  engorgement  the  note  is  higher  pitched 
and  may  have  a  somewhat  tympanitic  quality,  the  so-called  Skoda's  reso- 
nance. This  can  often  be  obtained  over  the  lung  tissue  just  above  a  con- 
solidated area.  When  the  lung  is  hepatized,  the  percussion  note  is  dull, 
the  quality  varying  a  good  deal  from  a  note  which  has  in  it  a  certain  tym- 
IDanitie  quality  to  one  of  absolute  flatness.  There  is  not  the  wooden  flat- 
ness of  effusion  and  the  sense  of  resistance  is  not  so  great.  During  resolu- 
tion the  tympanitic  quality  of  the  percussion  note  usually  returns.  For 
weeks  or  months  after  convalescence  there  may  be  a  higher-pitched  note 
on  the  affected  side.  Among  variations  to  be  noticed  are  that  Wintrich's 
change  in  the  percussion  note  when  the  mouth  is  open  may  be  very  well 
marked  in  pneumonia  of  the  upper  lobe.  Occasionally  there  is  an  almost 
metallic  quality  over  the  consolidated  area,  and  when  this  exists  with  a 
very  pronounced  amphoric  quality  in  the  breathing  the  presence  of  a  cavity 
may  be  suggested.  In  deep-seated  pneumonias  there  may  be  for  several 
days  no  change  in  the  percussion  note,  and  in  a  few  rare  cases  percussion 
shows  no  change  throughout  the  disease. 

Auscultation. — Quiet,  suppressed  breathing  in  the  affected  part  is  often 
a  marked  feature  in  the  early  stage,  and  is  always  suggestive.  Very  early 
there  is  heard  at  the  end  of  inspiration  the  fine  crepitant  rale,  a  series  of 
minute  cracklings  heard  close  to  the  ear,  and  perhaps  not  audible  until  a 
full  breath  is  drawn.  This  is  probably  a  fine  pleural  crepitus,  as  J.  B. 
Learning  maintained;  it  is  usually  believed  to  be  produced  in  the  air-cells 
and  finer  bronchi  by  the  separation  of  the  sticky  exudate.  At  this  stage, 
before  consolidation  has  occurred,  the  breath-sounds  may  be,  as  before  men- 
tioned, much  feebler  than  in  health,  but  on  drawing  a  long  breath  they 
may  have  a  harsh  quality,  to  which  the  term  broncho-vesicular  has  been 
applied.  In  the  stage  of  red  hepatization  and  when  dulness  is  well  de- 
fined, the  respiration  is  tubular,  similar  to  that  heard  in  health  over  the 
larger  bronchi.  With  this  blowing  breathing  there  may  be  no  rales,  and 
it  may  present  an  intensity  unknown  in  any  other  pulmonary  affection. 
It  is  simply  the  propagation  of  the  laryngeal  and  tracheal  sounds  through 
the  bronchi  and  the  consolidated  lung  tissue.     The  permeability  of  the 


120  SPECIFIC  INFECTIOUS  DISEASES. 

bronchi  is  essential  to  its  production.  Tubular  breathing  is  absent  in  cer- 
tain cases  of  massive  pneumonia  in  which  the  larger  bronchi  are  completely 
filled  with  exudation.  When  resolution  begins  mucous  rales  of  all  sizes  can 
be  heard.  At  first  they  are  small  and  have  been  called  the  redux-crepitus. 
The  voice-sounds  are  transmitted  through  the  consolidated  lung  with  great 
intensity.  This  bronchophony  may  have  a  curious  nasal  quality  to  which 
the  term  aegophony  has  been  given.  There  are  cases  in  which  the  consoli- 
dation is  deeply  seated — so-called  central  pneumonia,  in  which  the  phys- 
ical signs  are  slight  or  even  absent,  yet  the  cough,  the  rusty  expectoration, 
and  general  features  make  the  diagnosis  certain. 

Circulatory  Symptoms.— During  the  chill  the  pulse  is  small,  but  in 
the  succeeding  fever  it  becomes  full  and  bounding.  In  cases  of  moderate 
severity  it  ranges  from  100  to  116.  It  is  not  often  dicrotic.  In  strong, 
healthy  individuals  and  in  children  there  may  be  no  sign  of  failing  pulse 
throughout  the  attack.  "With  extensive  consolidation  the  left  ventricle 
may  receive  a  very  much  diminished  amount  of  blood  and  the  pulse  in 
consequence  may  be  small.  In  the  old  and  feeble  it  may  be  small  and 
rapid  from  the  outset.  The  pulse  may  be  full,  soft,  very  deceptive,  and  of 
no  value  whatever  in  prognosis.  The  heart-sounds  are  usually  loud  and 
clear.  During  the  intensity  of  the  fever,  particularly  in  children,  bruits 
are  not  uncommon  both  in  the  mitral  and  in  the  pulmonic  areas.  The 
second  sound  over  the  pulmonary  artery  is  accentuated.  Attention  to  this 
sign  gives  a  valuable  indication  as  to  the  condition  of  the  lesser  circula- 
tion. With  distention  of  the  right  chambers  and  failure  of  the  right  ven- 
tricle to  empty  itself  completely  the  pulmonary  second  sound  becomes  much 
less  distinct.  When  the  right  heart  is  engorged  there  may  be  an  increase 
in  the  dulness  to  the  right  of  the  sternum.  With  gradual  heart  weakness 
and  signs  of  dilatation  the  long  pause  is  greatly  shortened,  the  sounds 
approach  each  other  in  tone  and  have  a  foetal  character  (embryocardia). 

There  may  be  a  sudden  early  collapse  of  the  heart  with  very  feeble, 
rapid  pulse  and  increasing  cyanosis.  I  have  known  this  to  occur  on  the 
third  day.  Even  when  these  symptoms  are  very  serious  recovery  may  take 
place.  In  other  instances  without  any  special  warning  death  may  occur 
even  in  robust,  previously  healthy  men.*  The  heart  weakness  may  be  due 
to  paralysis  of  the  vaso-motor  centre  and  consequent  lowering  of  the  gen- 
eral arterial  pressure.  The  soft,  easily  compressed  pulse,  with  the  gray, 
ashy  facies,  cold  hands  and  feet,  the  clammy  perspiration,  and  the  pro- 
gressive prostration  tell  of  a  toxic  action  in  the  vaso-motor  centres.  This 
is  a  feature  of  the  toxaemia  to  which  Eomberg  and  Passler  have  called  atten- 
tion.   Endocarditis  and  pericarditis  will  be  considered  under  complications. 

Blood. — Anaemia  is  rarely  seen.  Bollinger  has  called  attention  to  an 
oligsemia  due  to  the  large  amount  of  exudate.  A  decrease  in  the  red  cells 
may  occur  at  the  time  of  the  crisis.  There  is  in  most  cases  a  leucocytosis, 
which  appears  early,  persists,  and  disappears  with  the  crisis.  The  leuco- 
cytes may  number  from  12,000  to  40,000  or  even  100,000  per  cubic  mUli- 
metre.    The  fall  in  the  leucocytes  is  often  slower  than  the  drop  in  the  fever, 

*  For  illustrative  cases  see  Prognosis  in  Pneumonia,  Am.  Jr.  Med.  Sci.,  Jan.,  1897. 


LOBAR  PNEUMONIA. 


121 


particular!}^  wlien  resolution  is  delayed.  The  annexed  chart  from  J.  S. 
Billings'  paper  (J.  H.  H.  Bulletin,  ISTo.  43)  shows  well  the  coincident  drop  in 
the  fever  and  in  the  number  of  the  leucocytes.  The  leucocytosis  bears  rela- 
tion to  the  extent  of  the  exudate.  In  malignant  pneumonia  the  leucocytosis 
may  be  absent,  and  in  any  case  the  continuous  absence  may  be  regarded  as 
an  unfavorable  sign.     Of  64  cases  studied  in  my  clinic  during  the  session 


Feb.,  1893 

16         1         17         1         13         1         19         1        20        1         21         1        22 

6    m    G    12     6    m   6    12     6    in    6    12    G    m    6    12    6     m   6    12    6    m     G    12    6     m  6 

108° 
105° 
104° 
103° 
103° 
101° 

100° 
99° 
98° 

50,000 
10,000 
30,000 

20,000 
18,000 
10,000 
11,000 
12,000 
10,000 

8,000 

0,000 

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2,000 

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Chart  X. 


of  1900-1901,  the  highest  leucocytosis  was  64,000,  the  lowest  1,400.  A 
striking  feature  in  the  blood-slide  is  the  richness  and  density  of  the  fibrin 
network.     This  corresponds  to  the  great  increase  in  the  fibrin  elements. 


122  SPECIFIC  INFECTIOUS  DISEASES. 

which  has  long  been  known  to  occur  in  pneumonia,  the  proportion  rising 
from  4  to  10  parts  per  thousand.  Hayem  describes  the  blood-plates  as 
greatly  increased.  As  stated,  the  micrococci  can  frequently  be  cultivated 
from  the  blood. 

Digestive  Organs. — The  tongue  is  white  and  furred,  and  in  severe 
toxic  cases  rapidly  becomes  dry.  Vomiting  is  not  uncommon  at  the  onset 
in  children.  The  appetite  is  lost.  Constipation  is  more  common  than 
diarrhoea.  A  distressing  and  sometimes  dangerous  symptom  is  meteorism. 
Fibrinous,  pneumococcic  exudates  may  occur  in  the  conjunctivse,  nose, 
mouth,  prepuce,  and  anus  (Gary).  The  liver  may  be  depressed  by  the  large 
right  lung,  or  enlarged  from  the  engorged  right  heart,  or  as  a  result  of 
the  infection.  The  spleen  is  usually  enlarged,  and  the  edge  can  be  felt 
during  a  deep  inspiration. 

Skin. — Among  cutaneous  symptoms  one  of  the  most  interesting  is  the 
association  of  herpes  with  pneumonia.  Not  excepting  malaria,  we  see 
labial  herpes  more  frequently  in  this  than  in  any  other  disease,  occurring, 
as  it  does,  in  from  12  to  40  per  cent  of  the  cases.  It  is  supposed  to  be  of 
favorable  prognosis,  and  figures  have  been  quoted  in  proof  of  this  asser- 
tion. It  may  also  occur  on  the  nose,  genitals,  and  anus.  Its  significance 
and  relation  to  the  disease  are  unknown.  It  is  scarcely  necessary  to  men- 
tion the  theory  which  has  been  advanced,  that  it  is  an  external  expression 
of  a  neuritis  which  involves  the  pneumogastric  and  induces  the  pneumo- 
nia. At  the  height  of  the  disease  sweats  are  not  common,  but  at  the  crisis 
they  may  be  profuse.  Eedness  of  one  cheek  is  a  phenomenon  long  recog- 
nized in  connection  with  pneumonia,  and  is  usually  on  the  same  side  as 
the  disease.    Jaundice  is  referred  to  among  the  complications. 

Urine. — Early  in  the  disease  it  presents  the  usual  febrile  characters 
of  high  color,  high  specific  gravity,  and  increased  acidity.  A  trace  of  albu- 
min is  very  common.  There  may  be  tube-casts  and  in  a  few  instances  the 
existence  of  albumin,  tube-casts,  and  blood  indicate  the  presence  of  an 
acute  nephritis.  The  urea  and  uric  acid  are  usually  increased  at  first,  but 
may  be  much  diminished  before  the  crisis,  to  increase  greatly  with  its  onset. 
Eobert  Hutchison's  recent  researches  show  that  a  true  retention  of  chlo- 
rides within  the  body  takes  place,  the  average  amount  being  about  3  grams 
daily.  It  is  a  more  constant  feature  of  pneumonia  than  of  any  other 
febrile  disease,  and  this  being  the  case,  a  diminution  of  the  chlorides  in  the 
urine  may  be  of  value  in  the  diagnosis  from  pleurisy  with  effusion  or  em- 
pyema. It  is  to  be  remembered  that  in  dilatation  of  the  stomach  chlorides 
may  be  absent.     Hgematuria  is  a  rare  complication. 

Cerebral  Symptoms. — Headache  is  common.  Convulsions  occur 
frequently  at  the  outset  in  children.  Apart  from  meningitis,  which  will 
be  considered  separately,  one  may  group  the  cases  with  marked  cerebral 
features  into — 

First,  the  so-called  cerebral  pneumonias  of  children,  in  which  the  dis- 
ease sets  in  with  a  convulsion  and  there  are  high  fever,  headache,  delirium, 
great  irritability,  muscular  tremor,  and  perhaps  retraction  of  the  head 
and  neck.  The  diagnosis  of  meningitis  is  usually  made,  and  the  local 
affection  may  be  overlooked. 


LOBAR  PNEUMONIA.  123 

Secondly,  the  cases  with  maniacal  symptoms.  These  may  occur  at  the 
very  outset,  and  I  once  performed  an  autopsy  on  a  case  in  which  there  was 
no  suspicion  whatever  that  the  disease  was  other  than  acute  mania.  The 
house  physician  should  give  instructions  to  the  nurses  to  watch  such  cases 
very  carefully.  On  March  22,  1894,  a  patient  who  had  been  doing  very 
well,  with  the  exception  of  slight  delirium,  while  the  orderly  was  out  of  the 
room  for  a  few  moments,  got  up,  raised  the  window,  and  jumped  out,  sus- 
taining a  fracture  of  the  leg  and  of  the  upper  lumbar  vertebras,  of  which 
he  died. 

Thirdly,  alcoholic  cases  with  the  features  of  delirium  tremens.  It 
should  be  an  invariable  rule,  even  if  fever  be  not  present,  to  examine  the 
lungs  in  a  case  of  mania  a  potu. 

Fourthly,  cases  with  toxic  features,  resembling  rather  those  of  uremia. 
"Without  a  chill  and  without  cough  or  pain  in  the  side,  a  patient  may  de- 
velop fever,  a  little  shortness  of  breath,  and  then  gradually  grow  dull  men- 
tally, and  within  three  days  be  in  a  condition  of  profound  toxaemia  with 
low,  muttering  delirium. 

It  is  stated  that  apex  pneumonia  is  more  often  accompanied  with  severe 
delirium.  Occasionally  the  cerebral  symptoms  develop  immediately  after 
the  crisis.  Mental  disturbance  may  persist  during  and  after  convalescence, 
and  in  a  few  instances  delusional  insanity  follows,  the  outlook  in  which  is 
favorable. 

Complications. — Compared  with  typhoid  fever,  pneumonia  has  but 
few  complications  and  still  fewer  sequelae.  The  most  important  are  the 
following: 

Pleurisy  is  an  inevitable  event  when  the  inflammation  reaches  the  sur- 
face of  the  lung,  and  thus  can  scarcely  be  termed  a  complication.  But  there 
are  cases  in  which  the  pleuritic  features  take  the  first  place — cases  to  which 
the  term  pleuro-pneumonia  is  applicable.  The  exudation  may  be  sero- 
fibrinous with  copious  effusion,  differing  from  that  of  an  ordinary  acute 
pleurisy  in  the  greater  richness  of  the  fibrin,  which  may  form  thick, 
tenacious,  curdy  layers.  Pneumonia  on  one  side  with  extensive  pleurisy 
on  the  other  is  sometimes  a  puzzling  complication  to  diagnose  and  an 
aspirator  needle  may  be  required  to  settle  the  question.  Empyema  is  one 
of  the  most  conimon  complications,  and  has  of  late  increased  in  frequency. 
During  the  eight  years,  1891-98,  there  were  at  Guy's  Hospital  7  cases  of 
empyema  among  445  cases  of  pneumonia,  while  in  the  eight  years,  1891-'98, 
there  were  38  cases  among  896  cases  of  pneumonia  (Hale  While).  Influenza 
may  be  responsible  for  the  increase.  The  pneumococcus  is  usually  present; 
in  a  few  the  streptococcus,  in  which  case  the  prognosis  is  not  so  good. 
Recurrence  of  the  fever  after  the  crisis  or  persistence  of  it  after  the  tenth 
day  with  sweats,  leucocytosis,  and  perhaps  an  aggravation  of  the  cough, 
are  suspicious  symptoms.  Dulness  continues  at  the  base,  or  may  have 
extended.  The  breathing  is  feeble  and  there  are  no  rales.  Such  a  condition 
may  be  closely  simulated,  of  course,  by  the  thickened  pleura.  Exploratory 
aspiration  may  settle  the  question  at  once.  There  are  obscure  cases  in 
which  the  pus  has  been  found  only  after  operation,  as  the  collection  may 
be  very  small. 

8 


124  SPECIFIC  INFECTIOUS  DISEASES. 

Pericarditis  is  more  common  in  the  pneumonia  of  children^  particu- 
larly when  double,  and  it  is  said  with  the  pneumonia  of  the  left  side.  It 
is  particularly  apt  to  follow  or  to  be  associated  with  acute  rheumatism.  It 
was  present,  as  I  stated,  in  5  of  my  100  autopsies.  Though  usually  plastic, 
there  may  be  much  serous  effusion.  There  is  rarely  any  difficulty  in  the 
diagnosis,  but  when  the  pneumonia  involves  the  portion  of  lung  covering 
the  pericardium,  there  may  be  difficulty  in  determining,  by  physical  signs, 
the  existence  of  fluid.  The  increase  in  the  dyspnoea,  the  greater  feebleness 
of  the  pulse,  and  the  gradual  suppression  of  the  heart-sounds  will  give  the 
most  valuable  indications.  In  some  instances  the  fluid  is  purulent.  Though 
a  very  serious  event,  it  is  surprising  how  often  recovery  takes  place  even 
in  the  most  desperate  cases  of  pneumonia  complicated  with  pericarditis, 
a  point  to  which  I  have  heard  Murchison  refer. 

Endocarditis  is  still  more  frequent,  and  in  my  100  autopsies  was  pres- 
ent in  16.  I  called  attention  in  the  Goulstonian  lectures  for  1885  to  the 
great  frequency  of  this  complication.  Of  209  cases  of  malignant  endo- 
carditis collected  from  the  literature,  54  occurred  in  this  disease.  Sub- 
sequent observations  have  fully  confirmed  this  statement.  Kanthack  found 
an  antecedent  pneumonia  in  14.2  per  cent  of  all  instances  of  infective  endo- 
carditis. It  is  much  more  common  in  the  left  heart  than  in  the  right. 
It  is  particularly  liable  to  attack  persons  with  old  valvular  disease.  The 
pneumococcus  has  been  found  in  the  vegetations.  There  may  be  no  symp- 
toms indicative  of  this  complication  even  in  very  severe  cases.  It  may, 
however,  be  suspected  in  cases  (1)  in  which  the  fever  is  protracted  and 
"irregular;  (2)  when  signs  of  septic  mischief  arise,  such  as  chills  and  sweats; 
(3)  when  embolic  phenomena  appear.  The  frequent  complication  of 
meningitis  with  the  endocarditis  of  pneumonia,  which  has  already  been 
mentioned,  gives  prominence  to  the  cerebral  symptoms  in  these  cases.  The 
physical  signs  may  be  very  deceptive.  There  are  instances  in  which  no 
cardiac  murmurs  have  been  heard.  In  others  the  occurrence  under  ob- 
servation of  a  loud,  rough  murmur,  particularly  if  diastolic,  is  extremely 
suggestive. 

Myocarditis  is  rare. 

Ante-mortem  heart-clots  are  excessively  rare.  In  protracted  cases 
thrombi  occasionally  form  in  the  veins,  usually  the  femoral  or  internal 
saphenous.  Welch  (Allbutfs  System)  has  collected  23  cases,  occurring 
usually  during  convalescence.  Phlegmasia  alba  dolens  sometimes  follows. 
The  condition  is  rarely  serious.  A  rare  complication  is  embolism  of  one 
of  the  larger  arteries.  I  saw  in  Montreal  an  instance  of  embolism  of  the 
femoral  artery  at  the  height  of  pneumonia,  which  necessitated  amputation 
at  the  thigh.  The  patient  recovered.  Apfiasia  has  been  met  with  in  a  few 
instances,  setting  in  abruptly  with  or  without  hemiplegia. 

Meningitis  is  perhaps  the  most  serious  complication  of  pneumonia.  It 
varies  very  much  at  different  times  and  in  different  regions.  My  Montreal 
experience  is  rather  exceptional,  as  8  per  cent  of  the  fatal  cases  had  this 
complication.  It  usually  comes  on  at  the  height  of  the  fever,  and  in  the 
majority  of  the  cases  is  not  recognized  unless,  as  before  mentioned,  the 
base  is  involved,  which  is  not  common.     Meningitis  may  occur  later  in 


LOBAR  PNEUMONIA.  125 

the  disease,  and  is  then  more  easily  diagnosed.  In  some  cases  it  is  associ- 
ated with  infective  endocarditis.  The  pneumococcus  has  been  found  in 
the  exudate. 

Peripheral  neuritis  is  a  rare  complication,  of  which  several  cases  have 
been  described.  I  saw  one  well-marked  instance  following  pneumonia  and 
influenza  in  the  spring  of  1890.  There  was  neuritis  of  the  left  arm  with 
considerable  wasting. 

Gastric  complications  are  rare.  A  croupous  gastritis  has  already  been 
mentioned.  The  croupous  colitis  may  induce  severe  diarrhoea.  Jaundice 
is  one  of  the  most  interesting  complications  of  pneumonia  and  occurs  with 
curious  irregularity  in  different  outbreaks  of  the  disease.  It  sets  in  early, 
is  rarely  very  intense,  and  has  not  the  characters  of  obstructive  jaundice. 
There  are  cases  in  which  it  assumes  a  very  serious  form.  The  mode  of  pro- 
duction is  not  well  ascertained.  It  does  not  appear  to  bear  any  definite 
relation  to  the  degree  of  hepatic  engorgement  and  it  is  not  always  due 
to  catarrh  of  the  ducts.    Possibly  it  may  be,  in  great  part,  hsematogenous. 

Parotitis  occasionally  occurs,  commonly  in  association  with  endocar- 
ditis.   In  children  middle-ear  disease  is  not  an  infrequent  complication. 

Brighfs  disease  does  not  often  follow  pneumonia.  Peritonitis  is  ex- 
ceedingly rare. 

The  relations  of  rheumatism  and  pneumonia  are  very  interesting.  The 
arthritis  may  precede  the  onset,  and  the  pneumonia,  possibly  with  endo- 
carditis and  pleurisy,  may  occur  as  a  complication  of  the  rheumatism.  In 
other  instances  at  the  height  of  an  ordinary  pneumonia  one  or  two  joints 
may  become  red  and  sore.  On  the  other  hand,  after  the  crisis  has  occurred 
pains  and  swelling  may  come  on  in  the  joints. 

Relapse. — There  are  eases  in  which  from  the  ninth  to  the  eleventh 
day  the  fever  subsides,  and  after  the  temperature  has  been  normal  for  a 
day  or  two  a  rise  occurs  and  fever  may  persist  for  another  ten  days  or  even 
two  weeks.  Though  this  might  be  termed  a  relapse,  it  is  more  correct  to 
regard  it  as  an  instance  of  an  anomalous  course  of  delayed  resolution. 
Wagner,  who  has  studied  the  subject  carefully,  says  that  in  his  large  ex- 
perience of  1,100  cases  he  met  with  only  3  doubtful  cases.  When  it  does 
occur,  the  attack  is  usually  abortive  and  mild.  In  the  case  of  Z.  R.  (Medical 
No,  4223),  with  pneumonia  of  the  right  lower  lobe,  crisis  occurred  on 
the  seventh  day,  and  after  a  normal  temperature  for  thirteen  days  he  was 
discharged.  That  night  he  had  a  shaking  chill,  followed  by  fever,  and  he 
had  recurring  chills  with  reappearance  of  the  pneumonia.  In  a  second 
case  (Medical  No.  4538)  crisis  occurred  on  the  third  day,  and  tliere  was 
recurrence  of  pneumonia  on  the  thirteenth  day. 

Recurrence  is  more  common  in  pneumonia  than  in  any  other  acute 
disease.  Rush  gives  an  instance  in  which  there  were  28  attacks.  Other 
authorities  narrate  cases  of  8,  10,  and  even  more  attacks. 

Convalescence  in  pneumonia  is  usually  rapid,  and  sequelas  are  rare. 
After  the  crisis,  sudden  death  has  occurred  when  the  patient  has  got  up  too 
soon.  Lusk,  of  Weymouth,  writes  of  such  a  case.  With  the  onset  of  fever 
and  persistence  of  the  leucocytosis  the  affected  side  should  be  very  carefully 
examined  for  pleurisy.     With  a  persistence  of   the  dulness  the  physical 


126  SPECIFIC  INFECTIOUS  DISEASES. 

signs  may  be  obscure,  but  the  use  of  a  small  exploratory  needle  will  help 
to  clear  the  diagnosis. 

Clinical  Varieties. — 1.  Local  variation  are  responsible  for  some  of 
the  most  marked  deviations  from  the  usual  type. 

AjMx  pneumonia  is  said  to  be  more  often  associated  with  adynamic 
features  and  with  marked  cerebral  symptoms.  The  expectoration  and 
cough  may  be  slight.  I  can  not  say  that  in  my  experience  the  cerebral 
symptoms  in  adults  have  been  more  marked  in  this  form,  nor  do  I  think 
it  necessarily  graver  than  if  situated  at  the  base. 

Migratory  or  creeping  pneumonia,  a  form  which  successively  involves 
one  lobe  after  the  other. 

Douhle  pneumonia  has  no  peculiarities  other  than  the  greater  danger 
connected  with  it. 

Massive  pneumonia  is  a  rare  form,  in  which  not  alone  the  air-cells  but 
the  bronchi  of  an  entire  lobe  or  even  of  a  lung  are  filled  with  the  fibrinous 
exudate.  The  auscultatory  signs  are  absent;  there  is  neither  fremitus  nor 
tubular  breathing,  and  on  percussion  the  lung  is  absolutely  flat.  It  closely 
resembles  pleurisy  with  effusion.  The  moulds  of  the  bronchi  may  be  ex- 
pectorated in  violent  fits  of  coughing. 

Central  Pneumonia. — The  inflammation  may  be  deep-seated  at  the 
root  of  the  lung  or  centrally  placed  in  a  lobe,  and  for  several  days  the  diag- 
nosis may  be  in  doubt.  It  may  not  be  until  the  third  or  fourth  day  that  a 
pleural  friction  is  detected,  or  that  dulness  or  blowing  breathing  and  rales 
are  recognized.  I  saw  in  1898  with  Dr.  Henry  Adler  and  Dr.  Chew  an 
instance  in  which  at  the  end  of  the  fourth  day  in  a  young,  thin-chested 
girl  all  the  usual  symptoms  of  pneumonia  were  present  without  any  phys- 
ical signs  other  than  a  few  clicking  rales  at  the  left  apex  behind.  The  thin- 
ness of  the  patient  greatly  facilitated  the  examination.  The  general  fea- 
tures of  pneumonia  continued,  and  the  crisis  occurred  on  the  seventh  day. 

2.  Pneumonia  in  Infants. — It  is  sometimes  seen  in  the  newborn.  In 
infants  it  very  often  sets  in  with  a  convulsion.  The  summit  of  the  lung 
seems  more  frequently  involved  than  in  adults,  and  the  cerebral  s}Tiiptoms 
are  more  marked.  The  torpor  and  coma,  particularly  if  they  follow  con- 
vulsions, and  the  preliminary  stage  of  excitement,  may  lead  to  the  diag- 
nosis of  meningitis.     Pneumonic  sputum  is  rarely  seen  in  children. 

3.  Pneumonia  in  the  Aged. — The  disease  may  be  latent  and  set  in  with- 
out a  chill;  the  cough  and  expectoration  are  slight,  the  physical  signs  ill- 
defined  and  changeable,  and  the  constitutional  symptoms  out  of  all  pro- 
portion to  the  extent  of  the  local  lesion. 

4.  Pneumonia  in  Alcoholic  Subjects. — The  onset  is  insidious,  the  symp- 
toms masked,  the  fever  slight,  and  the  clinical  picture  usually  that  of 
delirium  tremens.  The  thermometer  alone  may  indicate  the  presence  of 
an  acute  disease.  Often  the  local  condition  is  overlooked,  as  the  patient 
makes  no  complaint  of  pain,  and  there  may  be  very  little  shortness  of 
breath,  no  cough,  and  no  sputum. 

5.  Terminal  Pneumonia. — The  wards  and  the  post-mortem  room  show 
a  very  striking  contrast  in  their  pneumonia  statistics,  owing  to  the  occur- 
rence of  what  may  be  called  terminal  pneumonia.     During  the  winter 


LOBAR  PNEUMONIA.  127 

months  patients  with  chronic  pulmonary  tuberculosis,  arterio-sclerosis, 
heart  disease,  Bright's  disease,  and  diabetes  are  not  infrequently  carried 
off  by  a  pneumonia  which  may  give  few  or  no  signs  of  its  presence.  There 
may  be  a  slight  elevation  of  temperature,  with  increase  in  the  respirations, 
but  the  patient  is  near  the  end  and  perhaps  not  in  a  condition  in  which 
a  thorough  physical  examination  can  be  made.  The  autopsy  may  show 
pneumonia  of  the  greater  part  of  one  lower  lobe  or  of  the  apex,  which  had 
entirely  escaped  notice.  In  diabetic  patients  the  disease  often  runs  a  rapid 
and  severe  course,  and  may  end  in  abscess  or  gangrene. 

Some  of  the  most  remarkable  variations  in  the  clinical  course  of  pneu- 
monia depend  probably  upon  the  severity,  possibly  upon  the  nature  of  the 
infective  agent.  Further  investigation  may  enable  us  to  say  how  far  the 
associated  organisms,  so  often  present,  may  be  responsible  for  the  differ- 
ences in  the  clinical  course. 

6.  Secondary  Pneumonias. — These  are  met  with  chiefly  in  the  specific 
fevers,  particularly  diphtheria,  typhoid  fever,  typhus,  influenza,  and  the 
plague.  Anatomically,  they  rarely  present  the  typical  form  of  red  or  gray 
hepatization.  The  surface  is  smoother,  not  so  dry,  and  it  is  often  a  pseudo- 
lobar  condition,  a  consolidation  caused  by  closely  set  areas  of  lobular  in- 
volvement. Histologically,  they  are  characterized  in  many  instances  by  a 
more  cellular,  less  fibrinous  exudate,  which  may  also  infiltrate  the  alveolar 
walls.  Bacteriologically,  a  large  number  of  different  organisms  have  been 
found,  the  specific  microbe  of  the  primary  disease,  usually  in  association 
with  the  streptococcus  pyogenes  or  the  staphylococcus;  in  some  instances 
the  colon  bacillus  has  been  present.  Finkler  has  attempted  to  separate  a 
special  form,  which  he  calls  the  acute  cellular  pneumonia,  to  which  most  of 
these  secondary  types  conform  and  which  have  the  histological  characters 
already  referred  to  (Die  Acuten  Lungenentziindungen,  1891). 

The  symptoms  of  the  secondary  pneumonias  often  lack  the  striking 
definiteness  of  the  primary  croupous  pneumonia.  The  pulmonary  features 
may  be  latent  or  masked  altogether.  There  may  be  no  cough  and  only  a 
slight  increase  in  the  number  of  respirations.  The  lower  lobe  of  one  lung 
is  most  commonly  involved,  and  the  physical  signs  are  obscure  and  rarely 
amount  to  more  than  impaired  resonance,  feeble  breathing,  and  a  few 
crackling  rales.  In  some  instances  when  the  consolidation  is  extensive  the 
breathing  is  distinctly  tubular. 

7.  Epidemic  pneumonia  has  already  been  referred  to.  It  is,  as  a  rule, 
more  fatal,  and  often  displays  minor  complications  which  differ  in  differ- 
ent outbreaks.  In  some  the  cerebral  manifestations  are  very  marked;  in 
others,  the  cardiac;  in  others,  again,  the  gastro-intestinal. 

8.  Larval  Pneumonia. — Mild,  abortive  types  are  seen,  particularly  in 
institutions  when  pneumonia  is  prevailing  extensively.  A  patient  may 
have  the  initial  symptoms  of  the  disease,  a  slight  chill,  moderate  fever, 
a  few  indefinite  local  signs,  and  herpes.  The  whole  process  may  only  last 
for  two  or  three  days;  some  authors  recognize  even  a  one-day  pneumonia. 

9.  Asthenic,  Toxic,  or  Typhoid  Pneumonia. — The  toxemic  features 
dominate  the  scene  throughout.  The  local  lesions  may  be  slight  in  extent 
and  the  subjective  phenomena  of  the  disease  absent.     The  nervous  symp- 


128  SPECIFIC  INFECTIOUS  DISEASES. 

toms  usually  predominate.  There  are  delirium^  prostration,  and  early 
weakness.  Very  frequently  there  is  jaundice.  Gastro-intestinal  symptoms 
may  be  present,  particularly  diarrhoea  and  meteorism.  In  such  a  case,  seen 
about  the  end  of  the  first  week,  it  may  be  difficult  to  say  whether  the  con- 
dition is  one  of  asthenic  pneumonia  or  one  of  typhoid  fever  which  has  set 
in  with  early  localization  in  the  lung.  Here  the  Widal  reaction  would  be 
an  important  aid.  In  these  cases  there  is  really  a  pneumococcus  septi- 
cgemia,  and  the  organisms  may  sometimes  be  isolated  from  the  blood. 
Possibly,  too,  there  is  a  mixed  infection,  and  the  streptococcus  pyogenes 
may  be  in  large  part  responsible  for  the  toxic  features  of  the  disease. 

10.  Association  of  Pneumonia  with  other  Diseases. — (a)  With  Malaria. 
— A  malarial  pneumonia  is  described  by  many  .observers  and  thought  to  be 
particularly  prevalent  in  some  parts  of  this  country.  One  hears  of  it,  in- 
deed, even  where  true  malaria  is  rarely  seen.  With  our  large  experience  in 
malaria,  amounting  now  to  nearly  2,000  cases,  and  a  considerable  number 
of  pneumonia  patients  every  year,  we  have  only  had  a  few  eases  in  which 
the  latter  disease  has  set  in  during  malarial  fever,  or  vice  versa.  In 
either  case  the  malaria  yields  promptly  to  the  action  of  quinine.  So  far  as 
the  Southern  States  are  concerned,  the  question  of  a  special  form  was 
thrashed  out  years  ago  in  a  discussion  between  Manson  and  W.  T.  Howard, 
and  was  decided  in  the  negative.  A  form  of  pneumonia  directly  dependent 
upon  the  malarial  parasite  is  unknown.  We  have  not  been  able  to  recog- 
nize here  a  pneumonia  which  is  influenced  in  any  way  by  the  malarial 
poison.  Such  a  case  as  the  following  we  see  occasionally:  A  patient  was 
admitted,  March  16,  1894,  with  tertian  malarial  fever.  The  lungs  were 
clear.  A  pneumonia  began  thirty-six  hours  after  admission.  Quinine  was 
given  that  evening,  and  the  malarial  organisms  rapidly  disappeared  from 
the  blood.  There  was  successive  involvement  of  the  right  lower,  the  middle, 
and  the  left  lower  lobe.  The  temperature  fell  by  crisis  on  the  24th,  and 
there  were  no  features  in  the  disease  whatever  suggestive  of  malaria.  In 
other  instances  we  have  found  a  chill  in  the  course  of  an  ordinary  pneu- 
monia to  be  associated  with  a  malarial  infection,  and  quinine  has  rapidly 
and  promptly  caused  the  disappearance  of  the  parasites  from  the  blood. 

(&)  Pneumonia  and  Acute  Bheumatism. — We  have  already  spoken  under 
complications  of  this  association,  which  is  more  frequently  seen  in  children. 

(c)  Pneumonia  and  Tu])erculosis. — Many  subjects  of  chronic  pulmonary 
tuberculosis  die  of  an  acute  croupous  pneumonia.  A  point  to  be  specially 
borne  in  mind  is  the  fact  that  acute  tuberculous  pneumonia  may  set  in 
with  all  the  features  and  physical  signs  of  fibrinous  pneumonia  (see  page 
290). 

For  the  consideration  of  the  association  of  pneumonia  with  tj^phoid 
fever  and  infliienza,  the  reader  is  referred  to  the  sections  on  those  diseases. 

11.  Posf-nperation  Pneumonia. — Before  the  days  of  anaesthesia,  lobar 
pneumonia  was  a  well-recognized  cause  of  death  after  surgical  injuries  and 
operations.  ISTorman  Cheevers,  in  an  early  number  of  the  Guy's  Hospital 
Reports,  calls  attention  to  it  as  one  of  the  most  frequent  causes  of  death 
after  surgical  procedures,  and  Erichsen  states  that  of  41  deaths  after  sur- 
gical injuries  23  cases  exhibited  signs  of  pneumonia.     The  lobular  form 


LOBAR  PNEUMONIA.  129 

is  the  most  frequent.    I  have  already  referred  to  the  contusion-pneumonia 
described  by  Litten. 

12.  Ether  Pneumonia. — The  question  of  a  direct  relation  between  ether 
narcosis  and  pneumonia  has  been  much  discussed  of  late  years,  having 
been  raised  by  Mr.  Lucas,  of  Guy's  Hospital.  The  statistics  are  by  no 
means  unanimous.  Prescott,  of  Boston,  in  40,000  cases  found  only  3  of 
acute  lobar  pneumonia.  The  London  ansesthetists,  particularly  Hewitt 
and  Silk,  seem  also  to  have  had  a  fortunate  experience.  Silk  having  found 
among  5,000  cases  13  of  pneumonia;  8  of  these  were  tongue  or  jaw  cases. 
The  German  experience  is  very  different.  Von  Beck  states  that,  owing  to 
the  injurious  after-effects  upon  the  respiratory  tract,  the  use  of  ether  has 
been  largely  restricted  in  Czerny's  clinic.  Gurlt  reports  52,177  cases,  with 
30  cases  of  pneumonia  and  15  deaths.  Of  15  cases  of  pneumonia  following 
anaesthesia  on  the  surgical  side  of  the  Johns  Hopkins  Hospital,  12  were 
broncho-pneumonias;  there  were  7  deaths  and  8  recoveries;  79  per  cent  of 
the  cases  followed  abdominal  section  or  hernia  operations.  Czerny  sug- 
gests that  the  relation  of  these  ether  pneumonias  to  abdominal  operations 
is  associated  with  the  pain  on  coughing,  which  leads  to  an  accumulation 
of  secretion,  and  through  this  to  retention  or  aspiration  pneumonia. 
Among  the  various  views  brought  forward  to  account  for  it  are  the  rapid 
evaporation  of  the  ether,  causing  chilling  of  the  pulmonary  tissues,  chill- 
ing of  the  patient  at  the  time  of  operation,  infection  from  the  inhaler,  and 
direct  action  of  the  ether. 

The  probability  is  that  the  prolonged  etherization  lowers  the  vitality 
of  the  tissues  of  the  finer  bronchi  and  permits  the  pathogenic  organisms 
(which  are  almost  always  present)  to  do  their  work.  The  pneumonia  is 
more  frequently  lobular  than  lobar.  Neuwerck,  and  subsequently  Wliitney, 
have  suggested  thorough  disinfection  of  the  mouth  and  throat  before 
operation. 

13.  Delayed  Resolution  in  Pneumonia. — The  lung  is  restored  to  its  nor- 
mal state  partly  by  the  expectoration  of  the  exudate,  partly  by  its  liquefac- 
tion and  absorption.  There  are  cases  in  which  resolution  takes  place  rapidly 
without  any  increase  in  (or,  indeed,  without  any)  expectoration;  on  the 
other  hand,  during  resolution  it  is  not  uncommon  to  find  in  the  sputa  the 
little  plugs  of  fibrin  and  leucocytes  which  have  been  loosened  from  the 
air-cells  and  expelled  by  coughing.  In  a  majority  of  cases  both  processes 
are  probably  at  work.  A  variable  time  is  taken  in  the  restoration  of  the 
lung.  Sometimes  within  a  week  or  ten  days  the  dulness  is  greatly  dimin- 
ished, the  breath-sounds  become  clear,  and,  so  far  as  physical  signs  are 
any  guide,  the  lung  seems  perfectly  restored.  It  is  to  be  remembered  that 
in  any  case  of  pneumonia  with  extensive  pleurisy  a  certain  amount  of 
dulness  will  persist  for  months,  owing  to  thickening  of  the  pleura. 

Delayed  resolution  is  a  condition  which  causes  much  anxiety  to  the 
physician.  While  it  is  perhaps  more  frequent  in  debilitated  persons,  yet 
it  is  met  with  in  robust,  previously  healthy  individuals,  and  in  cases  which 
have  had  a  very  typical  onset  and  course.  The  condition  is  stated  to  be 
most  frequent  in  apex  pneumonia.     Venesection  has  been  assigned  as  a 


130  SPECIFIC  INFECTIOUS  DISEASES. 

cause.  There  is  no  question  that  the  solid  exudate  can  persist  for  weeks 
and  yet  the  integrity  of  the  lung  may  ultimately  be  restored.  Grissole  de- 
scribes the  lung  from  a  patient  who  died  on  the  sixtieth  day,  in  which  the 
affected  part  showed  a  condition  not  unlike  that  of  the  acute  stage. 

Clinically,  there  are  several  groups  of  cases:  First,  those  in  which  the 
crisis  occurs  naturally,  the  temperature  falls  and  remains  normal,  but  the 
local  features  persist — ^well-marked  flatness  with  tubular  breathing  and 
rales.  Eesolution  may  occur  very  slowly  and  gradually,  taking  from  two 
to  three  weeks.  In  a  second  group  of  cases  the  temperature  falls  by  lysis, 
and  with  the  persistence  of  the  local  signs  there  is  slight  fever,  sometimes 
sweats  and  rapid  pulse.  The  condition  may  persist  for  three  or  four  weeks, 
or,  as  in  one  of  my  cases,  for  eleven  weeks,  and  ultimately  perfect  resolution 
occur.  During  all  this  time  there  may  be  little  or  no  sputum.  The  prac- 
titioner is  naturally  much  exercised,  and  he  dreads  lest  tuberculosis  should 
supervene.  In  a  third  group  the  crisis  occurs  or  the  fever  falls  by  lysis, 
but  the  consolidation  persists  and  there  may  be  intense  bronchial  breath- 
ing, with  few  or  no  rales,  or  the  fever  may  recur  and  the  patient  may  die 
exhausted.  In  1  of  my  100  autopsies  a  patient,  aged  fifty-eight,  had 
died  on  the  thirty-second  day  from  the  initial  chill.  The  right  lung  was 
solid,  grayish  in  color,  firm,  and  presented  in  places  a  translucent,  semi- 
homogeneous  aspect.  In  these  areas  the  alveolar  walls  were  thickened,  and 
the  plugs  filling  the  air-cells  were  undergoing  transformation  into  new 
connective  tissue.  This  fibroid  induration  may  proceed  gradually  and  be 
associated  with  shrinkage  of  the  affected  side,  and  the  gradual  production 
of  a  cirrhosis  or  chronic  interstitial  pneumonia. 

Ordinary  fibrinous  pneumonia  never  terminates  in  tuberculosis.  The 
instances  of  caseous  pneumonia  and  softening  which  have  followed  an 
acute  pneumonic  process,  have  been  from  the  outset  tuberculous  (see  page 
290). 

14.  Termination  in  Abscess. — This  occurred  in  4  of  my  100  autopsies. 
Usually  the  lung  breaks  down  in  limited  areas  and  the  abscesses  are  not 
large,  but  they  may  fuse  and  involve  a  considerable  proportion  of  a  lobe. 
The  condition  is  recognized  by  the  sputum,  which  is  usually  abundant  and 
contains  pus  and  elastic  tissue,  sometimes  cholesterin  crystals  and  hsema- 
toidin  crystals.  The  cough  is  often  paroxysmal  and  of  great  severity; 
usually  the  fever  is  remittent,  or  in  protracted  cases  intermittent  in  char- 
acter, and  there  may  be  pronounced  hectic  symptoms.  When  a  case  is 
seen  for  the  first  time  it  may  be  difficult  to  determine  whether  it  is  one 
of  abscess  of  the  lung  or  a  local  empygema  which  has  perforated  the 
lung. 

15.  Gangrene. — This  is  most  commonly  seen  in  old  debilitated  persons. 
It  was  present  in  3  of  my  100  autopsies.  It  very  often  occurs  with  abscess. 
The  gangrene  is  associated  with  the  growth  of  the  saprophytic  bacteria  on 
a  soil  made  favorable  by  the  presence  of  the  pneumococcus  or  the  strepto- 
coccus. Clinically,  the  gangrene  is  rendered  very  evident  by  the  horribly 
fetid  odor  of  the  expectoration  and  its  characteristic  features.  In  some 
instances  the  gangrene  may  be  found  post-mortem  when  clinically  there 
has  not  been  any  evidence  of  its  existence. 


LOBAR  PNEUMONIA.  131 

Prognosis. — Pneumonia  is  the  most  fatal  of  all  acute  diseases,  killing 
more  than  diphtheria,  and  outranking  even  consumption  as  a  cause  of  death. 

Hospital  statistics  show  that  the  mortality  ranges  from  20  to  40  per 
cent.  Of  1,012  cases  at  the  Montreal  General  Hospital,  the  mortality 
was  20.4  per  cent.  It  appears  to  be  somewhat  more  fatal  in  southern 
climates.  Of  3,969  cases  treated  at  the  Charity  Hospital,  New  Orleans, 
the  death-rate  was  38.01  per  cent.  Our  mortality  at  the  Johns  Hopkins 
Hospital  is  about  25  per  cent  in  the  whites  and  30  per  cent  in  the  colored. 
In  f04  cases  at  the  Pennsylvania  Hospital  the  mortality  was  29  per  cent. 
At  the  Boston  City  Hospital  in  1,443  cases  the  mortality  was  29.1  per  cent. 
It  has  been  urged  that  the  mortality  in  this  disease  has  been  steadily  in- 
creasing, and  attempts  have  been  made  to  connect  this  increase  with  the 
expectant  plan  of  treatment  at  present  in  vogue.  But  the  careful  and  thor- 
ough analysis  by  C.  IST.  Townsend  and  A.  Coolidge,  Jr.,  of  1,000  cases  at 
the  Massachusetts  General  Hospital  indicates  clearly  that,  when  all  cir- 
cumstances are  taken  into  consideration,  this  conclusion  is  not  justified. 
They  found  that  when  all  fatal  cases  over  fifty  years  of  age  were  omitted, 
and  those  patients  who  were  delicate,  intemperate,  or  the  subject  of  some 
complication,  there  was  very  little  variation  from  decade  to  decade,  and 
that,  excluding  these  cases,  the  rate  was  but  little  over  10  per  cent.  In 
answer  to  the  assertion  that  the  modified  treatment  is  in  part  responsible 
for  the  increased  mortality,  these  authors  show  clearly  that  the  rise  in 
death-rate  took  place  in  the  period  prior  to  1860,  when  the  treatment  was 
entirely  or  in  great  part  heroic. 

According  to  the  analysis  of  708  cases  at  St.  Thomas's  Hospital  by 
Hadden,  H.  W.  G.  McKenzie,  and  W.  W.  Ord,  the  mortality  progressively 
increases  from  the  twentieth  year,  rising  from  3.7  per  cent  under  that  age 
to  22  per  cent  in  the  third  decade,  30.8  per  cent  in  the  fourth,  47  per  cent 
in  the  fifth,  51  per  cent  in  the  sixth,  65  per  cent  in  the  seventh  decade. 
Of  223,730  cases  collected  by  Wells  from  various  sources,  40,276  died,  a 
mortality  of  18.1  per  cent. 

The  mortality  in  private  practice  varies  greatly.  K.  P.  Howard  treated 
170  cases  with  only  6  per  cent  of  deaths.  Fussell  has  recently  reported  134 
cases  with  a  mortality  of  17.9  per  cent.  The  mortality  in  children  is  some- 
times very  low.  Morrill  has  recently  reported  6  deaths  in  123  cases  of  frank 
pneumonia.     On  the  other  hand,  Goodhart  had  25  deaths  in  120  cases. 

The  following  are  among  the  circumstances  which  influence  the  prog- 
nosis: 

Age. — As  Sturges  remarks,  the  old  are  likely  to  die,  the  young  to  re- 
cover. Under  one  year  it  is  more  fatal  than  between  two  and  five.  Fus- 
sell lost  5  out  of  8  cases  in  yearlings.  At  about  sixty  the  death-rate  is  very 
high,  amounting  to  60  or  80  per  cent.  So  fatal  is  it  in  this  country,  at  least, 
that  one  may  say  that  to  die  of  pneumonia  is  the  natural  end  of  old  people. 

As  already  stated,  the  disease  is  more  fatal  in  the  negro  than  in  the 
white  race. 

Previous  habits  of  life  and  the  condition  of  bodily  health  at  the  time 
of  the  attack  form  the  most  important  factors  in  the  prognosis  of  pneu- 
monia.   In  analyzing  a  series  of  fatal  cases  one  is  very  much  impressed  with 


132  SPECIFIC  INFECTIOUS  DISEASES. 

the  number  of  cases  in  which  the  organs  show  signs  of  degeneration.  In 
25  of  my  100  autopsies  at  the  Montreal  General  Hospital  the  kidneys 
showed  extensive  interstitial  changes.  Individuals  debilitated  from  sick- 
ness or  poor  food,  hard  drinkers,  and  that  large  class  of  hospital  patients, 
composed  of  robust-looking  laborers  between  the  ages  of  forty-five  and 
sixty,  whose  organs  show  signs  of  wear  and  tear,  and  who  have  by  excesses 
in  alcohol  weakened  the  reserve  power,  fall  an  easy  prey  to  the  disease. 
Very  few  fatal  cases  occur  in  robust,  healthy  adults.  Some  of  the  statistics 
given  by  army  surgeons  show  better  than  any  others  the  low  mortality  from 
pneumonia  in  healthy  picked  men.  The  death-rate  in  the  German  army 
in  over  40,000  cases  was  only  3.6  per  cent. 

Certain  complications  and  terminations  are  particularly  serious.  The 
meningitis  of  pneumonia  is  probably  always  fatal.  Endocarditis  is  ex- 
tremely grave,  much  more  so  than  pericarditis.  Apart  from  these  serious 
complications,  the  fatal  event  in  pneumonia  is  due  either  to  a  gradual 
toxaemia  or  to  mechanical  interference  with  the  respiration  and  circulation. 

Toxcemia  is  the  important  prognostic  feature  in  the  disease,  to  which  in 
a  majority  of  the  cases  the  degree  of  pyrexia  and  the  extent  of  consolidation 
are  entirely  subsidiary.  It  is  not  at  all  proportionate  to  the  degree  of  lung 
involved.  A  severe  and  fatal  toxaemia  may  occur  with  the  consolidation 
of  only  a  small  part  of  one  lobe.  On  the  other  hand,  a  patient  with  com- 
plete solidification  of  one  lung  may  have  no  signs  of  a  general  infection. 
The  question  of  individual  resistance  seems  to  be  the  most  important  one, 
and  one  sees  even  most  robust-looking  individuals  fatally  stricken  within 
a  few  days. 

Much  stress  has  been  laid  of  late  upon  the  factor  of  leucocytosis  as  an 
element  in  the  prognosis.  A  very  slight  or  complete  absence  of  a  leuco- 
cytosis is  regarded  as  very  unfavorable.  Of  the  64  cases  in  my  wards 
during  the  session  of  1900-1901  all  the  low  counts  were  in  fatal  cases. 
The  lowest  counts  in  5  fatal  cases  were  1,400,  3,800,  5,000,  2,350,  and  3,660. 
As  a  rule,  it  may  be  said  that  the  continuous  absence  of  leucocytosis  is 
unfavorable. 

Death  from  direct  interference  with  the  function  of  respiration  is  rare. 
It  may  happen  in  extensive  double  pneumonia,  but  even  with  involvement 
of  a  very  large  section  of  both  lungs  recovery  may  take  place.  A  very  im- 
portant element  in  the  prognosis  is  the  condition  of  the  heart,  from  failure 
of  which  quite  as  many  die  as  from  the  intoxication.  The  heart  weakness 
may  be  due  either  to  the  specific  action  of  the  poison,  to  the  prolonged 
fever,  or  to  over-distention  of  the  right  chambers.  All  three  factors  may 
be  at  work  together.  I  have  already  referred  to  the  sudden  onset  of  serious 
cardiac  weakness;  more  commonly  there  is  a  gradually  increased  rapidity 
with  increasing  weakness  of  the  heart  muscle.  The  pulse  is  not  always  a 
safe  guide;  since,  as  I  mentioned  before,  it  may  be  full  and  soft  and  not 
very  rapid  within  a  few  hours  of  a  fatal  termination,  even  in  cases  without 
pronounced  toxsemia. 

Diagnosis.— No  disease  is  more  readily  recognized  in  a  large  majority 
of  the  cases.  The  external  characters,  the  sputa,  and  the  physical  signs 
combine  to  make  one  of  the  clearest  of  clinical  pictures.     After  a  study 


LOBAR  PNEUMONIA.  133 

in  the  post-mortem  room  of  my  own  and  others'  mistakes,  I  think  that 
the  ordinary  lobar  pneumonia  of  adults  is  rarely  overlooked.  Errors  are 
particularly  liable  to  occur  in  the  intercurrent  pneumonias,  in  those  com- 
plicating chronic  affections,  and  in  the  disease  as  met  with  in  children,  the 
aged,  and  drunkards.  Tuberculo-pneumonic  phthisis  is  frequently  con- 
founded with  pneumonia.  Pleurisy  with  effusion  is,  I  believe,  not  often 
mistaken  except  in  children.  The  diagnostic  points  will  be  referred  to 
imder  pleurisy. 

In  diabetes,  Bright's  disease,  chronic  heart-disease,  pulmonary  phthisis, 
and  cancer,  an  acute  pneumonia  often  ends  the  scene,  and  is  frequently 
overlooked.  In  these  cases  the  temperature  is  perhaps  the  best  index, 
and  should,  more  particularly  if  cough  develops,  lead  to  a  careful  examina- 
tion of  the  lungs.  The  absence  of  expectoration  and  of  pulmonary  symp- 
toms may  make  the  diagnosis  very  difficult. 

In  children  there  are  two  special  sources  of  error;  the  disease  may  be 
entirely  masked  by  the  cerebral  symptoms  and  the  case  mistaken  for  one 
of  meningitis.  It  is  remarkable  in  these  cases  how  few  indications  there 
are  of  pulmonary  trouble.  The  other  condition  is  pleurisy  with  effusion, 
which  in  children  often  has  deceptive  physical  signs.  The  breathing  may 
be  intensely  tubular  and  tactile  fremitus  may  be  present.  The  exploratory 
needle  is  sometimes  required  to  decide  the  question.  In  the  old  and  de- 
bilitated a  knowledge  that  the  onset  of  pneumonia  is  insidious,  and  that 
the  symptoms  are  ill-defined  and  latent,  should  put  the  practitioner  on  his 
guard  and  make  him  very  careful  in  the  examination  of  the  lungs  in  doubt- 
ful cases.  In  chronic  alcoholism  the  cerebral  symptoms  may  predominate 
and  completely  mask  the  local  process.  As  mentioned,  the  disease  may 
assume  the  form  of  violent  mania,  but  more  commonly  the  symptoms  are 
those  of  delirium  tremens.  In  any  case  rapid  pulse,  rapid  respiration,  and 
fever  are  symptoms  which  should  invariably  excite  suspicion  of  inflamma- 
tion of  the  lungs.  Under  cerebro-spinal  meningitis  will  be  found  the  points 
of  differential  diagnosis  between  pneumonia  and  that  disease. 

Pneumonia  is  rarely  confounded  with  ordinary  consumption,  but  to 
differentiate  acute  tuberculo-pneumonic  phthisis  is  often  difficult.  The 
case  may  set  in  with  a  chill.  It  may  be  impossible  to  determine  which 
condition  is  present  until  softening  occurs  and  elastic  tissue  and  tubercle 
bacilli  appear  in  the  sputum.  A  similar  mistake  is  sometimes  made  in 
children.  With  typhoid  fever,  pneumonia  is  not  infrequently  confounded. 
There  are  instances  of  pneumonia  with  the  local  signs  well  marked  in 
which  the  patient  rapidly  sinks  into  what  is  known  as  the  typhoid  state, 
with  dry  tongue,  rapid  pulse,  and  diarrhoea.  Unless  the  case  is  seen  from 
the  outset  it  may  be  very  difficult  to  determine  the  true  nature  of  the 
malady.  On  the  other  hand,  there  are  cases  of  typhoid  fever  which  set  in 
with  symptoms  of  lobar  pneumonia — the  so-callecl  pneumo-typhus.  It  may 
be  impossible  to  make  a  differential  diagnosis  in  such  a  case  unless  the 
charactoristic  eruption  develops  or  the  Widal  reaction  be  found. 

Prophylaxis. — The  question  of  the  prevention  of  pneumonia  is  a 
rlifficult  one,  which  has  hardly  yet  come  within  the  sphere  of  practical 
knowledge.     More  care  should  be  taken  with  pneumonic  sputum  tlian  has 


134  SPECIFIC  INFECTIOUS  DISEASES. 

been  done  heretofore,  and  it  should  be  carefully  disinfected.  Individuals 
who  have  had  pneumonia  should  be  specially  careful  to  keep  the  mouth 
and  throat  thoroughly  cleansed,  and  any  house  in  which  several  cases  of 
pneumonia  have  occurred  in  rapid  succession  should  be  thoroughly  dis- 
infected. 

Treatment. — Pneumonia  is  a  self -limited  disease,  which  can  neither 
be  aborted  nor  cut  short  by  any  known  means  at  our  command.  Even 
under  the  most  unfavorable  circumstances  it  may  terminate  abruptly  and 
naturally,  without  a  dose  of  medicine  having  been  administered.  A  patient 
was  admitted  into  the  Philadelphia  Hospital  on  the  evening  of  the  seventh 
day  after  the  chill,  in  which  he  had  been  seen  by  one  of  my  assistants,  who 
had  ordered  him  to  go  to  a  hospital.  He  remained,  however,  in  his  house 
alone,  without  assistance,  taking  nothing  but  a  little  milk  and  bread  and 
whisky,  and  was  brought  into  the  hospital  by  the  police  in  a  condition  of 
active  delirium.  That  night  his  temperature  was  105°  and  his  pulse  above 
120.  In  his  delirium  he  came  near  escaping  through  the  window  of  the 
ward.  The  following  morning — the  eighth  day — the  crisis  occurred,  and 
at  ward  class  his  temperature  was  below  98°.  The  entire  lower  lobe  of  the 
right  side  was  found  involved,  and  he  entered  upon  a  rapid  convalescence. 
So  also,  under  the  favoring  circumstances  of  good  nursing  and  careful 
diet,  the  experience  of  many  physicians  in  different  lands  has  shown  that 
pneumonia  runs  its  course  in  a  definite  time,  terminating  sometimes  spon- 
taneously on  the  third  or  the  fifth  day,  or  continuing  until  the  tenth  or 
twelfth. 

There  is  no  specific  treatment  for  pneumonia.  The  young  practitioner 
may  bear  in  mind  that  patients  are  more  often  damaged  than  helped  by 
the  promiscuous  drugging,  which  is  still  only  too  prevalent. 

1.  General  Management  of  a  Case. — The  same  careful  hygiene  of  the 
bed  and  of  the  sick-room  should  be  carried  out  as  in  typhoid  fever.  The 
patient  should  not  be  too  much  bundled  up  with  clothing.  For  the  heavy 
flannel  undershirts  should  be  substituted  a  thin,  light  flannel  jacket,  open 
in  front,  which  enables  the  physician  to  make  his  examinations  without 
unnecessarily  disturbing  the  patient.  The  room  should  be  bright  and 
light,  letting  in  the  sunshine  if  possible,  and  thoroughly  well  ventilated. 
Only  one  or  two  persons  should  be  allowed  in  the  room  at  a  time.  Even 
when  not  called  for  on  account  of  the  high  fever,  the  patient  should  be 
carefully  sponged  each  day  with  tepid  water.  This  should  be  done  with 
as  little  disturbance  as  possible.  Special  care  should  be  taken  to  keep  the 
mouth  and  gums  cleansed. 

2.  Diet. — Plain  water,  a  pleasant  table  water,  or  lemonade  should  be 
given  freely.  When  the  patient  is  delirious  the  water  should  be  given  at 
fixed  intervals.  The  food  should  be  liquid,  consisting  chiefly  of  milk, 
either  alone  or,  better,  mixed  with  food  prepared  from  some  one  of  the 
cereals,  and  eggs,  either  soft  boiled  or  raw. 

3.  Special  Treatment. — Certain  measures  are  believed  to  have  an  influ- 
ence in  arresting,  controlling,  or  cutting  short  the  disease.  It  i§  very  diffi- 
cult for  the  practitioner  to  arrive  at  satisfactory  conclusions  on  this  ques- 
tion in  a  disease  so  singularly  variable  in  its  course.    How  natural,  when 


LOBAR  PNEUMONIA.  135 

on  the  third  or  fourth  day  the  crisis  occurs  and  convalescence  sets  in,  to 
attribute  the  happy  result  to  the  effect  of  some  special  medication!  How 
easy  to  forget  that  the  same  unexpected  early  recoveries  occur  under 
other  conditions!  The  following  are  among  the  measures  which  may  be 
helpful: 

(a)  Bleeding, — The  reproach  of  Van  Helmont,  that  "  a  bloody  Moloch 
presides  in  the  chairs  of  medicine/'  can  not  be  brought  against  this  gen- 
eration of  physicians.  Before  Louis'  iconoclastic  paper  on  bleeding  in 
pneumonia  it  would  have  been  regarded  as  almost  criminal  to  treat  a  case 
without  venesection.  We  employ  it  nowadays  much  more  than  we  did 
a  few  years  ago,  but  more  often  late  in  the  disease  than  early.  To  bleed 
at  the  very  onset  in  robust,  healthy  individuals  in  whom  the  disease  sets 
in  with  great  intensity  and  high  fever  is,  I  believe,  a  good  practice.  I  have 
seen  instances  in  which  it  was  very  beneficial  in  relieving  the  pain  and  the 
dyspnoea,  reducing  the  temperature,  and  allaying  the  cerebral  symptoms. 

(&)  Drugs. — Certain  drugs  are  credited  with  the  power  of  reducing  the 
intensity  and  shortening  the  duration  of  the  attack.  Among  them  vera- 
trum  viride  still  holds  a  place,  doses  of  TT],  ii-v  of  the  tincture  given  every 
two  hours.  Tartar  emetic — a  remedy  which  had  great  vogue  some  years 
ago — is  now  very  rarely  employed.  To  a  third  drug,  digitalis,  has  been 
attributed  of  late  great  power  in  controlling  the  course  of  the  disease. 
Petresco  gives  at  one  time  as  much  as  from  4  to  12  grammes  of  the  pow- 
dered leaves,  and  claims  that  these  colossal  doses  are  specially  efl&cacious 
in  shortening  the  course  of  the  disease  and  diminishing  the  mortality. 

(c)  Antipneumonic  Serum. — Note  the  remark  on  p.  112.  The  Klemp- 
erer  brothers,  Auld,  Washbourn,  and  others  have  reported  favorable  re- 
sults. The  serum  is  injected  into  the  subcutaneous  tissues.  Washbourn 
recommends  as  a  dose  20  cc,  and  thinks  it  is  well  to  make  an  injection 
twice  a  day  until  the  patient  is  convalescent.  Of  141  cases  treated  with 
antipneumonic  serum,  collected  by  G.  E.  Tyler,  only  20  died. 

4.  Symptomatic  Treatment. — (a)  To  relieve  the  Pain. — The  ■  stitch  in 
the  side  at  onset,  which  is  sometimes  so  agonizing,  is  best  relieved  by  a 
hypodermic  injection  of  a  quarter  of  a  grain  of  morphia.  When  the  pain 
is  less  intense  and  diffuse  over  one  side,  the  Paquelin  cautery  applied  lightly 
is  very  efficacious,  or  hot  or  cold  applications  may  be  tried.  When  the  dis- 
ease is  fairly  established  the  pain  is  not,  as  a  rule,  distressing,  except  when 
the  patient  coughs,  and  for  this  the  Dover's  powder  may  be  used  in  5-grain 
doses,  according  to  the  patient's  needs.  Hot  poultices,  formerly  so  much 
in  use,  relieve  the  pain,  though  not  more  than  the  cold  applications.  For 
children  they  are  often  preferable. 

(6)  To  combat  the  Toxcemia. — Herein  lies  our  chief  weakness  in  dealing 
with  pneumonia.  We  have  as  yet  no  specific,  either  drug  or  the  product  of 
the  bacteriological  laboratory,  which  safely  and  surely  neutralizes  the 
poison  of  the  disease.  We  may  reasonably  hope  that  such  a  remedy  ere 
long  will  be  forthcoming,  but  meantime  we  must  be  content  with  measures 
which  aim  at  keeping  up  the  strength  of  the  patient.  The  saline  infusions 
aid  in  the  elimination  of  the  poison. 

(c)  The  third  and  all-important  indication  in  the  treatment  of  pneu- 


136  SPECIFIC  INFECTIOUS  DISEASES. 

monia  is  to  support  the  heart.  The  practitioner  must  ever  be  on  the  alert 
to  prevent  the  onset  of  cardiac  weakness,  and  to  treat  it  should  that  con- 
dition arise. 

To  prevent  the  Onset  of  Cardiac  Weakness. — "We  can  not  at  present  sepa- 
rate the  effects  of  the  fever  from  those  of  the  poisons  circulating  in  the 
blood.  It  is  possible,  indeed,  as  some  suppose,  that  the  fever  itself  may- 
be beneficial.  Undoubtedly,  however,  high  and  prolonged  pyrexia  is  dan- 
gerous to  the  heart,  and  should  be  combated.  For  this  our  most  trusty 
weapon  is  hydrotherapy,  which  in  pneumonia  is  used  in  several  difEerent 
ways.  The  ice-bag  to  the  affected  side  is  one  of  the  most  convenient  and 
serviceable.  Its  good  effects  have  been  strongly  insisted  upon  by  Mays.  I 
have  used  ice  systematically  in  my  wards  for  the  past  ten  years.  It  allays 
the  pain,  reduces  the  fever  slightly,  and,  as  a  rule,  the  patient  says  he 
feels  very  much  more  comfortable.  Broad,  flat  ice-bags  are  now  easUy 
obtained  for  the  purpose,  and  if  these  are  not  available  an  ice  poultice  can 
be  readily  made,  and  by  the  use  of  oil-silk  the  clothing  and  bedding  of 
the  patient  can  be  protected  from  the  water.  Cold  sponging  is  the  best 
form  of  hydrotherapy  to  employ  as  a  routine  measure.  When  done  limb 
by  limb  the  patient  is  but. little  disturbed,  and  it  is  refreshing  and  bene- 
ficial. With  very  pronounced  nervous  symptoms  and  persistent  high 
temperature,  or  with  hyperpyrexia,  a  cold  bath  of  ten  minutes'  dura- 
tion may  be  given.  Von  Jiirgensen,  one  of  the  best  of  living  students 
of  the  disease,  strongly  advises  it  under  these  conditions.  Personally, 
my  experience  with  the  full  cold  bath  is  not  large  enough  to  enable  me 
to  express  a  positive  opinion.  In  this  country  we  have  not,  I  think,  used 
it  sufficiently  in  the  toxic  cases,  in  which  in  typhoid  fever  we  see  such 
good  results. 

Of  medicinal  antipyretics,  quinine  has  been  much  vaunted  in  doses  of 
from  30  to  60  grains  daily.  Unfortunately,  it  is  apt  to  disturb  the  stomach 
and  cause  unpleasant  ringing  in  the  ears;  according  to  some,  also,  it  is  very 
depressing,  but  I  must  say  I  have  never  seen  any  injurious  effects  from  it, 
though  I  have  not  used  it  for  some  years.  Antipyrin,  antifebrin,  and 
phenacetin  have  been  thoroughly  tried  in  pneumonia,  and  the  general  opin- 
ion at  present  is  decidedly  against  their  systematic  employment. 

Alcohol  may  be  used  with  benefit  in  a  majority  of  cases  of  pneumonia. 
In  moderate  doses  it  diminishes  slightly  the  temperature,  increases  the 
appetite,  obviates  the  tendency  to  heart  weakness,  and  is  a  conservator 
of  energy,  being  itself  consumed  in  supplying  heat  in  place  of  the  body 
tissues.  Two  or  three  ounces  of  good  whisky  in  the  twenty-four  hours 
may  be  used  in  the  case  of  old  and  debilitated  patients. 

To  treat  Heart  Weakness  when  Present. — Now  the  resources  and  judg- 
ment of  the  physician  are  taxed  to  the  utmost.  Is  the  heart  weakness  due 
to  progressive  distention  and  overfilling  of  the  right  heart?  This  is 
usually  indicated  by  increasing  cyanosis,  increasing  shortness  of  breath, 
signs  of  oedematous  infiltration  in  the  uninvolved  parts  of  the  lung,  and  a 
small  and  feeble  radial  pulse.  Under  these  circumstances  a  free  venesection 
is  sometimes  helpful,  though  I  must  say  that  my  personal  experience  has 
not  been  very  satisfactory.     I  have,  however,  within  the  past  few  years 


LOBAR  PNEUMONIA.  137 

seen  several  cases  in  which  it  seemed  to  be  timely,  even  life-saving.  Too 
often  the  progressive  cardiac  asthenia  is  due  to  the  action  of  the  fever  and 
of  the  poisons,  partly  upon  the  heart  muscle  itself,  partly  upon  the  nerve 
centres,  cardiac  and  respiratory.  An  increase  in  the  amount  of  alcohol  is 
advisable  when  the  pulse  becomes  small,  frequent,  and  feeble  or  very  com- 
pressible, and  when  the  heart-sounds,  particularly  the  second  pulmonic, 
begin  to  lose  their  force.  The  amount  will  vary  with  the  age  of  the  pa- 
tient and  with  his  habits.  It  may  be  increased,  if  necessary,  to  12  or  16 
ounces  in  the  twenty-four  hours.  Strychnia  is  a  most  valuable  cardiac 
tonic  in  pneumonia.  It  may  be  given  in  doses  of  from  one  sixtieth  to  one 
thirtieth  of  a  grain  hypodermically,  or,  if  the  heart's  action  becomes  more 
feeble,  in  still  larger  doses,  up  to  one  twentieth  or  even  one  twelfth  of  a 
grain  every  three  or  four  hours.  Digitalis  is  indicated  with  the  earliest 
signs  of  cardiac  weakness.  If  the  heart's  action  becomes  very  rapid,  or  if, 
as  above  stated,  there  is  a  sudden  onset  of  cardiac  weakness,  indicated  by 
a  very  quick  and  irregular  pulse,  it  may  be  given  freely,  either  in  the  form 
of  the  tincture,  15  or  20  minims  every  two  hours  until  2  drachms  are  given, 
or  as  a  digitalin  hypodermically  in  doses  of  from  a  thirtieth  to  a  twentieth 
of  a  grain  every  three  hours.  Other  remedies  still  much  in  use  are  the  aro- 
matic spirits  of  ammonia,  camphor,  musk,  and  the  hypodermic  injections 
of  ether.    Two  other  measures  may  be  referred  to  under  this  section. 

Oxygen  Gas. — It  is  doubtful  whether  the  inhalation  of  oxygen  in  pneu- 
monia is  really  beneficial.  The  work  of  Lorrain-Smith  suggests,  indeed, 
that  it  may  under  certain  circumstances  be  positively  harmful.  He  has 
shown  experimentally  that  oxygen  may  be  a  serious  irritant,  actually  pro- 
ducing inflammation  of  the  lungs.  If  we  are  Justified  in  applying  his  results 
to  man,  there  can  be  but  little  doubt  that  the  administration  of  oxygen 
may  not  be  entirely  "  harmless,"  as  stated  in  the  last  edition  of  this  work. 
If  the  tension  of  the  oxygen  breathed  rises  to  80  per  cent  of  an  atmosphere, 
which  it  might  easily  do  in  certain  methods  of  administration,  it  may  be 
injurious.  When  used  it  should  be  allowed  to  flow  gently  from  the  nozzle 
held  at  a  little  distance,  in  which  way  it  is  freely  diluted  with  air. 

Saline  injections  hypodermically  have  been  much  used,  and  certainly  do 
good  in  helping  to  tide  over  a  critical  period  of  cardiac  depression.  As 
much  as  a  couple  of  pints  may  be  allowed  to  run  beneath  the  skin  by  grav- 
ity, a  rubber  bag  and  either  a  large  hypodermic  or  a  middle-sized  aspirator 
needle  being  used.  The  injection  may  be  made  in  the  flanks  or  in  the 
thighs.  Our  experience  of  the  past  three  years  is  decidedly  favorable  to 
the  use  of  saline  infusions  in  the  disease. 

Treatment  of  Complications. — If  the  fever  persists  it  is  important  to 
look  out  for  pleurisy,  particularly  for  the  meta-pneumonic  empyema.  The 
exploratory  needle  should  be  used  if  necessary.  A  sero-fibrinous  efl'usion 
should  be  aspirated,  a  purulent  opened  and  drained.  In  a  complicating 
pericarditis  Vith  a  large  efl'usion  aspiration  may  be  necessary.  Delayed 
resolution  is  a  difficult  condition  to  treat.  Riess  has  recommended  pilo- 
carpine, which  I  have  tried  in  one  or  two  cases  without  much  benefit. 


138  SPECIFIC  INFECTIOtTS  DISEASES. 


XVI.    DIPHTHERIA. 

Definition. — A  specific  infectious  disease,  characterized  by  a  local 
fibrinous  exudate,  usually  upon  a  mucous  membrane,  and  by  constitutional 
symptoms  due  to  toxins  produced  at  the  site  of  the  lesion.  The  presence 
of  the  Klebs-LoefQer  bacillus  is  the  etiological  criterion  by  which  true 
diphtheria  is  distinguished  from  other  forms  of  membranous  inflamma- 
tion. 

The  clinical  and  bacteriological  conceptions  of  diphtheria  are  at  present 
not  in  full  accord.  On  the  one  hand,  there  are  cases  of  simple  sore  throat 
which  the  bacteriologists,  finding  the  Klebs-Loeffler  bacillus,  call  true 
diphtheria.  On  the  other  hand,  cases  of  membranous,  sloughing  angina, 
diagnosed  by  the  physician  as  diphtheria,  are  called  by  the  bacteriologists, 
in  the  absence  of  the  Klebs-Loeffler  bacillus,  pseudo-diphtheria  or  diph- 
theroid angina. 

The  term  diphtheroid  may  be  used  for  the  present  to  designate  those 
forms  in  which  the  Klebs-Loeffler  bacillus  is  not  present.  Though  usually 
milder,  severe  constitutional  disturbance,  and  even  paralysis,  may  follow 
these  so-called  pseudo-diphtheritic  processes. 

Historical  Note. — The  disease  was  known  to  Aretseus  and  to  Galen, 
Epidemics  occurred  throughout  the  middle  ages.  It  appeared  early  among 
the  settlers  of  New  England,  and  accounts  are  extant  of  epidemics  in  this 
country  in  the  seventeenth  and  eighteenth  centuries.  Huxham  and  Fother- 
gill  gave  excellent  descriptions  of  the  disease.  An  admirable  account  was 
given  by  Samuel  Bard,*  of  New  York,  whose  essay  is  one  of  the  most  solid 
contributions  made  to  medicine  in  America.  It  was  reserved  for  Pierre 
Bretonneau,  of  Tours,  to  grasp  the  fact  that  angina  suffocativa,  "  cynanche 
maligne,"  the  "  putrid,"  and  other  forms  of  malignant  sore  throat,  were 
one  and  the  same  disease,  to  which  he  gave  the  name  "  diphtherite." 

Etiology.' — The  disease  is  endemic  in  the  larger  centres  of  population, 
and  becomes  epidemic  at  certain  seasons  of  the  year.  ^Yhile  other  con- 
tagious diseases  have  diminished  within  the  past  decade,  diphtheria  has  in- 
creased, particularly  in  cities.  It  has  prevailed  also  with  great  severity  in 
country  districts,  in  which  indeed  the  affection  seems  to  be  specially  viru- 
lent. A  close  relation  between  imperfect  drainage  or  a  polluted  water- 
supply  and  diphtheria  has  not  been  determined. 

Diphtheria  is  a  highly  contagious  disease,  readily  communicated  from 
person  to  person.  The  bacilli  may  be  received,  "  (1)  from  the  membranous 
exudate  or  discharges  from  diphtheria  patients;  (2)  from  the  secretions 
of  the  nose  and  throat  of  convalescent  cases  of  diphtheria  in  which  the 
virulent  bacilli  persist;  (3)  from  the  throats  of  healthy  individuals  who 
have  acquired  the  bacilli  from  being  in  contact  with  others  having  virulent 
germs  on  their  person  or  clothing:  in  such  cases  the  bacilli  may  sometimes 
live  and  develop  for  days  or  weeks  in  the  throat  without  causing  any  lesion  " 
(Park  and  Beebe).  In  the  tenement  districts  of  New  York  these  authors 
recognized  two  varieties  of  local  epidemics.     In  one,  the  cases  were  evi- 

*  Transactions  of  the  American  Philosophical  Society,  vol.  i,  Philadelphia,  1770. 


DIPHTHERIA.  139 

dently  from  neighborhood  infection;  while  in  the  other,  the  infection  was 
derived  from  schools,  since  a  whole  district  would  suddenly  become  the 
seat  of  scattered  cases.  "  At  times  in  a  certain  area  of  the  city,  from  which 
several  schools  drew  their  scholars,  all  the  cases  of  diphtheria  Avould  occur 
(as  investigation  showed)  in  families  whose  children  attended  one  school, 
the  children  of  the  other  schools  being  for  the  time  exempt." 

No  disease  of  temperate  regions  proves  more  fatal  to  physicians  and 
nurses.  There  seems  to  be  particular  danger  in  the  examination  and  swab- 
]jing  of  the  throat,  for  in  the  gagging,  coughing,  and  spluttering  efforts 
the  patient  may  cough  mucus  and  flakes  of  membrane  into  the  physician's 
face.  The  virus  attaches  itself  to  the  clothing,  the  bedding,  and  the  room 
in  which  the  patient  has  lived,  and  has  in  many  instances  displayed  great 
tenacity.  It  has  been  found  to  live  on  blood  serum  for  one  hundred  and 
fifty-five  days,  in  gelatin  for  eighteen  months,  dried  on  silk  threads  for  one 
hundred  and  seventy-two  days,  on  a  child's  plaything  which  had  been  kept 
in  a  dark  place  for  five  months,  and  in  bits  of  dried  membrane  for  from 
fourteen  to  twenty  weeks.  An  instance  has  been  reported  (Golay)  in  which 
ihe  bacilli  were  present  in  the  throat  for  three  hundred  and  sixty-two  days. 
During  this  period  there  were  three  acute  relapses.  They  have  been  found, 
±00,  in  the  dust  of  a  diphtheria  pavilion,  and  in  the  hair  and  clothing  of 
the  nurses  in  attendance  upon  diphtheria  babies  (Wright  and  Emerson). 
Forbes  isolated  diphtheria  bacilli  from  a  vessel  which  was  regarded  as  the 
cause  of  the  disease  in  twenty-four  families.  The  bacilli  grow  readily  in 
milk  without  changing  its  appearance.  From  cheese  which  was  made  on 
a  farm  on  which  diphtheria  prevailed,  pure  cultures  of  diphtheria  bacilli 
were  obtained  (Few  York  Board  of  Health  Eeport,  1894). 

The  disease  may  be  transmitted  by  inoculation. 

Calves,  cats,  and  fowls  are  subject  to  contagious  membranous  diseases, 
which  are,  however,  not  identical  with  diphtheria  in  man  and  are  not  com- 
municable to  him. 

As  in  other  infectious  disorders,  individual  susceptibility  plays  an  im- 
portant role.  Not  only  do  very  many  of  those  exposed  escape,  but  even  of 
.those  in  whose  throats  the  bacilli  lodge  and  grow. 

Of  predisposing  causes  age  is  one  of  the  most  important.  Very  young 
(C^hi'Wlren  are  rarely  attacked,  but  Jacobi  states  that  he  has  seen  three  in- 
:StanoQS  of  the  disease  in  the  newly  born.  Between  the  second  and  the  fif- 
teenth yjear  a  large  majority  of  the  cases  occur.  In  this  period  the  greatest 
tnumber  of  deaths  is  between  the  second  and  the  fifth  years.  Girls  are 
attacked  in  larger  numbers  than  boys,  probably  because  they  are  brought 
into  closer  contact  with  the  sick.  Adults  are  frequently  affected.  The 
disease  is  most  prevalent  in  the  cold  autumn  weather.  The  secondary 
pseudo-membranous  inflammations,  caused  usually  by  the  streptococcus, 
attack  debilitated  persons,  the  subjects  of  fevers,  particularly  of  scarlet 
fever,  typhoid,  and  measles. 

Caillc  regards  as  special  predisposing  elements  in  children  enlarged 
tonsils,  chronic  naso-pharyngeal  catarrh,  carious  teeth,  and  an  unhealthy 
condition  of  the  mucous  membrane  of  the  mouth  and  throat. 

Epidemics  vary  in  intensity.  Wliile  in  some  the  affection  is  mild  and 
9 


140  SPECIFIC  INFECTIOUS  DISEASES. 

rarely  fatal,  in  others  it  is  characterized  by  wide  extension  of  the  mem- 
brane, and  shows  a  special  tendency  to  attack  the  larynx. 

The  Klebs-Loeffler  bacillus  occurs  in  a  large  percentage  of  all 
suspected  cases.  It  is  found  chiefly  in  the  false^  membrane,  and  does  not 
extend  into  the  subjacent  mucosa.  In  the  majority  of  instances  the  organ- 
isms are  localized,  and  only  a  few  penetrate  into  the  interior.  In  many 
instances  the  bacilli  are  found  in  the  blood  and  in  the  internal  organs. 
It  may  be  the  predominating  or  sole  organism  in  the  broncho-pneu- 
monia so  common  in  the  disease.  Outside  the  throat,  the  common  site 
of  its  morbid  action,  the  Klebs-Loeffler  bacillus  has  been  found  in  diph- 
theritic conjunctivitis,  in  otitis  media,  sometimes  in  wound  diphtheria,  in 
fibrinous  rhinitis,  and  in  an  attenuated  condition  by  Howard  in  a  case  of 
ulcerative  endocarditis. 

Morphological  Characters. — The  bacillus  is  non-motile,  varies  from  2.5 
to  3  /i  in  length,  and  from  0.5  to  0.8  /*  in  thickness.  It  appears  as  a  straight 
or  slightly  bent  rod  with  rounded  ends;  irregular,  bizarre  forms,  such  as 
rods  with  one  or  both  ends  swollen  and  simple  branching  forms,  are  more 
or  less  common.  The  bacillus  stains  in  sections  or  on  the  cover-glass  by 
the  Gram  method. 

It  grows  best  upon  a  mixture  of  glucose  bouillon  and  blood  serum 
(Loeffler),  forming  large,  elevated,  grayish-white  colonies  with  opaque  cen- 
tres. It  grows  also  upon  all  the  ordinary  culture  media.  The  growth 
usually  ceases  at  temperatures  belo"^  20°  C. 

The  bacillus  is  very  resistant,  and  cultures  have  been  made  from  a  bit 
of  membrane  preserved  for  five  months  in  a  dry  cloth.  Incorporated  with 
dust  and  kept  moist,  the  bacilli  were  still  cultivatable  at  the  end  of  eight 
weeks;  kept  in  a  dried  state  they  no  longer  grew  at  the  end  of  this  period 
(Eitter). 

Variation  in  Virulence. — For  testing  the  virulence  the  guinea-pig  is 
used,  being  most  susceptible  to  the  poison.  An  amount  of  a  forty-eight 
hour  bouillon  culture  equalling  one  half  per  cent  of  the  weight  of  the  ani- 
mal is  injected  subcutaneously.  "  A  fully  virulent  culture  is  one  which 
causes  the  death  of  a  guinea-pig  within  three  days  or  less;  a  culture  of 
medium  virulence  one  which  causes  the  death  of  the  animal  in  from  three  to 
five  days.  Cultures  which  only  produce  local  necrosis  and  ulceration  or  death 
after  a  greater  number  of  days  may  be  considered  as  of  slight  virulence  " 
(J.  H.  Wright).  At  the  seat  of  the  inoculation  there  is  local  necrosis  with 
fibrinous  exudate  which  contains  the  bacilli,  and  there  is  also  a  more  or 
less  extensive  oedema  of  the  subcutaneous  tissue.  The  Klebs-Loeffler 
bacillus  evidently  has  very  varying  grades  of  virulence  down  even  to  com- 
plete absence  of  pathogenic  effects.  The  name  pseudo-bacillus  of  diph- 
theria should  not  be  give]ji  to  this  avirulent  organism. 

The  Presence  of  the  Klebs-Loeflfler  Bacillus  in  Non-membranous  Angina 
and  in  Healthy  Throats. — The  bacillus  has  been  isolated  from  cases  which 
show  nothing  more  than  a  simple  catarrhal  angina,  of  a  mild  type  without 
any  membrane,  with  diffuse  redness,  and  perhaps  huskiness  and  signs  of 
catarrhal  laryngitis.  In  other  cases  the  anatomical  picture  may  be  that  of 
a  lacunar  tonsillitis. 


DIPHTHERIA.  141 

The  organisms  may  be  met  with  in  perfectly  healthy  throats,  particu- 
larly in  persons  in  the  same  house,  or  the  ward  attendants  and  nurses  in 
fever  hospitals. 

Following  an  attack  of  diphtheria  the  bacilli  may  persist  in  the  throat 
or  nose  after  all  the  membrane  has  disappeared  for  weeks  or  months — even 
15  months.  In  explanation  of  this  persistence  Councilman  has  called  at- 
tention to  the  frequency  with  which  the  antrum  is  affected. 

Toxine  of  the  Klebs-Loeffler  Bacillus. — Roux  and  Yersin  showed  that 
a  fatal  result  following  the  inoculation  with  the  bacillus  was  not  caused 
by  any  extension  of  the  micro-organisms  within  the  body;  and  they  were 
enabled  in  bouillon  cultures  to  separate  the  bacilli  from  the  poison.  The 
toxine  so  separated  killed  with  very  much  the  same  effects  as  those  caused 
by  the  inoculation  of  the  bacilli;  the  pseudo-membrane,  however,  is  not 
formed.  These  results  were  confirmed  by  many  observers,  particularly  by 
Sidney  Martin,  who  separated  a  toxic  albumose.  The  precise  composition 
of  the  body  and  whether  it  is  a  proteid  at  all  is  still  doubtful. 

Susceptible  animals  may  be  rendered  immune  from  diphtheritic  in- 
fection by  injecting  weakened  cultures  of  the  bacillus  or,  what  is  better, 
suitable  doses  of  the  diphtheria  toxine.  The  result  of  the  injections  is 
a  febrile  reaction  which  soon  passes  away  and  leaves  the  animal  less  sus- 
ceptible to  the  poison  or  the  living  bacilli.  By  repeating  and  gradually 
increasing  the  quantity  of  poison  injected  a  high  degree  of  immunity  can 
be  produced  in  large  animals  (goat,  horse). 

The  Bacteria  associated  with  the  Diphtheria  Bacillus. — The  most  com- 
mon is  the  streptococcus  jDyogenes.  Others,  in  addition  to  the  organisms 
constantly  found  in  the  mouth,  are  the  micrococcus  lanceolatus,  the  ba- 
cillus coli  communis,  and  the  staphylococcus  aureus  and  albus.  Of  these, 
probably  the  streptococcus  pyogenes  is  the  most  important,  as  cases  of 
general  infection  with  this  organism  have  been  found  in  diphtheria.  The 
suppuration  in  the  lymph-glands  and  the  broncho-pneumonia  are  usually 
(though  not  always)  caused  by  this  organism. 

Pseudo-Diphtheria  Bacillus. — Bacillus  Xerosis. — As  mentioned  above, 
the  Klebs-Loeffler  bacillus  varies  very  much  in  its  virulence,  and  it  exists 
in  a  form  entirely  devoid  of  pathogenic  properties.  This  organism  should 
not,  however,  be  designated  pseudo-diphtheria  bacillus.  The  name  should 
be  confined  to  bacilli,  which,  though  resembling  the  diphtheria  bacillus, 
differ  from  it  not  only  by  absence  of  virulence,  but  also  by  cultural  pecul- 
iarities. A  similar  bacillus,  showing,  however,  certain  cultural  differ- 
ences from  the  pseudo-diphtheria  bacillus,  has  been  repeatedly  found  in 
the  conjunctival  sac  in  health  and  disease  {B.  xerosis).  Organisms  having 
the  morphology  of  the  diphtheria  bacillus,  but  devoid  of  virulence,  probably 
belonging  to  the  group  of  pseudo-diphtheria  and  xerosis  bacilli,  have  been 
described  in  human  beings  in  association  with  a  number  of  diseases,  such 
as  Egyptian  dysentery  (Kruse  and  Pasquale);  they  have  been  demonstrated 
upon  the  skin,  in  the  crusts  of  variola  pustules,  and  in  impetigo,  in  sputum, 
in  pneumonia  (Kruse,  Ohlmacher),  in  gangrene  of  the  lung  (Babes),  in 
ulcerative  endocarditis  (Howard),  in  ascitic  fluid  (Harris),  in  pus  from 
pyuria  (Bergly),  in  oza^ia  (Wilder),  and  in  tulicreulosis  (Schiiltz  and  Ehret). 
Both  the  pseudu-dipliUirria  mid  xerosis  1)acilli  show  occasional  branchings. 


142  SPECIFIC  IKFECTIOITS  DISEASES, 

Diphtheroid  Inflammations. — Under  the  term  diphtheroid  may 
be  grouped  those  membranous  inflammations  which  are  not  associated  with 
the  Klebs-LoeflQer  bacillus.  It  is  perhaps  a  more  suitable  designation  than 
pseudo-dij)htheria  or  secondary  diphtheria.  As  in  a  great  majority  of  cases 
the  streptococcus  pyogenes  is  the  active  organism,  the  term  "  streptococcus 
diphtheritis  "  is  often  employed.  The  name  "  diphtheritis  "  is  best  used  in 
an  anatomical  sense  to  designate  an  inflammation  of  a  mucous  membrane 
or  integumentary  surface  characterized  by  necrosis  and  a  fibrinous  exudate, 
whereas  the  term  "  diphtheria  "  should  be  limited  to  the  disease  caused  by 
the  Klebs-LoefQer  bacillus.  The  proportion  of  cases  of  diphtheroid  in- 
flammation varies  greatly  in  the  difllerent  statistics.  Of  the  large  number 
of  observations  made  by  Park  and  Beebe  (5,611)  in  New  York,  40  per  cent 
were  diphtheroid.  Figures  from  other  sources  do  not  show  so  high  a  per- 
centage. 

It  is  not  to  be  inferred  from  these  statistics  that  any  considerable  num- 
ber of  the  cases  which  present  the  appearances  of  typical  and  characteristic 
primary  diphtheria  are  due  to  other  micro-organisms  than  the  Klebs- 
Loeffler  bacillus.  Nearly  all  such  cases,  when  carefully  examined  by  a  com- 
petent bacteriologist,  are  found  to  be  due  to  the  diphtheria  bacillus.  It 
is  the  less  characteristic  cases,  with  more  or  less  suspicion  of  diphtheria, 
which  are  most  likely  to  be  caused  by  other  bacteria  than  the  Klebs- 
Loefller  bacillus.  It  is  also  to  be  remembered  that  in  the  routine  exam- 
ination of  a  large  number  of  cases  for  boards  of  health  and  diphtheria 
wards  of  hospitals,  some  cases  of  genuine  diphtheria  may  escape  recog- 
nition from  lack  of  such  repeated  and  thorough  bacteriological  tests  as  are 
sometimes  required  for  the  detection  of  cases  presenting  unusual  diffi- 
culties. 

Conditions  under  which  the  Diphtheroid  Affection  occurs. — Of  450  cases 
(Park  and  Beebe),  300  occurred  in  the  autumn  months  and  150  in  the 
spring;  198  occurred  in  children  from  the  first  to  the  seventh  year.  In  a 
large  proportion  of  all  the  cases  the  disease  develops  in  children,  and  can 
only  be  differentiated  from  diphtheria  proper  by  the  bacteriological  ex- 
amination. In  many  of  the  cases  it  is  simply  an  acute  catarrhal  angina 
with  lacunar  tonsillitis. 

The  diphtheroid  inflammations  are  particularly  prone  to  develop  in 
connection  with  the  acute  fevers. 

(a)  Scarlet  Fever. — In  a  large  proportion  of  the  cases  of  angina  in  scar- 
let fever  the  Klebs-Loeffler  bacillus  is  not  present.  Booker  has  reported 
11  cases  complicating  scarlet  fever,  in  all  of  Avhich  the  streptococci  were 
the  predominant  organisms.  Of  the  450  cases  of  Park  and  Beebe,  42  com- 
plicated scarlet  fever.  The  angina  of  this  disease  is  not  always,  however, 
due  to  the  streptococcus.  Where  diphtheria  is  prevalent  and  opportunities 
are  favorable  for  exposure,  a  large  proportion  of  the  cases  of  membranous 
throats  in  scarlet  fever  may  be  genuine  diphtheria,  as  is  shown  by  the  sta- 
tistics of  Williams  and  Morse  in  the  Boston  City  Hospital.  Here,  of  97 
cases  of  scarlet  fever,  membranous  angina  was  present  in  35;  in  12  with 
the  Klebs-Loeffler  bacillus,  and  in  23  with  other  organisms.  Morse  reports 
99  cases  of  angina  in  scarlet  fever  in  which  76  were  diphtheritic.     This 


DIPHTHERIA.  143 

large  proportion  of  cases  in  which  scarlet  fever  was  associated  with  true 
diphtheria  is  attributed  to  local  conditions  in  the  hospital. 

(b)  Measles. — Membranous  angina  is  much  less  common  in  this  disease. 
It  occurred  in  6  of  the  450  diphtheroid  cases  in  New  York.  Of  4  cases 
with  severe  membranous  angina  at  the  Boston  City  Hospital,  1  only  pre- 
sented the  Klebs-Loeffler  bacillus. 

(c)  Whooping-cough  may  also  be  complicated  with  membranous  angina. 
The  bacteriological  examinations  have  not  been  very  numerous.  Escherich 
gives  4  cases,  in  all  of  which  the  Klebs-Loeffler  bacillus  was  found. 

(d)  Typhoid  Fever. — Membranous  inflammations  in  this  disease  are  not 
very  infrequent;  they  may  occur  in  the  throat,  the  pelvis  of  the  kidney, 
the  bladder,  or  the  intestines.  The  complication  may  be  caused  by  the 
Klebs-Loeffler  bacillus,  which  was  present  in  4  cases  described  by  Morse. 
It  is  frequently,  however,  a  streptococcus  infection. 

Ernst  Wagner  has  remarked  upon  the  greater  frequency  of  these  mem- 
branous inflammations  in  typhoid  fever  when  diphtheria  is  prevailing. 

Clinical  Features  of  the  Diphtheroid  Affection. — The  cases,  as  a  rule, 
are  milder,  and  the  mortality  is  low,  only  2.5  per  cent  in  the  450  cases  of 
Park  and  Beebe.  The  diphtheroid  inflammations  complicating  the  specific 
fevers  are,  however,  often  very  fatal,  and  a  general  streptococcus  infection 
is  by  no  means  infrequent.  As  in  the  Klebs-Loeffler  angina,  there  may 
be  only  a  simple  catarrhal  process.  In  other  instances  the  tonsils  are  cov- 
ered with  a  creamy,  pultaceous  exudate,  without  any  actual  membrane. 
An  important  group  may  begin  as  a  simple  lacunar  tonsillitis,  while  in 
others  the  entire  fauces  and  tonsils  are  covered  by  a  continuous  membrane, 
and  there  is  a  foul  sloughing  angina  with  intense  constitutional  disturb- 
ance. 

Are  the  diphtheroid  cases  contagious?  General  clinical  experience  war- 
rants the  statement  that  the  membranous  angina  associated  with  the  fevers 
is  rarely  communicated  to  other  patients.  The  health  department  of  New 
York  does  not  keep  the  diphtheroid  cases  under  supervision.  Their  inves- 
tigation of  the  450  diphtheroid  cases  seems  to  justify  this  conclusion.  Park 
and  Beebe  say  that  "  it  did  not  seem  that  the  secondary  cases  were  any  less 
liable  to  occur  when  the  primary  case  was  isolated  than  when  it  was  not." 

Sequelce  of  the  Diphtheroid  Angina. — The  usual  mildness  of  the  disease 
is  in  part,  no  doubt,  due  to  the  less  frequent  systemic  invasion.  Some  of 
the  worst  forms  of  general  streptococcus  infection  are,  however,  seen  in 
this  disease.  There  are  no  peculiarities,  local  or  general,  which  can  be  in 
any  way  regarded  as  distinctive;  and  if  the  observation  of  Bourges  should 
be  corroborated,  even  the  most  extensive  paralysis  may  follow  an  angina 
caused  by  it. 

Morbid  Anatomy. — Distribution  of  Membrane. — A  definite  mem- 
brane was  found  in  127  of  the  220  fatal  Boston  cases,  distributed  as  follows: 
tonsils,  65  cases;  epiglottis,  60;  larynx,  75;  trachea,  66;  pharynx,  51;  mu- 
cous membrane  of  nares,  43;  bronchi,  42;  soft  palate,  including  uvula,  13; 
oesophagus,  12;  tongue,  9;  stomach,  5;  duodenum,  1;  vagina,  2;  vulva,  1; 
skin  of  ear,  1;  conjunctiva,  1.  An  interesting  point  in  the  Boston  in- 
vestigation was  the  great  frequency  with  which  the  accessory  sinuses 
of  the  nose  were  found  to  be  infected.     In  the  fatal  cases,  the  exuda- 


144  SPECIFIC  INFECTIOUS  DISEASES. 

tion  is  very  extensive,  involving  the  uvula,  tlie  soft  palate,  the  posterior 
nares,  and  the  lateral  and  posterior  walls  of  the  pharynx.  These  parts  are 
covered  with  a  dense  pseudo-membrane,  in  places  firmly  adherent,  in  others 
beginning  to  separate.  In  extreme  cases  the  necrosis  is  advanced  and 
there  is  a  gangrenous  condition  of  the  parts.  The  membrane  is  of  a  dirty 
greenish  or  gray  color,  and  the  tonsils  and  palate  may  be  in  a  state  of 
necrotic  sloughing.  The  erosion  may  be  deep  enough  in  the  tonsils  to 
open  the  carotid  artery,  or  a  false  aneurism  may  be  produced  in  the  deep 
tissues  of  the  neck.  The  nose  may  be  completely  blocked  by  the  false  mem- 
brane, which  may  also  extend  into  the  conjunctivse  and  through  the 
Eustachian  tubes  into  the  middle  ear.  In  cases  of  laryngeal  diphtheria 
the  exudate  in  the  pharynx  may  be  extensive.  In  many  cases,  however,  it 
is  slight  upon  the  tonsils  and  fauces  and  abundant  upon  the  epiglottis  and 
the  larynx,  which  may  be  completely  occluded  by  false  membrane.  In 
severe  cases  the  exudate  extends  into  the  trachea  and  to  the  bronchi  of 
the  third  or  fourth  dimension.  This  occurred  in  nearly  half  of  my  30 
Montreal  autopsies. 

In  all  these  situations  the  membrane  varies  very  much  in  consistence, 
depending  greatly  upon  the  stage  at  which  death  has  taken  place.  If  death 
has  occurred  early,  it  is  firm  and  closely  adherent;  if  late,  it  is  soft,  shreddy, 
and  readily  detached.  When  firmly  adherent  it  is  torn  off  with  difficulty 
and  leaves  an  abraded  mucosa.  In  the  most  extreme  cases,  in  which  there 
is  extensive  necrosis,  the  parts  look  gangrenous.  In  fatal  cases  the  lym- 
phatic glands  of  the  neck  are  enlarged,  and  there  is  a  general  infiltration 
of  the  tissues  with  serum;  the  salivary  glands,  too,  may  be  swollen.  In 
rare  instances  the  membrane  extends  to  the  gullet  and  stomach. 

On  inspection  of  the  larynx  of  a  child  dead  of  membranous  croup,  the 
rima  is  seen  filled  with  mucus  or  with  a  shreddy  material  which,  when 
washed  off  carefully,  leaves  the  mucosa  covered  by  a  thin  gra}dsh-yellow 
membrane,  which  may  be  uniform  or  in  patches.  It  covers  the  ary-epi- 
glottic  folds  and  the  true  cords,  and  may  be  continued  into  the  ventricles 
or  even  into  the  trachea.  Above,  it  may  involve  the  epiglottis.  It  varies 
much  in  consistency.  I  have  seen  fatal  cases  in  which  the  exudation  was 
not  actually  membranous,  but  rather  friable  and  granular.  It  may  form 
a  thick,  even  stratified  membrane,  which  fills  the  entire  glottis.  The  ex- 
udation may  extend  down  the  trachea  and  into  the  bronchi,  and  may  pass 
beyond  the  epiglottis  to  the  fauces.  Usually  it  is  readily  stripped  off  from 
the  mucous  membrane  of  the  larynx  and  leaves  exposed  the  swollen  and 
injected  mucosa.  On  examination  it  is  seen  that  the  fibrinous  material 
has  involved  chiefly  the  epithelial  lining  and  has  not  greatly  infiltrated  the 
subjacent  tissues. 

Histological  Changes. — We  owe  largely  to  the  labors  of  Wagner,  Wei- 
gert,  and  more  particularly  to  the  splendid  Avork  of  Oertel,  our  knowledge 
of  the  minute  changes  which  take  place  in  diphtheria.  The  following  is 
a  brief  abstract  of  the  recent  studies  of  Councilman,  Mallory,  and  Pearce : 

The  beginning  of  the  lesion  is  due  to  the  toxic  action  of  the  bacilli 
growing  in  the  throat.  The  primary  lesion  is  a  necrosis  and  degeneration 
of  the  ej)ithelial  tissues.     The  organisms  grow,  not  in  the  living,  but  in 


DIPHTHERIA.  145 

the  necrotic  tissues.  The  first  step  is  necrosis  of  the  epithelium,  often  pre- 
ceded by  active  proliferation  of  the  nuclei  of  the  cells,  which  become 
changed  into  refractive  hyaline  masses.  From  the  structures  below  an 
inflammatory  exudate  rich  in  fibrin  factors  is  poured  out,  and  fibrin  is 
formed  when  this  comes  in  contact  with  the  necrotic  epithelium.  "  The 
fibrin  in  part  is  formed  into  a  reticulum  around  exudation  cells  and 
degenerated  epithelium;  in  part  it  combines  with  the  hyaline  degen- 
erated cells  to  form  a  hyaline  membrane.  It  is  probable  that  a  hya- 
line membrane  may  be  formed  without  the  exudation;  in  this  case  the 
network  of  the  membrane  represents  the  edges  of  the  cells,  and  the 
spaces  the  former  nuclei.  The  hyaline  membrane  is  most  often  formed  on 
those  surfaces  which  are  covered  with  epithelium  having  several  layers  of 
cells.  ...  It  is  probable  that  the  fibrinous  membrane  is  formed  both  on 
the  surfaces  and  in  the  tissue.  The  fibrin  is  first  formed  around  cells  which 
afterward  disappear.  The  membrane  may  disintegrate  and  be  broken  up 
into  a  mass  of  detritus  (the  process  commences  on  the  surface),  or  it  may  be 
cast  off  as  a  whole  by  being  elevated  by  an  exudation  beneath.  Very  thick 
masses  of  membrane  may  be  formed  by  the  constant  addition  of  fibrinous 
exudation.  The  membrane  is  never  formed  primarily  on  an  intact  epi- 
thelial surface,  but  it  may  extend  over  it.  .  .  .  The  connective  tissue  and 
blood-vessels  undergo  a  hyaline  fibrinoid  degeneration  very  similar  to  the 
degeneration  of  the  epitheliiun.  Necrosis  may  extend  deeply  into  the 
tissue,  but  there  is  little  tendency  to  deep  ulceration  or  abscess  formation. 
The  degeneration  in  the  mucous  glands  of  the  tissue  is  so  pronounced  as  to 
be  almost  specific." 

The  following  are  the  important  changes  in  the  other  organs: 

Heart. — Fatty  degeneration  is  found  in  a  majority  of  the  cases.  It  may 
precede  the  more  advanced  degeneration,  in  which  the  sarcous  elements 
become  swollen  and  converted  into  hyaline  masses.  There  is  a  primary, 
acute,  interstitial  myositis,  and  also  a  form  secondary  to  degeneration  of  the 
heart  muscle,  to  which  it  is  possible  that  some  of  the  cases  of  fibrous  myo- 
carditis are  due.  Pericarditis  and  endocarditis  are  rare;  endocarditis  was 
present  in  7  of  220  cases  at  the  Boston  City  Hospital.  The  diphtheria 
bacilli  have  been  found  in  the  vegetations  by  W.  T.  Howard,  Jr.,  and  by 
J.  W.  Wright. 

The  pulmonary  complications  are  the  most  important,  and  death  is  due 
to  them  as  often  as  to  the  throat  lesion.  Broncho-pneumonia,  or,  as  Coun- 
cilman terms  it,  acinous  pneumonia,  is  the  most  common,  and  was  present 
in  131  of  the  220  Boston  cases.  Acute  lobar  pneumonia  is  rare.  The 
pneumococcus  is  the  principal  agent  in  producing  the  lung  infection.  The 
streptococci  and  the  diphtheria  bacilli  are  frequently  met  with. 

Kidneys. — The  lesions,  which  are  due  to  the  action  of  the  toxins,  not 
to  the  presence  of  bacteria,  vary  from  simple  degeneration  to  an  intense 
nephritis.  There  is  no  specific  type  of  lesion.  Interstitial  and  glomerular 
nephritis  are  most  common  in  the  older  subjects.  Degenerative  changes 
are  present  in  a  large  proportion  of  all  the  fatal  cases. 

The  liver  and  the  spleen  show  the  degenerative  lesions  of  the  acute 
infections. 

General  infection  is  common,  and  is  about  equal  with  the  strepto- 


146  SPECIFIC  INFECTIOUS  DISEASES. 

coccus  and  the  diphtheria  bacillus.  It  occurs  generally  in  the  grave  septic 
eases,  in  which  type  of  cases  the  former  organism  is  more  frequently  met 
with. 

Symptoms. — The  period  of  incubation  is  "from  two  to  seven  days, 
cftenest  two." 

The  initial  symptoms  are  those  of  an  ordinary  febrile  attack — slight 
chilliness,  fever,  and  aching  pains  in  the  back  and  limbs.  In  mild  cases 
these  symptoms  are  trifling,  and  the  child  may  not  feel  ill  enough  to  go 
to  bed.  Usually  the  temperature  rises  within  the  first  twenty-four  hours 
to  103.5°  or  103°;  in  severe  cases  to  104°.  In  young  children  there  may 
be  convulsions  at  the  outset. 

Pharyngeal  Diphtheria. — In  a  typical  case  there  is  at  first  redness  of 
the  fauces,  and  the  child  complains  of  slight  difficulty  in  swallowing. 
The  membrane  first  appears  upon  the  tonsils,  and  it  may  be  a  little  diffi- 
cult to  distinguish  a  patchy  diphtheritic  pellicle  from  the  exudate  of  the 
tonsillar  crypts.  The  pharyngeal  mucous  membrane  is  reddened,  and  the 
tonsils  themselves  are  swollen.  By  the  third  day  the  membrane  has  covered 
the  tonsils,  the  pillars  of  the  fauces,  and  perhaps  the  uvula,  which  is  thick- 
ened and  oedematous,  and  may  fill  completely  the  space  between  the  swollen 
tonsils.  The  membrane  may  extend  to  the  posterior  wall  of  the  pharynx. 
At  first  grayish-white  in  color,  it  changes  to  a  dirty  gray,  often  to  a  yellow- 
white.  It  is  firmly  adherent,  and  when  removed  leaves  a  bleeding,  slightly 
eroded  surface,  which  is  soon  covered  by  fresh  exudate.  The  glands  in 
the  neck  are  swollen,  and  may  be  tender.  The  general  condition  of  a 
patient  in  a  case  of  moderate  severity  is  usually  good;  the  temperature  not 
very  high,  in  the  absence  of  complications  ranging  from  102°  to  103°. 
The  pulse  range  is  from  100  to  120.  The  local  condition  of  the  throat 
is  not  of  great  severity,  and  the  constitutional  depression  is  slight.  The 
symptoms  gradually  abate,  the  swelling  of  the  neck  diminishes,  the  mem- 
branes separate,  and  from  the  seventh  to  the  tenth  day  the  throat  becomes 
clear  and  convalescence  sets  in. 

Clinically  atypical  forms  are  extremely  common,  and  I  follow  here 
Koplik's  division: 

(a)  There  may  be  no  local  manifestation  of  membrane,  but  a  simple 
catarrhal  angina  associated  sometimes  with  a  croupy  cough.  The  detec- 
tion in  these  cases  of  the  Klebs-Loeffler  bacillus  can  alone  determine  the 
diagnosis.  Such  cases  are  of  great  moment,  inasmuch  as  they  may  com- 
municate the  severer  disease  to  other  children. 

.  (b)  There  are  cases  in  which  the  tonsils  are  covered  by  a  pultaeeous 
exudate,  not  a  consistent  membrane. 

(c)  Cases  presenting  a  punctate  form  of  membrane,  isolated,  and  usually 
on  the  surface  of  the  tonsils. 

(d)  Cases  which  begin  and  often  run  their  entire  course  with  the  local 
picture  of  a  typical  lacunar  amygdalitis.  They  may  be  mild,  and  the  local 
exudate  may  not  extend,  but  in  other  cases  there  are  rapid  development 
of  membrane,  and  extension  of  the  disease  to  the  pharynx  and  the  nose, 
with  severe  septic  and  constitutional  symptoms. 


DIPHTHERIA.  147 

(e)  Under  the  term  "  latent  diphtheria  "  Heubner  has  described  cases, 
usnally  secondary,  occurring  chiefly  in  hospital  practice,  in  young  persons 
the  subject  of  wasting  affections,  such  as  rickets  and  tuberculosis.  There 
are  fever,  naso-pharyngeal  catarrh,  and  gastro-intestinal  disturbances. 
Diphtheria  may  not  be  suspected  until  severe  laryngeal  complications  de- 
velop, or  the  condition  may  not  be  determined  until  autopsy. 

Systemic  Infection. — The  constitutional  disturbance  in  mild  diphtheria 
is  very  slight.  There  are  instances,  too,  of  extensive  local  disease  without 
grave  systemic  symptoms.  As  a  rule,  the  general  features  of  a  case  bear 
a  definite  relation  to  the  severity  of  the  local  disease.  There  are  rare  in- 
stances in  which  from  the  outset  the  constitutional  prostration  is  extreme, 
the  pulse  frequent  and  small,  the  fever  high,  and  the  nervous  phenomena 
are  pronounced;  the  patient  may  sink  in  two  or  three  days  overwhelmed  by 
the  intensity  of  the  toxemia.  There  are  cases  of  this  sort  in  which  the 
exudate  in  the  throat  may  be  slight,  but  usually  the  nasal  symptoms  are 
pronounced.  The  temperature  may  be  very  slightly  raised  or  even  sub- 
normal. More  commonly  the  severe  systemic  symptoms  appear  at  a  later 
date  when  the  pharyngeal  lesion  is  at  its  height.  They  are  constantly  pres- 
ent in  extensive  disease,  and  when  there  is  a  sloughing,  foetid  condition. 
The  lymphatic  glands  become  greatly  enlarged;  the  pallor  is  extreme;  the 
face  has  an  ashen-gray  hue;  the  pulse  is  rapid  and  feeble,  and  the  tempera- 
ture sinks  below  normal.  In  the  most  aggravated  forms  there  are  gan- 
grenous processes  in  the  throat,  and  in  rare  instances,  when  life  is  pro- 
longed, extensive  sloughing  of  the  tissues  of  the  neck. 

Escherich  accounts  for  the  discrepancy  sometimes  observed  between 
the  severity  of  the  constitutional  disturbance  and  the  intensity  of  the  local 
process,  by'  assuming  varying  degrees  of  susceptibility  to  the  diphtheria 
bacillus  on  the  one  hand,  and  to  its  poison  on  the  other  hand.  With  high 
local  susceptibility  of  a  part  to  the  action  of  the  bacillus,  with  little  gen- 
eral susceptibility  to  the  toxine,  there  is  extensive  local  exudate  with  mild 
constitutional  symptoms,  or  vice  versa,  severe  systemic  disturbance  with 
limited  local  inflammation. 

A  leucocytosis  is  present  in  diphtheria.  Morse  does  not  think  it  of  any 
prognostic  value,  since  it  is  present  and  may  be  pronounced  in  mild  cases. 

Nasal  Diphtheria. — In  cases  of  pharyngeal  diphtheria  the  Klebs-Loef- 
fier  bacillus  is  found  on  the  mucous  membrane  of  the  nose  and  in  the  secre- 
tions, even  when  no  membrane  is  present,  but  it  may  apparently  produce 
two  affections  similar  enough  locally  but  widely  differing  in  their  general 
features. 

In  membranous  or  fibrinous  rhinitis,  a  very  remarkable  affection  seen 
usually  in  children,  the  nares  are  occupied  by  thick  membranes,  but  there 
is  an  entire  absence  of  any  constitutional  disturbance.  The  condition 
has  been  studied  very  carefully  by  Park,  Abbott,  Gerber  and  Podack,  and 
others.  Ravenel  has  collected  77  cases  (Medical  News,  1895,  I),  in  41  of 
which  a  bacteriological  examination  was  made,  in  33  the  Klebs-Loeflfler  ba- 
cillus being  present.  All  the  cases  ran  a  benign  course,  and  in  all  but  a 
few  the  membrane  was  limited  to  the  nose,  and  the  constitutional  symp- 
toms were  either  absent  or  very  slight.    Remarkable  and  puzzling  features 


148  SPECIFIC  INFECTIOUS  DISEASES. 

are  that  the  disease  runs  a  benign  course,  and  that  infection  of  other  chil- 
dren in  the  family  is  extremely  rare. 

On  the  other  hand,  nasal  diphtheria  is  apt  to  present  a  most  malignant 
type  of  the  disease.  The  infection  may  be  primary  in  the  nose,  and  in  a 
case  recently  in  my  wards  there  was  otitis  media,  and  the  Klebs-Loeffler 
bacillus  was  separated  from  the  discharge  before  the  condition  of  nasal 
diphtheria  was  suspected.  While  some  cases  are  of  mild  characl;er,  others 
are  very  intense,  and  the  constitutional  symptoms  most  profound.  The 
glandular  inflammation  is  usually  very  intense,  owing,  as  Jacobi  points  out, 
to  the  great  richness  of  the  nasal  mucosa  in  lymphatics.  From  the  nose 
the  inflammation  may  extend  through  the  tear-ducts  to  the  conjunctivae 
and  into  the  antra. 

Laryngeal  Diphtheria. — Memlranous  Croup. — With  a  very  large  pro- 
portion of  all  the  cases  of  membranous  laryngitis  the  Klebs-Loeffler  bacil- 
lus is  associated;  in  a  much  smaller  number  other  organisms,  particularly 
the  streptococcus,  are  found.  Membranous  croup,  then,  may  be  said  to  be 
either  genuine  diphtheria  or  diphtheroid  in  character.  Of  286  cases  in 
which  the  disease  was  confined  to  the  larynx  or  bronchi,  in  229  the  Klebs- 
Loeffler  bacilli  were  found.  In  57  they  were  not  present,  but  17  of  these 
cultures  were  unsatisfactory  (Park  and  Beebe).  The  streptococcus  cases 
are  more  likely  to  be  secondary  to  other  acute  diseases. 

Symptoms. — -Naturally,  the  clinical  symptoms  are  almost  identical  in 
the  non-specific  and  specific  forms  of  membranous  laryngitis. 

The  affection  begins  like  an  acute  laryngitis  with  slight  hoarseness  and 
rough  cough,  to  which  the  term  croupy  has  been  applied.  After  these 
symptoms  have  lasted  for  a  day  or  two  with  varying  intensity,  the  child 
suddenly  becomes  worse,  usually  at  night,  and  there  are  signs  "of  impeded 
respiration.  At  first  the  difficulty  in  breathing  is  paroxysmal,  due  prob- 
ably to  more  or  less  spasm  of  the  muscles  of  the  glottis.  Soon  the  dyspnoea 
becomes  continuous,  inspiration  and  expiration  become  difficult,  particu- 
larly the  latter,  and  with  the  inspiratory  movements  the  epigastrium  and 
lower  intercostal  spaces  are  retracted.  The  voice  is  husky  and  may  be  re- 
duced to  a  whisper.  The  color  gradually  changes  and  the  imperfect  aera- 
tion of  the  blood  is  shown  in  the  lividity  of  the  lips  and  finger-tips.  Eest- 
lessness  comes  on  and  the  child  tosses  from  side  to  side,  vainly  trying  to 
get  breath.  Occasionally,  in  a  severer  paroxysm,  portions  of  membrane  are 
coughed  out.  The  fever  in  membranous  laryngitis  is  rarely  very  high  and 
the  condition  of  the  child  is  usually  very  good  at  the  time  of  the  onset. 
The  pulse  is  always  increased  in  frequency  and  if  cyanosis  be  present  is 
small.  In  favorable  cases  the  dyspnoea  is  not  very  urgent,  the  color  of  the 
face  remains  good,  and  after  one  or  two  paroxysms  the  child  goes  to  sleep 
and  wakes  in  the  morning,  perhaps  without  fever  and  feeling  comfortable. 
The  attack  may  recur  the  following  night  with  greater  severity.  In  un- 
favorable cases  the  dyspnoea  becomes  more  and  more  urgent,  the  cyanosis 
deepens,  the  child,  after  a  period  of  intense  restlessness,  sinks  into  a  semi- 
comatose state,  and  death  finally  occurs  from  poisoning  of  the  nerve  cen- 
tres by  carbon  dioxide.  In  other  cases  the  onset  is  less  sudden  and  is  pre- 
ceded by  a  longer  period  of  indisposition.    As  a  rule,  there  are  pharyngeal 


DIPHTHERIA.  149 

s\Tiiptoins.  The  constitutional  disturbance  may  be  more  severe,  tlie  fever 
higher,  and  there  may  be  swelling  of  the  glands  of  the  neck.  Inspection 
of  the  fauces  may  show  the  i^resence  of  false  membranes  on  the  pillars  or 
on  the  tonsils.  Bacteriological  examination  can  alone  determine  whether 
these  are  due  to  the  Klebs-Loeflfler  bacillus  or  to  the  streptococcus.  Fagge 
held  that  non-contagious  membranous  croup  may  spread  upward  from  the 
larynx  Just  as  diphtheritic  inflammation  is  in  the  habit  of  spreading  down- 
ward from  the  fauces.  Ware,  of  Boston,  whose  essay  on  croup  is  perhaps 
the  most  solid  contribution  to  the  subject  made  in  this  country,  reported 
the  presence  of  exudate  in  the  fauces  in  74  out  of  75  cases  of  croup.  These 
observations  were  made  prior  to  1840,  during  periods  in  which  diphtheria 
was  not  epidemic  to  any  extent  in  Boston.  In  protracted  cases  pulmonary 
symptoms  may  develop,  which  are  sometimes  due  to  the  difficulty  in  expel- 
ling the  muco-pus  from  the  tubes;  in  others,  the  false  membrane  extends 
into  the  trachea  and  even  into  the  bronchial  tubes.  During  the  paroxysm 
the  vesicular  murmur  is  scarcely  audible,  but  the  larj^ngeal  stridor  may  be 
loudly  communicated  along  the  bronchial  tubes. 

DipMlieria  of  Other  Parts. — Primary  diphtheria  occurs  occasionally 
in  the  conjunctiva.  It  follows  in  some  instances  the  affection  of  the  nasal 
mucous  membrane.  Some  of  the  cases  are  severe  and  serious,  but  it  has 
been  shown  by  C.  Frankel  and  others  that  the  diphtheria  bacilli  may  be 
present  in  a  conjunctivitis  catarrhal  in  character,  or  associated  with  only 
slight  croupous  deposits. 

Diphtheria  of  the  external  auditory  meatus  is  seen  in  rare  instances  in 
A\-hicli  there  are  diphtheritic  otitis  media  and  extension  through  the  tym- 
panic membrane. 

Diphtheria  of  the  shin  is  most  frequently  seen  in  the  severer  forms  of 
pharyngeal  diphtheria,  in  which  the  membrane  extends  to  the  mouth  and 
lips,  and  invades  the  adjacent  portions  of  the  skin  of  the  face.  The  skin 
about  the  anus  and  genitals  may  also  be  attacked.  Pseudo-membranous 
inflammation  is  not  uncommon  on  ulcerated  surfaces  and  wounds.  In 
very  many  of  these  cases  it  is  a  streptococcus  infection,  but  in  a  majority, 
perhaps,  in  which  the  patient  is  suffering  with  diphtheria,  the  Klebs-Loef- 
fler  bacillus  will  be  found  in  the  fibrinous  exudate.  As  proposed  by  Welch, 
the  term  "  wound  diphtheria  "  should  be  limited  to  infection  of  a  wound 
by  the  Klebs-Loeflfler  bacillus.  This  "  may  manifest  itself  as  a  simple 
inflammation,  or  inflammation  with  superficial  necrosis,  or  inflammation 
with  more  or  less  adherent  pseudo-membrane.  The  conditions  as  regards 
varying  intensity  and  character  of  the  infection,  association  with  other 
bacteria,  particularly  streptococci,  and  the  necessity  of  a  bacteriological 
examination  to  establish  the  diagnosis,  are  in  no  way  different  in  the  diph- 
theria of  wounds  from  those  in  diphtheria  of  mucous  membranes.  Wound 
diphtheria  may  occur  without  demonstrable  connection  with  cases  of  diph- 
theria and  without  affection  of  the  throat  in  the  individual  attacked,  but 
such  occurrences  are  rare"  (Welch).  Paralysis  may  follow  wound  diph- 
theria. Pseudo-membranous  inflammations  of  wounds  are  caused  more  fre- 
quently 1)y  other  micro-organisms,  particularly  the  streptococcus  pyogenes, 
than  by  the  Klebs-Loefller  bacillus,    The  fibrinous  membrane  so  common 


150  SPECIFIC  INFECTIOUS  DISEASES. 

in  the  neighborhood  of  the  tracheotomy  wound  in  diphtheria  is  rarely 
associated  with  the  Klebs-Loeffler  bacillus.  Diphtheria  of  the  genitals  is 
occasionally  seen. 

Coinplications  and  Sequelae. — Of  local  complications,  haemor- 
rhage from  the  nose  or  throat  may  occur  in  the  severe  ulcerative  cases. 
Skin  rashes  are  not  infrequent,  particukrly  the  diffuse  erythema.  Occa- 
sionally there  is  urticaria  and  in  the  severe  cases  purpura.  Fatal  cases 
almost  invariably  show  capillary  bronchitis  with  broncho-pneumonia  and 
large  patches  of  collapse,  or  the  septic  particles  may  reach  the  bronchi  and 
3xcite  gangrenous  processes  which  may  lead  to  severe  and  fatal  hsemor- 
rhage.  Jaundice,  usually  a  feature  of  the  toxaemia,  may  be  catarrhal,  and 
not  of  serious  import. 

Eenal  complications  are  common.  Albuminuria  is  present  in  all  severe 
cases.  It  is  only  when  the  albumin  is  in  considerable  quantity  and  asso- 
ciated with  epithelial  or  blood  casts  that  the  condition  indicates  parenchym- 
atous nephritis  and  is  alarming.  The  nephritis  may  appear  quite  early  in 
the  disease.  It  sets  in  occasionally  with  complete  suppression  of  the  urine. 
In  comparison  with  scarlet  fever  the  renal  changes  lead  less  frequently  to 
general  dropsy.  In  rare  instances  there  may  be  coma,  and  even  convulsions, 
without  albumin  in  the  urine,  and  without  dropsy.  Mention  has  already 
been  made  of  the  frequency  and  gravity  of  septicasmia  and  local  infec- 
tion of  internal  parts  due  to  invasion  of  the  streptococcus  pyogenes, 
which  is  a  very  constant  attendant  of  the  Klebs-Loeffler  bacillus  in  the 
human  body. 

Of  the  sequelae  of  diphtheria,  paralysis  is  by  far  the  most  important. 
This  can  be  experimentally  produced  in  animals  by  the  inoculation  of  the 
toxins.  The  paralysis  occurs  in  a  variable  proportion  of  the  cases,  ranging 
from  10  to  15  and  even  to  20  per  cent.  It  is  strictly  a  sequel  of  the  dis- 
ease, coming  on  usually  in  the  second  or  third  week  of  convalescence. 
Occasionally  it  occurs  as  early  as  the  seventh  or  eighth  day  of  the  disease. 
It  may  follow  very  mild  cases;  indeed,  the  local  lesion  may  be  so  trifling 
that  the  onset  of  the  paralysis  alone  calls  attention  to  the  true  nature  of 
the  trouble.    It  is  proportionately  less  frequent  in  children  than  in  adults. 

The  disease  is  a  toxic  neuritis,  due  to  the  absorption  of  the  poison. 
In  494  cases  collected  by  Woodhead,  the  palate  was  involved  in  155,  the 
ocular  muscles  in  197,  in  10  other  muscles.  Mnety-one  of  the  patients 
died. 

Of  the  local  paralyses  the  most  common  is  that  which  affects  the  pal- 
ate. This  gives  a  nasal  character  to  the  voice,  and,  owing  to  a  return  of 
liquids  through  the  nose,  causes  a  difficulty  in  swallowing.  These  may  be 
the  only  symptoms.  The  palate  is  seen  to  be  relaxed  and  motionless,  and 
the  sensation  in  it  is  also  much  impaired.  The  affection  may  extend  to 
the  constrictors  of  the  pharynx,  and  deglutition  become  embarrassed. 
Within  two  or  three  weeks  or  even  a  shorter  time  the  paralysis  disappears. 
In  many  cases  the  affection  of  the  palate  is  only  part  of  a  general  neuritis.- 
Of  other  local  forms  perhaps  the  most  common  are  paralysis  of  the  eye- 
muscles,  intrinsic  and  extrinsic.  There  may  be  strabismus,  ptosis,  and  loss 
of  power  of  accommodation.    Facial  paralysis  may  develop,  and  in  one 


DIPHTHERIA.  151 

case,  two  and  a  half  years  later,  it  still  persisted  with  contractures.  The 
neuritis  may  be  confined  to  the  nerves  of  one  limb,  though  more  commonly 
the  legs  or  the  arms  are  affected  together.  Very  often  with  the  palatal  pa- 
ralysis is  associated  a  weakness  of  the  legs  without  definite  palsy  but  with 
loss  of  the  knee-jerk. 

The  multiple  form  of  diphtheritic  neuritis  is  not  uncommon.  It  may 
begin  with  the  palatal  affection,  or  with  loss  of  power  of  accommodation 
and  loss  of  the  tendon  reflexes.  This  last  is  an  important  sign,  which,  as 
Bernhardt,  Buzzard,  and  E.  L.  MacDonnell  have  shown,  may  occur  early, 
but  is  not  necessarily  followed  by  other  symptoms  of  neuritis.  There  is 
paraplegia,  which  may  be  complete  or  involve  only  the  extensors  of  the 
feet.  The  paralysis  may  extend  and  involve  the  arms  and  face  and  render 
the  patient  entirely  helpless.  The  muscles  of  respiration  may  be  spared. 
The  chief  danger  in  these  severer  forms  comes  from  the  involvement  of 
the  heart  and  of  the  muscles  of  respiration;  but  the  outlook  is  in  many 
cases  not  so  bad  as  the  patient's  condition  would  indicate.  Of  13  cases  col- 
lected by  Cadet  de  Gassicourt  6  died.  The  sphincters  may  be  involved, 
though  they  are  often  spared. 

Heart. — According  to  the  studies  of  J.  J.  Thomas  and  Hibbard  (Bos- 
ton City  Hospital),  about  one  death  in  five  in  diphtheria  is  due  to  heart 
failure.  It  is  most  frequent  during  the  second  week  of  the  disease.  A 
slow  pulse  is  a  more  common  indication  of  a  serious  condition  than  a 
rapid  one.  Perhaps  after  an  exaggeration  of  symptoms  the  child  presents 
an  unusual  pallor;  the  pulse  may  become  weak  and  rapid,  but  more  often 
falls  to  fifty,  forty,  or  even  lower.  The  extremities  are  cold,  the  tempera- 
ture sinks,  and  death  takes  place,  with  all  the  features  of  collapse,  within  a 
few  hours.  More  frequently  the  fatal  collapse  comes  during  convalescence, 
even  as  late  as  the  sixth  or  seventh  week  after  apparent  recovery.  The 
attack  may  set  in  abruptly,  perhaps  following  a  sudden  exertion.  More 
commonly  there  have  been  symptoms  pointing  to  disturbed  cardiac  rhythm, 
or  even  fainting-spells.  In  some  instances  vomiting  has  preceded  the 
serious  cardiac  attack.  There  may  be  no  physical  signs  other  than  slight 
increase  in  the  cardiac  dulness  and  a  gallop-rhythm  or  embryocardia  indi- 
cating dilatation.  These  symptoms  were  formerly  ascribed  to  cardiac 
thrombosis  or  to  endocarditis.  Possibly  in  some  of  the  cases  the  result  is 
due,  as  pointed  out  by  Hosier  and  Leyden,  to  an  infectious  myocarditis,  but 
in  a  majority  of  the  cases  the  symptoms  are  probably  due  to  a  neuritis  of 
the  cardiac  nerves. 

Diagnosis. — The  presence  of  the  Klebs-Loeffler  bacillus  is  regarded 
by  bacteriologists  as  the  sole  criterion  of  true  diphtheria,  and  as  this  organ- 
ism may  be  associated  with  all  grades  of  throat  affections,  from  a  simple 
catarrh  to  a  sloughing,  gangrenous  process,  it  is  evident  that  in  many 
instances  there  will  be  a  striking  discrepancy  between  the  clinical  and  the 
bacteriological  diagnosis.  One  inestimable  value  of  the  recent  studies  has 
been  the  determination  of  the  diphtheritic  character  of  many  of  the  milder 
forms  of  tonsillitis  and  pharyngitis. 

The  bacteriological  diagnosis  is  simple.  The  plan  adopted  by  the 
New  York  Health  Department  is  a  model  which  may  be  followed  with 


152  SPECIFIC  INFECTIOUS  DISEASES. 

advantage  in  other  cities.  Outfits  for  making  cultures,  consisting  of  a 
box  containing  a  tube  of  blood-serum  and  a  sterilized  swab  in  a  test-tube, 
are  distributed  to  about  forty  stations  >at  conyenient  points  in  the  city. 
A  list  of  these  places  is  published,  and  a  physician  can  obtain  the  outfit 
free  of  cost.  The  directions  are  as  follows :  "  The  patient  should  be  placed 
in  a  good  light,  and,  if  a  child,  properly  held.  In  cases  where  it  is  possible 
to  get  a  good  view  of  the  throat,  dejDress  i\iQ  tongue  and  rub  the  cotton 
swab  gently  but  freely  against  any  visible  exudate.  In  other  cases,  includ- 
ing those  in  which  the  exudate  is  confined  to  the  larynx,  avoiding  the 
tongue,  pass  the  swab  far  back  and  rub  it  freely  against  the  mucous  mem- 
brane of  the  pharynx  and  tonsils.  Without  laying  the  swab  down,  with- 
draw the  cotton  plug  from  the  culture-tube,  insert  the  swab,  and  rub  that 
portion  of  it  which  has  touched  the  exudate  gently  but  thoroughly  all  over 
the  surface  of  the  blood-serum.  Do  not  push  the  swab  into  the  blood- 
serum,  nor  break  the  surface  in  any  way.  Then  replace  the  swab  in  its  own 
tube,  plug  both  tubes,  put  them  in  the  box,  and  return  the  culture  outfit 
at  once  to  the  station  from  which  it  was  obtained.'^  The  culture-tubes 
which  have  been  inoculated  are  kept  in  an  incubator  at  3?°  C.  for  twelve 
hours  and  are  then  ready  for  examination.  Some  prefer  a  method  by  which 
the  material  from  the  throat  collected  on  a  sterile  swab,  or,  as  recom- 
mended by  von  Esmarch,  on  small  pieces  of  sterilized  sponge,  is  sent  to 
the  laboratory  where  the  cultures  and  microscopical  examination  are  made 
by  a  bacteriologist. 

An  immediate  diagnosis  without  the  use  of  cultures  is  often  possible 
by  making  a  smear  preparation  of  the  exudate  from  the  throat.  The  Klebs- 
Loeffler  bacilli  may  be  present  in  sufficient  numbers,  and  may  be  quite 
characteristic  to  an  expert.  In  this  connection  may  be  given  the  following 
statement  by  Park,  who  has  had  such  an  exceptional  experience:  "  The  ex- 
amination by  a  competent  bacteriologist  of  the  bacterial  growth  in  a  blood- 
serum  tube  which  has  been  properly  inoculated  and  kept  for  fourteen  hours 
at  the  body  temperature  can  be  thoroughly  relied  upon  in  cases  where  there 
is  visible  membrane  in  the  throat,  if  the  culture  is  made  during  the  period 
in  which  the  membrane  is  forming,  and  no  antiseptic,  especially  no  mer- 
curial solution,  has  lately  been  applied.  In  cases  in  which  the  disease  is 
confined  to  the  larynx  or  bronchi,  surprisingly  accurate  results  can  be 
obtained  from  cultures,  but  in  a  certain  proportion  of  cases  no  diphtheria 
bacilli  will  be  found  in  the  first  culture,  and  yet  will  be  abundantly  present 
in  later  cultures.  We  believe,  therefore,  that  absolute  reliance  for  a  diag- 
nosis cannot  be  placed  upon  a  single  culture  from  the  pharynx  in  purely 
laryngeal  cases." 

TT/iere  a  lacteriological  examination  cannot  he  made,  the  practitioner  must 
regard  as  suspicious  all  forms  of  throat  affections  in  children,  and  carry  out 
measures  of  isolation  and  disinfection.  In  this  way  alone  can  serious  errors 
be  avoided.  It  is  not,  of  course,  in  the  severer  forms  of  membranous  an- 
gina that  mistake  is  likely  to  occur,  but  in  the  various  lighter  forms,  many 
of  which  are  in  reality  due  to  the  Klebs-Loeffler  bacillus. 

A  large  proportion  of  the  cases  of  diphtheroid  inflammation  of  the 
throat  are  due  to  the  streptococcus  pyogenes.     They  are  usually  milder, 


DIPHTHERIA.  153 

and  the  liability  to  general  infection  is  less  intense;  still,  in  scarlet  fever 
and  other  specific  fevers  some  of  the  most  virulent  cases  of  throat  disease 
which  we  see,  with  intense  systemic  infection,  are  caused  by  this  micro- 
organism. These  streptococcus  cases  are  probably  much  less  numerous 
than  the  figures  which  I  have  given  would  indicate.  The  more  careful  ex- 
aminations in  the  diphtheria  pavilions  of  hospitals,  particularly  in  Eu- 
rope, have  shown  that  in  the  large  majority  of  cases  admitted  the  Klebs- 
Loeffier  bacillus  is  present.  I  have  already  referred,  under  the  section  on 
scarlet  fever,  to  the  question  of  the  diagnosis  between  scarlet  fever  with 
severe  angina  and  diphtheria. 

Prognosis. — In  hospital  practice  the  mortality  was  formerly  from 
30  to  50  per  cent.  In  the  Boston"  City  Hospital  with  the  antitoxin 
treatment  the  death-rate  has  fallen  from  46  to  12  per  cent.  In  country 
places  the  disease  may  display  an  appalling  virulence.  In  cases  of  ordi- 
nary severity  the  outlook  is  usually  good.  Death  results  from  involvement 
of  the  larynx,  septic  infection,  sudden  heart-failure,  diphtheritic  paralysis, 
occasionally  from  urasmia,  and  sometimes  from  broncho-pneumonia  devel- 
oping during  convalescence. 

Prophylaxis. — Isolation  of  the  sick,  disinfection  of  the  clothing 
and  of  everything  that  has  come  in  contact  with  the  patient,  careful 
scrutiny  of  the  milder  cases  of  throat  disorder,  and  more  stringent  surveil- 
lance in  the  period  of  convalescence  are  the  essential  measures  to  prevent 
the  spread  of  the  disease.  Suspected  cases  in  families  or  schools  should  be 
at  once  isolated  or  removed  to  a  hospital  for  infectious  disorders.  "Wlien  a 
death  has  occurred  from  diphtheria,  the  body  should  be  wrapped  in  a  sheet 
which  has  been  soaked  in  a  corrosive-sublimate  solution  (1  to  3,000),  and 
placed  in  a  closely  sealed  coffin.    The  funeral  should  always  be  private. 

In  cases  of  well-marked  diphtheria  these  precautions  are  usually  car- 
ried out,  but  the  chief  danger  is  from  the  milder  eases,  particularly  the 
ambulatory  form,  in  which  the  disease  has  perhaps  not  been  suspected. 
But  from  such  patients  mingling  with  susceptible  children  the  disease  is 
often  conveyed.  The  healthy  children  in  a  family  in  which  diphtheria 
exists  may  carry  the  disease  to  their  school-fellows.  The  question  of  the 
influence  of  isolation  hospitals  on  the  spread  of  the  disease  has,  I  think, 
been  solved  in  Boston,  a  city  which  has  suffered  terribly  from  diphtheria. 
The  ratio  of  mortality  per  10,000  living  in  1893  was  11+,  and  in  1894  it 
was  19-|-.  In  1895  the  infectious  pavilion  was  opened.  Prior  to  that  year 
only  about  10  per  cent  of  the  reported  cases  were  treated  in  hospital;  in 
succeeding  years  50  per  cent  were  treated  in  hospital.  In  1898  the  mor- 
tality per  10,000  had  fallen  to  3,  and  in  1899  it  was  4.9. 

A  very  important  matter  in  the  prophylaxis  relates  to  the  period  of 
convalescence.  It  has  been  .shown  by  numerous  observations  that,  after  all 
the  membrane  has  cleared  away,  virulent  bacilli  may  persist  in  the  throat 
from  periods  ranging  from  six  weeks  to  six  months,  or  even  longer.  There 
is  evidence  to  show  that  the  disease  may  be  communicated  by  such  patients, 
so  that  isolation  should  be  continued  in  any  given  case  until  the  bacteri- 
ological examination  shows  tbat  the  throat  is  free. 

It  can  not  be  too  strongly  emphasized  that  the  important  elements  in 


154  SPECIFIC  INFECTIOUS  DISEASES. 

the  prophylaxis  of  diphtheria  are  the  rigid  scrutiny  of  the  milder  types  of 
throat  affection,  and  the  thorough  isolation  and  disinfection  of  the  indi- 
vidual patients. 

Careful  attention  should  be  given  to  the  throats  and  mouths  of  chil- 
dren, particularly  to  the  teeth  and  tonsils,  as  Caille  has  urged.  Swollen 
and  enlarged  tonsils  should  be  removed.  In  persons  exposed,  the  anti- 
septic mouth  washes,  such  as  corrosive  sublimate  (1  to  10,000),  chlorine 
water  (1  to  1,100),  or  swabbing  the  throat  with  a  diluted  Loeffler's  solu- 
tion, should  be  employed. 

Treatment. — The  important  points  are  hygienic  measures  to  pre- 
vent the  spread  of  the  malady,  local  treatment  of  the  throat  to  destroy 
the  bacilli,  medication,  general  or  specific,  to  counteract  the  effects  of  the 
toxines,  and,  lastly,  to  meet  the  complications  and  sequelae.    . 

(a)  Hygienic  Measures. — The  patient  should  be  in  a  room  from  which 
the  carpets,  curtains,  and  superfluous  furniture  have  been  removed.  The 
temperature  should  be  about  68°,  and  thorough  ventilation  should  be 
secured.  The  air  may  be  kept  moist  by  a  kettle  or  a  steam-atomizer.  If 
possible,  only  the  nurse,  the  child's  mother,  and  the  doctor  should  come 
in  contact  with  the  patient.  During  the  visit  the  physician  should  wear 
a  linen  overall,  and  on  leaving  the  room  he  should  thoroughly  wash  his 
hands  and  face  in  a  corrosive-sublimate  solution.  The  strictest  quarantine 
should  be  employed  against  other  members  in  the  house. 

(b)  Local  Treatment. — In  mild  cases  the  throat  symptoms  are  alone 
prominent.  Vigorous  local  treatment  from  the  outset  should  be  carried 
out,  taking  especial  care  in  all  instances  to  avoid  mechanical  injury  to 
the  tissues.  A  very  large  number  of  solutions  have  been  recommended. 
They  are  best  employed  with  a  swab  of  cotton-wool  or  a  soft  sponge,  or 
irrigation  with  hot  antiseptic  solutions  may  be  used.  The  direct  applica- 
tion with  a  swab  of  cotton-wool  or  sponge  is,  as  a  rule,  effective.  In  many 
young  children  it  is  really  a  most  trying  procedure  to  carry  out  the  treat- 
ment, and  sometimes  one  is  compelled  to  desist.  The  nurse  should  hold 
the  child  on  her  knees,  well  wrapped  in  a  shawl,  with  its  head  resting  on 
her  shoulder.  The  nose  is  then  held,  and  so  soon  as  the  child  opens  its 
mouth  a  cork  should  be  placed  between  the  molar  teeth.  The  local  appli- 
cation can  then  be  made,  or  thorough  irrigation  carried  out.  In  infants 
the  disinfecting  fluids  are  sometimes  better  applied  through  the  nostrils. 
The  following  solutions  may  be  employed: 

Loeffler's  solution:  Menthol,  10  grammes  dissolved  in  toluol  to  36  cc. 
Liq.  Ferri  sesquichlorati,  4  cc;  alcohol  absol.,  60  cc. 

Corrosive  sublimate,  1  to  1,000,  either  alone  or  with  tartaric  acid,  5 
grammes  to  the  litre. 

Carbolic  acid,  3  per  cent  in  30  per  cent  alcohol  solution,  is  much  em- 
ployed; some  prefer  to  touch  the  small  spots  of  exudate  with  pure  carbolic 
acid. 

Another  solution  is:  The  tincture  of  the  perchloride  of  iron,  a  drachm 
and  a  half,  in  glycerine,  one  ounce,  water,  one  ounce,  with  from  15  to  20 
minims  of  carbolic  acid.  Chlorine  water,  boric  acid,  peroxide  of  hydrogen, 
iodoform,  lactic  acid,  trypsin,  and  papain  are  also  recommended. 


DIPHTHERIA.  155 

Loeffler's  solution,  which  has  been  given  a  very  thorough  trial,  is  per- 
haps the  most  satisfactory. 

Nasal  diphtheria  requires  prompt  and  thorough  disinfection  of  the 
passages.  Jacobi  recommends  chloride  of  sodium,  saturated  boric  acid, 
or  1  part  of  bichloride  of  mercury,  35  of  chloride  of  sodium,  and  1,000 
of  water,  or  the  1-per-cent  solution  of  carbolic  acid.  Loeffler^s  solution 
may  be  diluted  and  applied  with  a  syringe  or  a  spray.  To  be  effectual 
the  injection  must  be  properly  given.  The  nurse  should  be  instructed  to 
pass  the  nozzle  of  the  syringe  horizontally,  not  vertically;  otherwise  the 
fluid  will  return  through  the  same  nostril. 

When  the  larynx  becomes  involved,  a  steam  tent  may  be  arranged 
upon  the  bed,  so  that  the  child  may  breathe  an  atmosphere  saturated 
Avith  moisture.  If  the  dyspnoea  becomes  urgent,  an  emetic  of  sulphate  of 
zinc  or  ipecacuanha  may  be  given.  When  the  signs  of  obstruction  are 
marked  there  should  be  no  delay  in  the  performance  of  intubation  or 
tracheotomy. 

Hot  applications  to  the  neck  are  usually  very  grateful,  particularly  to 
young  children,  though  in  the  case  of  older  children  and  adults  the  ice 
poultices  are  to  be  preferred. 

(c)  General  Measures. — The  food  should  be  liquid — milk,  beef  juices, 
barley  water,  albumen  water,  and  soups.  The  child  should  be  encouraged 
to  drink  water  freely.  When  the  pharyngeal  involvement  is  very  great 
and  swallowing  painful,  nutritive  enemata  should  be  used.  In  cases  with 
severe  constitutional  symptoms  stimulants  should  be  given  early. 

Medicines  given  internally  are  of  very  little  avail  in  the  disease.  There 
is  still  a  widespread  belief  in  the  profession  that  forms  of  mercury  are  bene- 
ficial. The  tincture  of  the  perchloride  of  iron  is  also  very  warmly  recom- 
mended. We  are  still,  however,  without  drugs  which  can  directly  coun- 
teract the  tox-albumins  of  this  disease,  and  we  must  rely  on  general 
measures  of  feeding  and  stimulants  to  support  the  strength. 

The  convalescence  of  the  disease  is  not  without  its  dangers,  and  patients 
should  be  very  carefully  watched,  particularly  if  there  are  signs  of  heart 
weakness. 

The  diphtheritic  paralysis  requires  rest  in  bed,  and  in  those  eases  in 
which  the  heart  rhythm  is  disturbed  the  avoidance  of  sudden  exertion. 
In  the  chronic  forms  with  wasting,  massage,  electricity,  and  strychnine 
are  invaluable  aids.  If  swallowing  becomes  very  difficult,  the  patient  must 
be  fed  with  the  stomach-tube,  which  is  very  much  preferable  to  feeding 
per  rectum. 

(d)  Antitoxin  Treatment. — As  the  years  go  on  additional  experi- 
ence has  shown  that,  thoroughly  carried  out,  this  method  of  treatment  is 
both  safe  and  efficacious.  There  are  no  reasonable  grounds  for  skepticism 
on  the  part  of  intelligent  practitioners,  and  still  less  on  the  part  of  those 
in  charge  of  the  hospitals  for  infectious  diseases.  In  this  country,  those  in 
charge  of  institutions  who  still  have  any  lingering  doubts  should,  in  the 
interests  of  their  little  patients,  and  in  a  spirit  of  humility,  visit  the  South 
Department  of  the  Boston  City  Hospital,  and  learn  a  few  salutary  lessons 
from  its  director,  Dr.  McCollom. 

10 


156  SPECIFIC  INFECTIOUS  DISEASES. 

The  principle  of  action  depends  on  the  circumstance  that  the  blood- 
serum  of  an  animal  rendered  immune,  when  introduced  into  another  ani- 
mal, protects  it  from  infection  with  the  diphtheria  bacilli,  and  has  also  an 
important  curative  influence  upon  diphtheria,  whether  artificially  given  to 
animals,  or  spontaneously  acquired  by  man.  In  the  preparation  of  the 
blood-serum  a  uniform  standard  strength  is  procured.  The  antitoxin  unit 
is  the  amount  of  antitoxin  which,  injected  into  a  guinea-pig  of  250  grammes 
in  weight,  neutralizes  100  times  the  minimum  fatal  dose  of  toxin  of  stand- 
ard strength. 

Dosage. — This  is  one  of  the  most  important  questions  relating  to  the 
use  of  the  antitoxin.  J.  H.  McCollom,  of  the  Boston  City  Hospital,  who 
has  probably  had  a  richer  experience  with  the  disease  than  any  man  in  this 
country,  insists  that  the  guiding  practice  in  the  use  of  the  antitoxin  is  to 
give  it  until  the  characteristic  effects  are  produced,  whether  4,000  or  70,000 
units  be  required  for  this  result.  He  very  rightly  remarks  that  in  the  case 
of  a  patient  ill  with  diphtheria  there  is  no  way  of  estimating  the  quantity 
of  toxin  generated  by  the  membrane,  and  therefore  one  must  administer  the 
agent  until  the  characteristic  effect  is  produced — viz.,  the  shriveling  of  the 
membrane,  the  diminution  of  the  nasal  discharge,  the  correction  of  the 
fetid  odor,  and  a  general  improvement  in  the  condition  of  the  patient.  No 
case,  he  says,  in  the  acute  stage  should  be  considered  hopeless.  "Wlien 
one  sees  a  patient  with  membrane  covering  the  tonsils  and  uvula,  profuse 
sanious  discharge  from  the  nose,  spots  of  ecchymosis  on  the  body  and  ex- 
tremities, cold,  clammy  hands  and  feet,  a  feeble  pulse,  and  the  nauseous 
odor  of  diphtheria,  and  finds  that  after  the  administration  of  10,000  units  of 
antitoxin  in  two  doses  the  condition  of  the  patient  improves  slightly;  that 
after  10,000  units  more  have  been  given  there  is  a  marked  abatement  in  the 
severity  of  the  symptoms;  that  when  an  additional  10,000  units  have  been 
given  the  patient  is  apparently  out  of  danger,  and  eventually  recovers — one 
must  believe  in  the  curative  power  of  antitoxin.  "Wlien  one  sees  a  patient 
in  whom  the  intubation  tube  has  been  repeatedly  clogged,  when  the  hope- 
less condition  of  the  patient  changes  for  the  better  after  the  administra- 
tion of  50,000  units,  one  can  not  help  but  be  convinced  of  the  importance 
of  giving  large  doses  of  antitoxin  in  the  very  severe  and  apparently  hope- 
less cases.  In  the  majority  of  instances  these  large  doses  are  not  required, 
particularly  if  the  patients  are  seen  early  in  the  attack,  4,000  to  6,000 
units  being  enough  to  produce  the  characteristic  effect  on  the  membrane." 

Favorable  effects  are  seen  in  improvement  in  both  the  local  and  general 
condition.  The  swelling  of  the  fauces  subsides,  the  membrane  begins  to 
disappear,  the  temperature  falls,  and  the  pulse  becomes  slower. 

Untoward  Effects. — Of  these  the  most  common  are  urticaria  and  arthral- 
gia, but  they  are  trifling  and  unimportant.     Abscess  is  rare. 

Eesults. — Of  183,256  cases  treated  in  150  cities  previous  to  the  serum 
period,  the  mortality  was  38.4  per  cent.  Since  the  introduction  of  serum 
132,548  cases  have  been  treated,  with  a  mortality  of  14.6  per  cent.  Leav- 
ing out  those  not  treated  with  the  serum,  the  mortality  was  9.8  per  cent 
(Edwin  Rosenthal).  In  the  Boston  City  Hospital  prior  to  1895  the  death- 
rate  from  diphtheria  was  46  per  cent;  in  five  subsequent  years,  with  the 


ERYSIPELAS.  157 

treatment  of  between  seven  and  eight  thousand  cases,  the  mortality  has 
been  just  12  per  cent.  One  of  the  most  remarkable  and  interesting  records 
is  from  the  city  of  Chicago.  In  the  ten  years  before  the  antitoxin  treat- 
ment, from  1886  to  1895,  there  was  a  yearly  average  death-rate  from  diph- 
theria and  croup  of  1,417,  while  in  three  years  after  the  antitoxin  treat- 
ment was  begun  the  yearly  average  was  only  851. 

Immunization  for  the  Prevention  of  Diphtheria. — Persons  exposed  to 
diphtheria  may  be  protected  by  a  sufficient  dose  of  the  antitoxin.  Chil- 
dren, particularly,  should  receive  an  immunizing  injection  at  once.  The 
minimum  dose  recommended  by  the  ISTew  York  Board  of  Health  is  300 
units  for  a  child,  500  for  an  adult,  which  may  be  repeated  in  a  few  days. 


XVII.    ERYSIPELAS. 

Definition. — An  acute,  contagious  disease,  characterized  by  a  special 
inflammation  of  the  skin  caused  by  streptococcus  erysipelatos  sen  pyo- 
genes. 

Etiology. — Erysipelas  is  a  widespread  affection,  endemic  in  most  com- 
munities, and  at  certain  seasons  epidemic.  We  are  as  yet  ignorant  of  the 
atmospheric  or  telluric  influences  which  favor  the  diffusion  of  the  poison. 

It  is  particularly  prevalent  in  the  spring  of  the  year.  Of  2,013  cases 
collected  by  Anders,  1,214  occurred  during  the  first  five  months  of  the 
year.  April  had  the  largest  number  of  cases.  The  affection  prevails  ex- 
tensively in  old,  ill-ventilated  hospitals  and  institutions  in  which  the  sani- 
tary conditions  are  defective.  With  the  improved  sanitation  of  late  years 
the  number  of  cases  has  materially  diminished.  It  has  been  observed, 
however,  to  break  out  in  new  institutions  under  the  most  favorable  hygienic 
circumstances.  Erysipelas  is  both  contagious  and  inoculable;  but,  except 
under  special  conditions,  the  poison  is  not  very  virulent  and  does  not 
seem  to  act  at  any  great  distance.  It  can  be  conveyed  by  a  third  person. 
The  poison  certainly  attaches  itself  to  the  furniture,  bedding,  and  walls 
of  rooms  in  which  patients  have  been  confined. 

The  disposition  to  the  disease  is  widespread,  but  the  susceptibility  is 
specially  marked  in  the  case  of  individuals  with  wounds  or  abrasions  of 
any  sort.  Recently  delivered  women  and  persons  who  have  been  the  sub- 
jects of  surgical  operations  are  particularly  prone  to  it.  A  wound,  how- 
ever, is  not  necessary,  and  in  the  so-called  idiopathic  form,  although  it  may 
be  difficult  to  say  that  there  was  not  a  slight  abrasion  about  the  nose  or 
lips,  in  very  many  cases  there  certainly  is  no  observable  external  lesion. 

Chronic  alcoholism,  debility,  and  Bright's  disease  are  predisposing 
agents.  Certain  persons  show  a  special  susceptibility  to  erysipelas,  and 
it  may  recur  in  them  repeatedly.  There  are  instances,  too,  of  a  family 
predisposition. 

The  specific  agent  of  the  disease  is  a  streptococcus  growing  in  long 
chains,  which  is  included  under  the  group  name  Streptococcus  pyogenes, 
with  which  Streptococcus  erysipelatos  appears  to  be  identical.  The  fever 
and  constitutional  symptoms  are  due  in  great  part  to  the  toxins;  the  more 


158  SPECIFIC  INFECTIOUS  DISEASES. 

serious  visceral  complications  are  the  result  of  secondary  metastatic  in- 
fection. 

Immunity. — Susceptible  animals  can  be  rendered  immune  to  virulent 
streptococci  by  repeated  non-lethal  injections  of  cultures.  Marmorek's 
protective  serum,  prepared  by  inoculating  the  horse  and  other  animals 
with  cultures  of  intensified  virulence,  belongs  to  the  bactericidal  and  not 
to  the  antitoxic  sera.  Notwithstanding  some  apparently  favorable  results, 
its  value  in  the  treatment  of  human  infections  has  not  been  demonstrated. 

Morbid  Anatomy. — Erysipelas  is  a  simple  inflammation.  In  its 
uncomplicated  forms  there  is  seen,  post  mortem,  little  else  than  inflamma- 
tory oedema.  Investigations  have  shown  that  the  cocci  are  found  chiefly 
in  the  lymph-spaces  and  most  abundantly  in  the  zone  of  spreading  inflam- 
mation. In  the  uninvolved  tissue  beyond  the  inflamed  margin  they  are 
to  be  found  in  the  lymph-vessels,  and  it  is  here,  according  to  Metschni- 
koff  and  others,  that  an  active  warfare  goes  on  between  the  leucocytes 
and  the  cocci  (phagocytosis).  In  more  extensive  and  virulent  forms  of 
the  disease  there  is  usually  suppuration.  It  is  stated  that  the  inflamma- 
tion may  pass  inward  from  the  scalp  through  the  skull  to  the  meninges. 
This  I  have  never  seen,  but  in  one  case  I  traced  the  extension  from  the 
face  along  the  flfth  nerve  to  the  meninges,  where  an  acute  meningitis  and 
thrombosis  of  the  lateral  sinus  were  excited. 

The  visceral  complications  of  erysipelas  are  numerous  and  important. 
The  majority  of  them  are  of  a  septic  nature.  Infarcts  occur  in  the  lungs, 
spleen,  and  kidneys,  and  there  may  be  the  general  evidences  of  pyaemic 
infection. 

Some  of  the  worst  cases  of  malignant  endocarditis  are  secondary  to 
erysipelas;  thus,  of  23  cases,  3  occurred  in  connection  with  this  disease. 
Septic  pericarditis  and  pleuritis  also  occur. 

As  just  mentioned,  the  disease  may  in  rare  cases  extend  to  and  involve 
the  meninges.    Pneumonia  is  not  a  very  common  complication. 

Acute  nephritis  is  also  met  with;  it  is  often  ingrafted  upon  an  old 
chronic  trouble. 

Symptoms. — The  following  description  applies  specially  to  erysipelas 
of  the  face  and  head,  the  form  of  the  disease  which  the  physician  is  most 
commonly  called  upon  to  treat. 

The  incubation  is  variable,  probably  from  three  to  seven  days. 

The  stage  of  invasion  is  often  marked  by  a  rigor,  and  followed  by  a 
rapid  rise  in  the  temperature  and  other  characteristics  of  an  acute  fever. 
When  there  is  a  local  abrasion,  the  spot  is  slightly  reddened;  but  if  the 
disease  is  idiopathic,  there  is  seen  within  a  feM^  hours  slight  redness  over 
the  bridge  of  the  nose  and  on  the  cheeks.  The  swelling  and  tension  of  the 
skin  increase  and  within  twenty-four  hours  the  external  symptoms  are  well 
marked.  The  skin  is  smooth,  tense,  and  oedematous.  It  looks  red,  feels 
hot,  and  the  superficial  layers  of  the  epidermis  may  be  lifted  as  small  bleb^. 
The  patient  complains  of  an  unpleasant  feeling  of  tension  in  the  skin; 
the  swelling  rapidly  increases;  and  during  the  second  day  the  eyes  are 
usually  closed.  The  first-affected  parts  gradually  become  pale  and  less 
swollen  as  the  disease  extends  at  the  periphery.    When  it  reaches  the  fore- 


ERYSIPELAS.  159 

head  it  progresses  as  an  advancing  ridge,  perfectly  well  defined  and  raised; 
and  often,  on  palpation,  hardened  extensions  can  be  felt  beneath  the  skin 
which  is  not  yet  reddened.  Even  in  a  case  of  moderate  severity,  the  face 
is  enormously  swollen,  the  eyes  are  closed,  the  lips  greatly  oedematous,  the 
ears  thickened,  the  scalp  is  swollen,  and  the  patient's  features  are  quite 
unrecognizable.  The  formation  of  blebs  is  common  on  the  eyelids,  ears, 
and  forehead.  The  cervical  lymph-glands  are  swollen,  but  are  usually 
masked  in  the  oedema  of  the  neck.  The  temperature  keeps  high  without 
marked  remissions  for  four  or  five  days  and  then  defervescence  takes  place 
by  crisis.  Leucocytosis  is  present.  Kirkbride  has  noted  the  presence  in 
one  case  of  leucin  and  tyrosin  in  the  urine.  The  general  condition  of  the 
patient  varies  much  with  his  previous  state  of  health.  In  old  and  de- 
bilitated persons,  particularly  in  those  addicted  to  alcohol,  the  constitu- 
tional depression  from  the  outset  may  be  very  great.  Delirium  is  present, 
the  tongue  becomes  dry,  the  pulse  feeble,  and  there  is  marked  tendency  to 
death  from  toxaemia.  In  the  majority  of  cases,  however,  even  with  ex- 
tensive lesions,  the  constitutional  disturbance,  considering  the  height  of 
the  fever  range,  is  slight.  The  mucous  membrane  of  the  mouth  and  throat 
may  be  swollen  and  reddened.  The  erysipelatous  inflammation  may  extend 
to  the  larynx,  but  the  severe  oedema  of  this  part  occasionally  met  with  is 
commonly  due  to  the  extension  of  the  inflammation  from  without  in- 
ward. 

There  are  cases  in  which  the  inflammation  extends  from  the  face  to  the 
neck,  and  over  the  chest,  and  may  gradually  migrate  or  wander  over  the 
greater  part  of  the  body  (U.  migrans). 

The  close  relation  between  the  erysipelas  coccus  and  the  pus  organisms 
is  shown  by  the  frequency  with  which  suppuration  occurs  in  facial  ery- 
sipelas. Small  cutaneous  abscesses  are  common  about  the  cheeks  and 
forehead  and  neck,  and  beneath  the  scalp  large  collections  of  pus  may 
accumulate.  Suppuration  seems  to  occur  more  frequently  in  some  epi- 
demics than  in  others,  and  at  the  Philadelphia  Hospital  one  year  nearly 
all  the  cases  in  the  erysipelas  wards  presented  local  abscesses. 

Complications. — Meningitis  is  rare.  The  cases  in  which  death 
occurs  with  marked  brain  symptoms  do  not  usually  show,  post  mortem, 
meningeal  affection.  The  delirium  and  coma  are  due  to  the  fever,  or  to 
toxaemia. 

Pneumonia  is  an  occasional  complication.  Ulcerative  endocarditis  and 
septicasmia  are  more  common.  Albuminuria  is  almost  constant,  particu- 
larly in  persons  over  fifty.  True  nephritis  is  occasionally  seen.  Da  Costa 
has  called  attention  to  curious  irregular  returns  of  the  fever  which  occur 
during  convalescence  without  any  aggravation  of  the  local  condition.  ]\Ia- 
laria  may  coexist  with  erysipelas.  L.  F.  Barker  has  reported  such  a  case 
occurring  in  my  wards. 

The  diagnosis  rarely  presents  any  difficulty.  The  mode  of  onset,  the 
rapid  rise  in  fever,  and  the  characters  of  the  local  disease  are  quite  dis- 
tinctive. Acute  necrosis  of  bone  may  sometimes  be  regarded  as  erysipelas, 
a  mistake  which  I  once  saw  made  in  connection  with  the  lower  end  of  the 
femur. 


160  SPECIFIC  IKPECTIOUS  DISEASES. 

Prognosis. — Healthy  adults  rarely  die.  The  general  mortality  in 
hospitals  is  about  7  per  cent,  in  private  practice  about  4  per  cent  (Anders), 
In  the  new-born,  when  the  disease  attacks  the  navel,  it  is  almost  always 
fatal.  In  drunkards  and  in  the  aged  erysipelas  is  a  serious  affection,  and 
death  may  result  either  from  the  intensity  of  the  fever  or,  more  commonly, 
from  toxEemia.  The  wandering  or  ambulatory  erysipelas,  which  has  a  more 
protracted  course,  may  cause  death  from  exhaustion. 

Treatment. — Isolation  should  be  strictly  carried  out,  particularly  in 
hospitals.  A  practitioner  in  attendance  upon  a  case  of  erysipelas  should 
not  attend  cases  of  confinement. 

The  disease  is  self -limited  and  a  large  majority  of  the  cases  get  well 
without  any  internal  medication.  I  can  speak  definitely  on  this  point, 
having,  at  the  Philadelphia  Hospital,  treated  many  cases  in  this  way. 
The  diet  should  be  nutritious  and  light.  Stimulants  are  not  required 
except  in  the  old  and  feeble.  For  the  restlessness,  delirium,  and  insomnia, 
chloral  or  the  bromides  may  be  given;  or,  if  these  fail,  opium.  "WTien  the 
fever  is  high  the  patient  may  be  bathed  or  sponged,  or,  in  private  practice, 
if  there  is  an  objection  to  this,  antipyrin  or  antifebrin  may  be  given. 

Of  internal  remedies  believed  to  influence  the  disease,  the  tincture  of 
the  perchloride  of  iron  has  been  highly  recommended.  At  the  Montreal 
General  Hospital  this  was  the  routine  treatment,  and  doses  of  half  a  drachm 
to  a  drachm  were  given  every  three  or  four  hours.  I  am  by  no  means 
convinced  that  it  has  any  special  action;  nor,  so  far  as  I  know,  has  any 
medicine,  given  internally,  a  definite  control  over  the  course  of  the 
disease. 

Of  local  treatment,  the  injection  of  antiseptic  solutions  at  the  margin 
of  the  spreading  areas  has  been  much  practised.  Two-per-cent  solutions 
of  carbolic  acid,  the  corrosive  sublimate  and  the  biniodide  of  mercury  have 
been  much  used.  The  injection  should  be  made  not  into  but  just  a  little 
beyond  the  border  of  the  inflamed  patch.  F.  P.  Henry  has  treated  a  large 
number  of  cases  at  the  Philadelphia  Hospital  with  the  last-mentioned  drug, 
and  this  mode  of  practice  is  certainly  most  rational. 

Of  local  applications,  ichthyol  is  at  present  much  used.  The  inflamed 
region  may  be  covered  with  salicylate  of  starch.  Perhaps  as  good  an  ap- 
plication as  any  is  cold  water,  which  was  highly  recommended  by  Hip- 
pocrates. 

XVIII.    SEPTICAEMIA  AND   PYy^MIA. 

In  these  days  of  asepsis  physicians  see  many  more  cases  of  septicaemia 
and  pyemia  than  do  the  surgeons.  For  one  case  in  the  post-mortem  room 
with  the  anatomical  diagnosis  of  septiccemia  which  comes  from  the  surgical 
or  gynascological  departments  of  the  Johns  Hopkins  Hospital,  at  least 
fifteen  or  twenty  come  from  my  medical  wards.  Certain  terms  must  first 
be  defined. 

An  infection  is  the  morbid  process  induced  by  the  invasion  and _ growth 
in  the  body  of  pathogenic  micro-organisms.  An  infection  may  be  local, 
as  in  a  boil,  or  general,  as  in  some  cases  of  anthrax. 


SEPTICEMIA  AND  PYEMIA.  161 

An  intoxication  is  the  morbid  condition  caused  by  the  absorption  of 
toxines,  in  large  part  derived  from  pathogenic  organisms.  The  term 
saprcemia  is  the  equivalent  of  septic  intoxication. 

A  hard-and-fast  line  cannot  be  drawn  between  an  infection  and  an 
intoxication,  but  agents  of  infection  alone  are  capable  of  reproduction, 
whereas  those  of  intoxication  are  chemical  poisons,  some  of  which  are  pro- 
duced by  the  agency  of  bacteria,  or  by  vegetable  and  animal  cells.  Infec- 
tious diseases  which  are  communicated  directly  from  one  person  to  another 
are  termed  contagious,  and  the  infecting  agent  is  sometimes  spoken  of  as 
a  contagium.  "  Whether  or  not  an  infectious  disease  is  contagious  in  the 
ordinary  sense  depends  upon  the  nature  of  the  infectious  agent,  and  espe- 
cially upon  the  manner  of  its  elimination  from  and  reception  by  the  body. 
Most  but  not  all  contagious  diseases  are  infectious.  Scabies  is  a  contagious 
disease,  but  it  is  not  infectious  "  (Welch). 

There  are  three  chief  clinical  types  of  infection. 

1.  LOCAL  INFECTIONS  WITH  THE  DEVELOPMENT  OF  TOXINES. 

This  is  the  common  mode  of  invasion  of  many  of  the  diseases  which 
we  have  already  considered.  Tetanus,  diphtheria,  erysipelas,  and  pneu- 
monia are  diseases  which  have  sites  of  local  infection  in  which  the  patho- 
genic organisms  develop;  but  the  constitutional  effects  are  caused  by  the 
absorption  of  the  poisonous  products.  The  diphtheria  toxine  produces  all 
the  general  symptoms,  the  tetanus  toxine  every  feature,  of  the  disease  with- 
out the  presence  of  their  respective  bacilli.  Certain  of  the  symptoms  fol- 
lowing the  absorption  of  the  toxines  are  general  to  all;  others  are  special 
and  peculiar,  according  to  the  organism  which  produces  them.  A  chill, 
fever,  general  malaise,  prostration,  rapid  pulse,  restlessness,  and  headache 
are  the  most  frequent.  With  but  few  exceptions  the  febrile  disturbance  is 
the  most  common  feature.  The  most  serious  effects  are  seen  upon  the 
nervous  system  and  upon  the  heart,  and  the  gravity  of  the  symptoms  on 
the  part  of  these  organs  is  to  some  extent  a  measure  of  the  intensity  of 
the  intoxication.  The  organisms  of  certain  local  infections  produce  poisons 
which  have  special  actions;  thus  the  diphtheria  toxine,  besides  having  the 
effects  already  referred  to,  is  especially  prone  to  attack  the  nervous  system 
and  to  cause  peripheral  neuritis.  The  tetanus  toxine  has  a  specific  action 
on  the  motor  neurones. 

2.  SEPTICEMIA. 

Formerly,  and  in  a  surgical  sense,  the  term  "  septicaemia  "  was  used  to 
designate  the  invasion  of  the  blood  and  tissues  of  the  body  by  the  organ- 
isms of  suppuration,  but  in  the  medical  sense  the  term  may  be  applied 
to  any  condition  in  which,  with  or  without  a  local  site  of  infection,  there 
is  microbic  invasion  of  the  blood  and  tissues,  but  without  metastatic  foci 
of  suppuration.  Owing  to  the  great  development  of  bacteria  in  the  blood, 
and  in  order  to  separate  it  sharply  from  local  infectious  processes  with 
toxic  invasion  of  the  body,  it  is  proposed  to  call  this  condition  bactersemia; 
toxaemia  denotes  the  latter  state. 


162  SPECIFIC  INFECTIOUS  DISEASES. 

{a)  Progressive  Septicaemia  from  Local  Infection. — The  common  strep- 
tococcus and  staphylococcus  infection  is  as  a  rule  first  local,  and  the  tox- 
ines  alone  pass  into  the  blood.  In  other  instances  the  cocci  appear  in  the 
blood  and  throughout  the  tissues,  causing  a  septicsemia  which  intensifies 
greatly  the  severity  of  the  case.  Other  infections  in  which  the  bacterial 
invasion,  local  at  first,  may  become  general  are  pneumonia,  typhoid  fever, 
anthrax,  gonorrhoea,  and  puerperal  fever. 

The  clinical  features  of  this  form  are  well  seen  in  the  cases  of  puer- 
peral septicasmia  or  in  dissection  wounds,  in  which  the  course  of  the  infec- 
tion may  be  traced  along  the  lymphatics.  The  symptoms  usually  set  in 
within  twenty-four  hours,  and  rarely  later  than  the  third  or  fourth  day. 
There  is  a  chill  or  chilliness,  with  moderate  fever  at  first,  which  gradually 
rises  and  is  marked  by  daily  remissions  and  even  intermissions.  The  pulse 
is  small  and  compressible,  and  may  reach  120  or  higher.  G-astro-intestinal 
disturbances  are  common,  the  tongue  is  red  at  the  margin,  and  the  dorsum 
is  dry  and  dark.  There  may  be  early  delirium  or  marked  mental  prostra- 
tion and  apathy.  As  the  disease  progresses  there  may  be  pallor  of  the  face 
or  a  yellowish  tint.     Capillary  hsemorrhages  are  not  uncommon. 

The  outlook  is  serious  in  streptococcus  cases.  Death  may  occur  within 
twenty-four  hours,  and  in  fatal  cases  life  is  rarely  prolonged  for  more  than 
seven  or  eight  days.  On  post-mgrtem  examination  there  may  be  no  gross 
focal  lesions  in  the  viscera,  and  the  seat  of  infection  may  present  only  slight 
changes.  The  spleen  is  enlarged  and  soft,  the  blood  may  be  extremely 
dark  in  color,  and  haemorrhages  are  common,  particularly  on  the  serous 
surfaces.    Neither  thrombi  nor  emboli  are  found. 

Many  instances  of  septicaemia  are  combined  infections;  thus  in  diph- 
theria streptococcus  septicaemia  is  a  common,  and  the  most  serious,  event. 
The  local  disease  and  the  symptoms  produced  by  absorption  of  the  tox- 
ines  dominate  the  clinical  picture;  but  the  features  are  usually  much 
aggravated  by  the  systemic  invasion.  A  similar  infection  may  occur  in 
typhoid  fever  and  in  tuberculosis,  and  may  obscure  the  typical  picture. 
These  secondary  septicaemias  are  caused  most  frequently  by  the  strepto- 
coccus, but  may  result  from  the  invasion  of  other  bacteria. 

(J)  General  Septicaemia  without  Recognizable  Local  Infection. — Cryp- 
togenetic  Septiccemias. — This  is  a  group  of  very  great  interest  to  the  physi- 
cian, the  full  importance  of  which,  we  are  only  now  beginning  to  recognize. 

The  subjects  when  attacked  may  be  in  perfect  health;  more  commonly 
they  are  already  weakened  by  acute  or  chronic  illness.  The  pathogenic 
organisms  are  varied.  Streptococcus  pyogenes  is  the  most  common;  the 
forms  of  staphylococcus  more  rare.  Other  occasional  causal  agents  are 
micrococcus  lanceolatus  (pneumococcus),  bacillus  proteus,  and  bacillus 
pyocyaneus.  Between  May  1,  1892,  and  June  1,  1895,  there  were  exam- 
ined in  the  post-mortem  room  from  my  wards  21  cases  of  general  infec- 
tion, of  which  13  were  due  to  streptococcus  pyogenes,  2  to  staphylococcus 
pyogenes,  and  6  to  the  pneumococcus.  In  19  of  these  cases  the  patients 
were  already  the  subjects  of  some  other  malady,  which  was  aggravated,  or 
in  most  instances  terminated,  by  the  general  septicsemia.  The  symptoms 
vary  somewhat  with  the  character  of  the  micro-organisms.    In  the  strep- 


SEPTICEMIA  AND  PYEMIA.  163 

tococcus  cases  there  may  be  chills  with  high,  irregular  fever,  and  a  more 
characteristic  septic  state  than  in  the  pneumococcus  infection. 

Most  of  these  cases  come  correctly  under  the  term  "  cryptogenetic  septi- 
caemia "  as  employed  by  Leube,  inasmuch  as  the  local  focus  of  infection  is 
not  evident  during  life,  and  may  not  be  found  after  death.  Although  most 
of  these  cases  are  terminal  infections,  yet  it  is  well  to  bear  in  mind  that 
there  are  instances  of  this  type  of  affection  coming  on  in  apparently 
healthy  persons.  The  fever  may  be  extremely  irregular,  characteristic- 
ally septic,  and  persist  for  many  weeks.  Foci  of  suppuration  may  not  de- 
velop, and  may  not  be  found  even  at  autopsy.  I  have  on  several  occa- 
sions met  with  cases  of  an  intermittent  pyrexia  persisting  for  weeks,  in 
which  it  seemed  impossible  to  give  any  explanation  of  the  phenomena,  and 
some  which  ultimately  recovered,  and  in  which  tuberculosis  and  malaria 
could  be  almost  positively  excluded.  These  cases  require  to  be  carefully 
studied  bacteriologically.  Dreschfeld  has  described  them  as  idiopathic  in- 
termittent fever  of  pysemic  character.  Local  symptoms  may  be  absent, 
though  in  three  of  his  cases  there  was  enlargement  of  the  liver,  and  in  two 
the  condition  was  a  diffuse  suppurative  hepatitis.  The  pyocyanic  disease, 
or  cyano-pysemia,  is  an  extremely  interesting  form  of  infection  with  bacil- 
lus pyocyaneus,  of  which  a  large  number  of  cases  have  been  reported  of 
late  years.  (See  Wollstein's  paper.  Archives  of  Pediatrics,  October,  1897, 
and  Barker,  Jour.  Am.  Med.  Assoc,  1897.) 

..-^ 

3.  SEPTICO-PYEMIA. 

The  pathogenic  micro-organisms  which  invade  the  blood  and  tissues 
may  settle  in  certain  foci  and  there  cause  suppuration.  When  multiple 
abscesses  are  thus  produced  in  connection  with  a  general  infection,  the 
condition  is  known  as  pyaemia  or,  perhaps  better,  septico-pyamia.  There 
are  no  specific  organisms  of  suppuration,  and  the  condition  of  pyaemia  may 
be  produced  by  organisms  other  than  the  streptococci  and  staphylococci, 
though  these  are  the  most  common.  Other  forms  which  may  invade  the 
system  and  cause  foci  of  suppuration  are  micrococcus  lanceolatus,  the  gono- 
coccus,  bacillus  coli  communis,  bacillus  typhi  abdominalis,  bacillus  pro- 
teus,  bacillus  pyocyaneus,  bacillus  influenzae,  and  very  probably  bacillus 
aerogenes  capsulatus.  In  a  large  propoftion  of  all  cases  of  pyaemia  there 
is  a  focus  of  infection,  either  a  suppurating  external  wound,  an  osteo- 
myelitis, a  gonorrhoea,  an  otitis  media,  an  empyema,  or  an  area  of  sup- 
puration in  a  lymph-gland  or  about  the  appendix.  In  a  large  majority 
of  all  these  cases  the  common  pus  cocci  are  present. 

In  a  suppurating  wound,  for  example,  the  pus  organisms  induce  hyaline 
necrosis  in  the  smaller  vessels  with  the  production  of  thrombi  and  purulent 
phlebitis.  The  entrance  of  pus  organisms  in  small  numbers  into  the 
blood  does  not  necessarily  produce  pyaemia.  Commonly  the  transmission 
to  various  parts  from  the  local  focus  takes  place  by  the  fragments  of 
thrombi  which  pass  as  emboli  to  different  parts,  where,  if  the  conditions 
are  favorable,  the  pus  organisms  excite  suppuration.  A  thrombus  which 
is  not  septic  or  contaminated,  when  dislodged  and  impacted  in  a  distant 
vessel,  produces  at  most  only  a  simple  infarction;  but,  coming  from  an 


164  SPECIFIC  INFECTIOUS  DISEASES. 

infected  source  and  containing  pus  microbes,  an  independent  centre  of 
infection  is  established  wherever  the  embolus  may  lodge.  These  inde- 
pendent suppurative  centres  in  pyaemia,  known  as  emholic  or  metastatic 
abscesses,  have  the  following  distribution: 

(a)  In  external  wounds,  in  osteo-myelitis,  and  in  acute  phlegmon  of 
the  skin,  the  embolic  particles  very  frequently  excite  suppuration  in  the 
lungs,  producing  the  well-known  wedge-shaped  pysemic  infarcts;  from 
these,  or  rarely  by  paradoxical  embolism  or  direct  passage  of  bacteria  or 
minute  emboli  through  the  pulmonary  capillaries,  metastatic  foci  of  in- 
flammation may  occur  in  other  parts. 

(&)  Suppurative  foci  in  the  territory  of  the  portal  system,  particularly 
in  the  intestines,  produce  metastatic  abscesses  in  the  liver  with  or  without 
suppurative  pylephlebitis. 

Endocarditis  is  an  event  which  is  very  liable  to  occur  in  all  forms  of 
septicsemia,  and  modifies  materially  the  character  of  the  clinical  features. 
Streptococci  and  staphylococci  are  the  most  common  organisms  present 
in  the  vegetations,  but  the  pneumococci,  gonococci,  tubercle  bacilli,  typhoid 
bacilli,  anthrax  bacilli,  and  other  forms  have  been  isolated.  The  vegeta- 
tions which  develop  at  the  site  of  the  valve  lesion  become  covered  with 
thrombi,  particles  of  which  may  be  dislodged  and  carried  as  emboli  to 
different  parts  of  the  body,  causing  multiple  abscesses  or  infarcts. 

Symptoms  of  Septico-pysemia. — In  a  case  of  wound  infection, 
prior  to  the  onset  of  the  characteristic  symptoms,  there  may  be  signs  of  local 
trouble,  and  in  the  case  of  a  discharging  wound  the  pus  may  change  in  char- 
acter. The  onset  of  the  disease  is  marked  by  a  severe  rigor,  during  which 
the  temperature  rises  to  103°  or  104°  and  is  followed  by  a  profuse  sweat. 
These  chills  are  repeated  at  intervals,  either  daily  or  every  other  day.  In 
the  intervals  there  may  be  slight  pyrexia.  The  constitutional  disturbance 
is  marked  and  there  are  loss  of  appetite,  nausea,  and  vomiting,  and,  as 
the  disease  progresses,  rapid  emaciation.  Transient  erythema  is  not  un- 
common. Local  symptoms  usually  occur.  If  the  lungs  become  involved 
there  are  dyspnoea  and  cough.  The  physical  signs  may  be  slight.  Involve- 
ment of  the  pleura  and  pericardium  is  common.  The  anemia,  often  pro- 
found, causes  great  pallor  of  the  skin,  which  later  may  be  bile-tinged.  The 
spleen  is  enlarged,  and  there  maybe  intense  pain  in  the  side,  pointing  to 
perisplenitis  from  embolism.  Usually  in  the  rapid  cases  a  typhoid  state 
supervenes,  and  the  patient  dies  comatose. 

In  the  chronic  cases  the  disease  may  be  prolonged  for  months;  the 
chills  recur  at  long  intervals,  the  temperature  is  irregular,  and  the  condi- 
tion of  the  patient  varies  from  month  to  month.  The  course  is  usually 
slow  and  progressively  downward. 

Diagnosis. — Pyaemia  is  a  disease  frequently  overlooked  and  often 
mistaken  for  other  affections. 

Cases  following  a  wound,  an  operation,  or  parturition  are  readily  recog- 
nized.    On  the  other  hand,  the  following  conditions  may  be  overlooked: 

Osteo-myelitis. — Here  the  lesion  may  be  limited,  the  constitutional 
symptoms  severe,  and  the  course  of  the  disease  very  rapid.  The  cause  of 
the  trouble  may  be  discovered  only  post  mortem. 


SEPTICAEMIA  AND  PYEMIA.  165 

So^  too,  acute  septico-pyjemia  may  follow  gonorrlicea  or  a  'prostatic 
abscess. 

Cases  are  sometimes  confounded  with  typhoid  fever,  particularly  the 
more  chronic  instances,  in  which  there  are  diarrhoea,  great  prostration, 
delirium,  and  irregular  fever.  The  spleen,  too,  is  often  enlarged.  The 
marked  leucocytosis  is  an  important  differential  point. 

In  some  of  the  instances  of  ulcerative  endocarditis  the  diagnosis  is  very 
difficult,  particularly  in  what  is  known  as  the  typhoid,  in  contradistinction 
to  the  septic,  type  of  this  disease.  In  acute  miliary  tuberculosis  the  symp- 
toms occasionally  resemble  those  of  septicaemia,  more  commonly  those  of 
typhoid  fever. 

The  post-febrile  arthritides,  such  as  occur  after  scarlet  fever  and  gon- 
orrhoea, are  really  instances  of  mild  septic  infection.  The  joints  may 
sometimes  suppurate  and  pygemia  develop.  So,  also,  in  tuberculosis  of 
theJcidneys  and  calculous  pyelitis  recurring  rigors  and  sweats  due  to  septic 
infection  are  common.  In  this  latitude  septic  and  pysemic  processes  are 
too  often  confounded  with  malaria.  In  early  tuberculosis,  or  even  when 
signs  of  excavation  are  present  in  the  lungs,  and  in  cases  of  suppuration 
in  various  parts,  particularly  empyema  and  abscess  of  the  liver,  the  diag- 
nosis of  malaria  is  made.  The  practitioner  may  take  it  as  a  safe  rule, 
to  which  he  will  find  very  few  exceptions,  that  an  intermittent  fever  which 
resists  quinine  is  not  malaria. 

Other  conditions  associated  with  chills  which  may  be  mistaken  for  pyae- 
mia are  profound  anaemia,  certain  cases  of  Hodgkin's  disease,  the  hepatic 
intermittent  fever  associated  with  the  lodgment  of  gall-stones  at  the  orifice 
of  the  common  duct,  rare  cases  of  essential  fever  in  nervous  women,  and 
the  intermittent  fever  sometimes  seen  in  rapidly  growing  cancer. 

Treatment. — The  treatment  of  septicemia  and  pyaemia  is  largely  a 
surgical  problem.  The  cases  which  come  under  the  notice  of  the  physi- 
cian usually  have  visceral  abscesses  or  ulcerative  endocarditis,  conditions 
which  are  irremediable.  We  have  no  remedy  which  controls  the  fever. 
Quinine  and  the  new  antipyretics  may  be  tried,  but  they  are  of  little  serv- 
ice. Quinine  is  probably  better  than  antipyrin  and  antif  ebrin,  which  lower 
the  temperature  for  a  time,  but  when  a  careful  two-hourly  twenty-four- 
hour  chart  is  taken,  it  is  often  found  that  the  depression  under  the  influ- 
ence of  the  drug  is  made  up  at  some  other  period  of  the  day;  a  morning 
may  be  substituted  for  an  afternoon  fever. 

The  brilliant  and  remarkable  results  which  follow  complete  evacuation 
of  the  pus  with  thorough  drainage  give  the  indication  for  the  only  success- 
ful treatment  of  this  condition. 

Unfortunately,  in  too  many  cases  which  the  physician  is  called  upon 
to  treat,  the  region  of  suppuration  is  not  accessible,  and  we  have  to  be 
content  with  the  employment  of  general  measures.  Antistreptococcus 
serum  has  not  proved  of  much  value  in  the  treatment  of  these  cases. 

TERMINAL  INPECTIOITS. 

It  may  seem  paradoxical,  but  there  is  truth  in  the  statement  that  per- 
sons rarely  die  of  the  disease  with  which  they  suffer.     Secondary  infec- 


166  SPECIFIC  INFECTIOUS  DISEASES. 

tions,  or^  as  we  are  apt  to  call  them  in  hospital  work,  terminal  infections, 
carry  off  many  of  the  incurable  cases  in  the  wards.  Flexner  *  has  analyzed 
255  cases  of  chronic  renal  and  cardiac  disease  in  which  complete  bacterio- 
logical examinations  were  made  at  autopsy.  Excluding  tuberculous  infec- 
tion, 213  gave  positive  and  42  negative  results. 

The  infections  may  be  local  or  general.  The  former  are  extremely 
common,  and  are  found  in  a  large  proportion  of  all  cases  of  Bright's  disease, 
arterio-sclerosis,  heart-disease,  cirrhosis  of  the  liver,  and  other  chronic  dis- 
orders. Affections  of  the  serous  membranes  (acute  pleurisy,  acute  peri- 
carditis, or  peritonitis),  meningitis,  and  endocarditis  are  the  most  frequent 
lesions.  It  is  perhaps  safe  to  say  that  the  majority  of  cases  of  advanced 
arterio-sclerosis  and  of  Bright's  disease  succumb  to  these  intercurrent  infec- 
tions. The  infective  agents  are  very  varied.  The  streptococcus  pyogenes 
is  perhaps  the  most  common,  but  the  pneumococcus,  staphylococcus  aureus, 
the  bacillus  proteus,  the  gonococcus,  the  gas  bacillus,  and  the  bacillus  pyo- 
cyaneus  are  also  met  with. 

Particular  mention  may  be  here  made  of  the  terminal  form  of  acute 
miliary  tuberculosis.  It  is  surprising  in  how  many  instances  of  arterio- 
sclerosis, of  chronic  heart-disease,  of  Bright's  disease,  and  more  particu- 
larly of  cirrhosis  of  the  liver,  the  fatal  event  is  determined  by  an  acute 
tuberculosis  of  the  peritonaeum  or  pleura. 

The  general  terminal  infections  are  somewhat  less  common.  Of  85  cases 
of  chronic  renal  disease  in  which  Flexner  found  micro-organisms  at  au- 
topsy, 38  exhibited  general  infections;  of  48  cases  of  chronic  cardiac  disease, 
in  14  the  distribution  of  bacteria  was  general.  The  blood-serum  of  persons 
suffering  from  advanced  chronic  disease  was  found  by  him  to  be  less  de- 
structive to  the  staphylococcus  aureus  than  normal  human  serum.  Other 
diseases  in  which  general  terminal  infection  may  occur  are  Hodgkin's  dis- 
ease, leuksemia,  and  chronic  tuberculosis. 

And,  lastly,  probably  of  the  same  nature  is  the  terminal  entero-colitis 
so  frequently  met  with  in  chronic  disorders. 


XIX.    RHEUMATIC    FEVER. 

Definition. — An  acute,  non-contagious  fever,  dependent  upon  an  un- 
known infective  agent,  and  characterized  by  multiple  arthritis  and  a  marked 
tendency  to  inflammation  of  the  fibrous  tissues. 

Etiology. — Distribution  and  Prevalence. — It  prevails  in  temperate  and 
humid  climates.  Church  has  collected  interesting  statistics  on  this  point. 
Oddly  enough,  the  two  countries  with  the  highest  admission  in  the  army  per 
thousand  of  strength — Egypt,  7.02,  and  Canada,  6.26 — have  climates  the 
most  diverse.  The  returns,  however,  from  Canada  for  the  six  years  from 
1886  to  1892  are  perhaps  more  correct,  2.83  per  thousand  of  strength.  The 
death-rate  for  the  five  years  1881-'85  in  Great  Britain  was  97  per  million. 
In  the  United  States  there  are  no  satisfactory  statistics;  the  disease  is  not 

*  Jour.  Exp.  Med.,  i,  1896. 


RHEUMATIC  FEVER.  167 

dealt  with  in  the  last  Census  Eeport  as  a  cause  of  death.  So  far  as  my 
personal  observation  goes,  it  certainly  seemed  to  be  more  prevalent  in  Mon- 
treal than  in  Philadelphia  or  Baltimore.  The  general  impression  is  that 
the  disease  prevails  more  in  the  British  Isles  than  elsewhere;  but,  as  Church 
remarks,  the  returns  are  very  imperfect  (this  holds  good  everywhere),  and 
probably  the  death-rate  from  rheumatic  fever  itself  is  very  much  lower 
than  the  figures  would  indicate,  as  very  many  different  diseases  are  grouped 
under  this  heading.  In  Norway,  where  cases  of  rheumatic  fever  are 
notified,  there  were  for  the  four  years  1888-93  13,654  cases,  with  250 
deaths. 

Season. — In  London  the  cases  reach  the  maximum  in  the  months  of 
September  and  October.  In  the  Montreal  General  Hospital  Bell's  statis- 
tics of  456  cases  show  that  the  largest  number  was  admitted  in  February, 
March,  and  April.  Newsholme  has  brought  forward  statistics  to  show  that 
the  disease  prevails  most  in  the  dry  years  or  a  succession  of  such,  and  is 
specially  prevalent  when  the  subsoil  water  is  abnormally  low  and  the  tem- 
perature of  the  earth  high. 

Age. — Young  adults  are  most  frequently  affected,  but  the  disease  is  by 
no  means  uncommon  in  children  between  the  ages  of  ten  and  fifteen 
years.  Sucklings  are  rarely  attacked.  Milton  Miller  has  analyzed  19 
undoubted  cases.  The  cases  have  to  be  distinguished  from  a  totally 
different  affection,  the  pyogenic  arthritis  of  infants.  The  following 
age  table  is  based  upon  456  cases  admitted  to  the  Montreal  General 
Hospital:  Under  fifteen  years,  4.38  per  cent;  from  fifteen  to  twenty- 
five  years,  48.68  per  cent;  from  twenty-five  to  thirty-five  years,  25.87  per 
cent;  from  thirty-five  to  forty-five  years,  13.6  per  cent;  above  forty-five 
years,  7.4  per  cent.  Of  the  655  cases  analyzed  by  Whipham  for  the  Col- 
lective Investigation  Committee  of  the  British  Medical  Association,  only 
32  cases  occurred  under  the  tenth  year  and  80  per  cent  between  the  twen- 
tieth and  fortieth  year.  These  figures  scarcely  give  the  ratio  of  cases  in 
children. 

Sex. — If  all  ages  are  taken,  males  are  affected  oftener  than  females. 
In  the  Collective  Investigation  Eeport  there  were  375  males  and  279 
females.  Up  to  the  age  of  twenty,  however,  females  predominate.  Be- 
tween the  ages  of  ten  and  fifteen  girls  are  more  prone  to  the  disease. 

Heredity. — It  is  a  deeply  grounded  belief  with  the  public  and  the  pro- 
fession that  rheumatism  is  a  family  disease,  but  Church  thinks  the  evidenoe 
is  still  imperfect.  Its  not  rare  occurrence  in  several  members  of  the  same 
family  is  used  by  those  who  believe  in  the  infectious  origin  as  an  argument 
in  favor  of  its  being  a  house  disease. 

The  occupations  which  necessitate  exposure  to  cold  and  great  changes 
of  temperature  predispose  strongly  to  rheumatic  fever.  The  disease  is  met 
with  oftenest  in  drivers,  servants,  bakers,  sailors,  and  laborers. 

Chill. — Exposure  to  cold,  a  wetting,  or  a  sudden  change  of  temperature 
are  among  the  most  important  factors  in  determining  the  onset  of  an 
attack. 

Immunity  is  not  afforded  by  an  attack;  on  the  contrary,  as  in  pneu- 
monia, one  attack  predisposes  the  subject  to  the  disease. 


168  SPECIFIC  INFECTIOUS  DISEASES. 

Rheumatic  Fever  as  an  Acute  Infectious  Disease. — (a)  General  Evidence. 
— Elieumatic  fever,  as  Newsholme  has  shown,  occurs  in  epidemics  without 
regular  periodicity,  recurring  at  intervals  of  three,  four,  or  six  years,  and 
varying  much  in  intensity.  A  severe  epidemic  is  apt  to  be  followed  by 
two  or  three  mild  outbreaks.  "  The  curves  of  the  mortality  statistics  .  .  . 
approximate  very  closely  to  those  of  pyaemia,  puerperal  fever,  and  erysipe- 
las, diseases  which  are  certainly  associated  with  specific  micro-organisms '' 
(Church).  The  constancy  also  of  the  seasonal  variations  is  an  additional 
support  to  this  view. 

(&)  Clinical  Features. — Physicians  have  long  been  impressed  with  the 
striking  similarity  of  the  symptoms  of  rheumatic  fever  to  those  of  septic 
infection.  In  the  character  of  the  fever,  the  mode  of  involvement  of  the 
joints,  the  tendency  to  relapse,  the  sweats,  the  anaemia,  the  leueocytosis,  and, 
above  all,  the  great  liability  to  endocarditis  and  involvement  of  the  serous 
membranes,  acute  rheumatic  fever  resembles  pyaemia  very  closely,  and 
may,  indeed,  be  taken  as  the  -very  type  of  an  acute  infection.  But,  as 
Stephen  Mackenzie  remarks,  acute  rheumatism  should  be  considered  not 
simply  from  the  point  of  view  of  the  rheumatic  polyarthritis  of  the  adult, 
but  as  a  whole  in  its  manifestations  at  different  periods  of  life;  yet  even 
from  this  standpoint  the  multiform  manifestations  of  the  rheumatic  poison 
in  childhood  and  young  adults  may  very  reasonably  be  referred  to  the  effect 
of  the  toxines  of  micro-organisms. 

(c)  Special  Evidence. — The  bacteriology  of  the  disease  is  still  under 
discussion.  Singer's  results  have  not  been  confirmed.  Achalme  has  found 
a  bacillus  in  the  blood  during  life.  Poynton  and  Paine  have  isolated  a 
diplococcus  from  16  cases,  which  is  apparently  identical  with  the  organism 
described  by  Triboulet  and  Wassermann,  and  have  produced  experimentally 
in  rabbits  a  painful  polyarthritis  with  fever.  Recently  they  have  obtained 
the  organism  from  the  rheumatic  nodules  in  pure  culture  and  have  repro- 
duced in  the  rabbit  valvulitis,  pericarditis,  and  polyarthritis.  Special 
stress  has  been  laid  upon  the  tonsils  as  the  point  of  entrance  of  the  infec- 
tion, as  it  has  long  been  known  that  tonsillitis  was  a  very  frequent  initial 
symptom — 28  out  of  %Q>  cases  in  Singer's  series.  Indeed,  some  have  gone 
so  far  as  to  say  that  there  is  always, a  primary  infective  trouble  in  the 
lacunae  of  the  tonsils,  to  which  the  rheumatic  fever  is  secondary,  arising 
from  the  absorption  of  microbes  or  their  products. 

Other  views  as  to  the  nature  of  rheumatism  are  the  metabolic  or  cJiemical: 
that  it  depends  upon  a  morbid  material  produced  within  the  system  in 
defective  processes  of  assimilation.  It  has  been  suggested  that  this  mate- 
rial is  lactic  acid  (Prout)  or  certain  combinations  with  lactic  acid  (Latham). 
Our  knowledge  of  the  chemical  relations  of  the  various  products  produced 
in  the  regressive  nutritive  changes  is  too  limited  to  warrant  much  reliance 
upon  these  views.  Richardson  claims  to  have  produced  rheumatism  by  in- 
jecting lactic  acid  and  by  its  internal  administration. 

Nervous  Theory  of  Acute  Rheumatism. — This  was  specially  advocated 
by  the  late  Dr.  J.  K.  Mitchell,  of  Philadelphia.  According  to  this  view, 
either  the  nerve  centres  are  primarily  affected  by  cold  and  the  local  lesions 
are  really  trophic  in  character,  or  the  primary  nervous  disturbance  leads 


RHEUMATIC  FEVER.  169 

to  errors  in  metabolism  and  tlie  accumulation  of  lactic  acid  in  the  system. 
The  advocates  of  this  view  regard  as  analogous  the  arthropathies  of  myelitis, 
locomotor  ataxia,  and  chorea. 

Morbid  Anatomy. — There  are  no  changes  characteristic  of  the  dis- 
ease. The  affected  joints  show  hyperemia  and  swelling  of  the  synovial 
membranes  and  of  the  ligamentous  tissues.  There  may  be  slight  erosion 
of  the  cartilage.  The  fluid  in  the  joint  is  turbid,  albuminous  in  character, 
and  contains  leucocytes  and  a  few  fibrin  flakes.  Pus  is  very  rare  in  uncom- 
plicated cases.  Rheumatism  rarely  proves  fatal,  except  when  there  are 
serious  complications,  such  as  pericarditis,  endocarditis,  myocarditis,  pleu- 
risy, or  pneumonia.  The  conditions  found  show  nothing  peculiar,  nothing 
to  distinguish  them  from  other  forms  of  inflammation.  In  death  from 
hyperpyrexia  no  special  changes  occur.  The  blood  usually  contains  an 
excessive  amount  of  fibrin.  In  the  secondary  rheumatic  inflammations, 
as  pleurisy  and  pericarditis,  various  pus  organisms  have  been  found,  pos- 
sibly the  result  of  a  mixed  infection. 

Symptoms. — As  a  rule,  the  disease  sets  in  abruptly,  but  it  may  be 
preceded  by  irregular  pains  in  the  joints,  slight  malaise,  sore  throat,  and 
particularly  by  tonsillitis.  A  definite  rigor  is  uncommon;  more  often 
there  is  slight  chilliness.  The  fever  rises  quickly,  and  with  it  one  or  more 
of  the  joints  become  painful.  Within  twenty-four  hours  from  the  onset, 
the  disease  is  fully  manifest.  The  temperature  range  is  from  103°  to 
104°.  The  pulse  is  frequent,  soft,  and  usually  above  100.  The  tongue  is 
moist,  and  rapidly  becomes  covered  with  a  white  fur.  There  are  the  ordi- 
nary symptoms  associated  with  an  acute  fever,  such  as  loss  of  appetite, 
thirst,  constipation,  and  a  scanty,  highly  acid,  highly  colored  urine.  In  a 
majority  of  the  cases  there  are  profuse,  very  acid  sweats,  of  a  peculiar  sour 
odor.  Sudaminal  and  miliary  vesicles  are  abundant,  the  latter  usually  sur- 
rounded by  a  minute  ring  of  hypersemia.  The  mind  is  clear,  except  in 
the  cases  with  hyperpyrexia.  The  affected  joints  are  painful  to  move, 
soon  become  swollen  and  hot,  and  present  a  reddish  flush.  The  knees, 
ankles,  elbows,  and  wrists  are  the  joints  usually  attacked,  not  together, 
but  successively.  For  example,  if  the  knee  is  first  affected,  the  redness 
may  disappear  from  it  as  the  wrists  become  painful  and  hot.  The  disease 
is  seldom  limited  to  a  single  articulation.  The  amount  of  swelling  is  vari- 
able. Extensive  effusion  into  a  joint  is  rare,  and  much  of  the  enlargement 
is  due  to  the  infiltration  of  the  periarticular  tissues  with  serum.  The 
swelling  may  be  limited  to  the  joint  proper,  but  in  the  wrists  and  ankles 
it  sometimes  involves  the  sheaths  of  the  tendons  and  produces  great  en- 
largement of  the  hands  and  feet.  Corresponding  joints  are  often  affected. 
In  attacks  of  great  severity  every  one  of  the  larger  joints  may  be  involved. 
The  vertebral,  sterno-clavicular,  and  phalangeal  articulations  are  less  often 
infiamed  in  acute  than  in  gonorrhoeal  rheumatism.  Perhaps  no  disease  is 
more  painful  than  acute  polyarthritis.  The  inability  to  change  the  posture 
without  agonizing  pain,  the  drenching  sweats,  the  prostration  and  utter 
helplessness,  combine  to  make  it  one  of  the  most  distressing  of  febrile 
aff'ections.  A  special  feature  of  the  disease  is  the  tendency  of  the  inflamma- 
tion to  subside  in  one  joint  while  increasing  with  great  intensity  in  another. 


lYO  SPECIFIC  INFECTIOUS  DISEASES.  — 

The  temperature  range  in  an  ordinary  attack  is  between  102°  and  104°. 
It  is  peculiarly  irregular,  with  marked  remissions  and  exacerbations,  de- 
pending very  much  upon  the  intensity  and  extent  of  the  articular  inflam- 
mation. Defervescence  is  usually  gradual.  The  profuse  sweats  materially 
influence  the  temperature  curve.  If  a  two-hourly  chart  is  made  and  ob- 
servations upon  the  sweats  are  noted,  the  remissions  will  usually  be  found 
coincident  with  the  sweats.  The  perspiration  is  sour-smelling  and  acid  at 
first;  but,  when  persistent,  becomes  neutral  or  even  alkaline. 

The  blood  is  profoundly  and  rapidly  altered  in  acute  rheumatism. 
There  is,  indeed,  no  acute  febrile  disease  in  which  the  anaemia  occurs 
with  greater  rapidity.     There  is  a  well-marked  leucocytosis. 

With  the  high  fever  a  murmur  may  often  be  heard  at  the  apex  region. 
Endocarditis  is  also  a  common  cause  of  an  apex  Iruit.  The  heart  should 
be  carefully  examined  at  the  first  visit  and  subsequently  each  day. 

The  urine  is,  as  a  rule,  reduced  in  amount,  of  high  density  and  high 
color.  It  is  very  acid,  and,  on  cooling,  deposits  urates.  The  chlorides 
may  be  greatly  diminished  or  even  absent.  Febrile  albuminuria  is  not 
uncommon. 

The  saliva  may  become  acid  in  reaction  and  is  said  to  contain  an  excess 
of  sulphocyanides. 

Subacute  Rheumatism. — This  represents  a  milder  form  of  the  dis- 
ease, in  which  all  the  symptoms  are  less  pronounced.  The  fever  rarely  rises 
above  101°;  fewer  Joints  are  involved;  and  the  arthritis  is  less  intense. 
The  cases  may  drag  on  for  weeks  or  months,  and  the  disease  may  finally 
become  chronic.  It  should  not  be  forgotten  that  in  children  this  mild  or 
subacute  form  may  be  associated  with  endocarditis  or  pericarditis. 

Complications. — These  are  important  and  serious. 

(1)  Hyperpyrexia. — The  temperature  may  rise  rapidly  a  few  days  after 
the  onset,  and  be  associated  with  delirium;  but  not  necessarily,  for  the 
temperature  may  rise  to  108°  or,  as  in  one  of  Da  Costa's  cases,  110°,  with 
out  cerebral  symptoms.  Hyperpyrexia  is  most  common  in  first  attacks, 
57  of  107  cases  (Church).  It  is  most  apt  to  occur  during  the  second  week. 
The  delirium  may  precede  or  follow  the  onset  of  the  hyperpyrexia.  As  a 
rule,  with  the  high  fever,  the  pulse  is  feeble  and  frequent,  the  prostration 
is  extreme,  and  finally  stupor  supervenes. 

(2)  Cardiac  Affections. — (a)  Endocarditis,  the  most  frequent  and  serious 
complication,  occurs  in  a  considerable  percentage  of  all  cases.  Of  889  cases, 
494  had  signs  of  old  or  recent  endocarditis  (Church).  The  liability  to 
endocarditis  diminishes  as  age  advances.  It  increases  directly  with  the 
number  of  attacks.  Of  116  cases  in  the  first  attack,  58.1  per  cent  had  endo- 
carditis, 63  per  cent  in  the  second  attack,  and  71  per  cent  in  the  third 
attack  (Stephen  Mackenzie).  The  mitral  segments  are  most  frequently  in- 
volved and  the  affection  is  usually  of  the  simple,  verrucose  variety.  Ulcer- 
ative endocarditis  in  the  course  of  acute  rheumatism  is  very  rare.  Of  209 
cases  of  this  disease  which  I  analyzed,  in  only  24  did  the  symptoms  of  a 
severe  endocarditis  arise  during  the  progress  of  acute  or  subacute  rheuma- 
tism. This  complication,  in  itself,  is  rarely  dangerous.  It  produces  few 
symptoms  and  is  usually  overlooked.    Unhappily,  though  the  valve  at  the 


RHEUMATIC  FEVER.  lYl 

time  may  not  be  seriously  damaged,  the  inflammation  starts  changes  which 
lead  to  sclerosis  and  retraction  of  the  segments,  and  so  to  chronic  valvular 
disease.    Venous  thrombosis  is  an  occasional  complication. 

(h)  Pericarditis  may  occur  independently  of  or  together  with  endocar- 
ditis. It  may  be  simple  fibrinous,  sero-fibrinous,  or  in  children  purulent. 
Clinically  we  meet  it  more  frequently  in  connection  with  rheumatism 
than  all  other  affections  combined.  The  physical  signs  are  very  character- 
istic. The  condition  will  be  fully  described  under  its  appropriate  section. 
A  peculiar  form  of  delirium  may  develop  during  the  progress  of  rheumatic 
pericarditis. 

(c)  Myocarditis  is  most  frequent  in  connection  with  endo-pericardial 
changes.  As  Sturges  insisted,  the  term  carditis  is  applicable  to  many  cases. 
The  anatomical  condition  is  a  granular  or  fatty  degeneration  of  the  heart- 
muscle,  which  leads  to  weakening  of  the  walls  and  to  dilatation.  It  is  not, 
I  think,  nearly  so  common  as  the  other  cardiac  affections.  S.  West  has  re- 
ported instances  of  acute  dilatation  of  the  heart  in  rheumatic  fever,  in  one 
of  which  marked  fatty  changes  were  found  in  the  heart-fibres. 

(3)  Pulmonary  Aflfections. — Pneumonia  and  pleurisy  occurred  in  9.94 
per  cent  of  3,433  cases  (Stephen  Mackenzie).  They  frequently  accompany 
the  cases  of  endo-pericarditis.  According  to  Howard's  analysis  of  a  large 
number  of  cases,  there  were  pulmonary  complications  in  only  10.5  per 
cent  of  cases  of  rheumatic  endocarditis;  in  58  per  cent  of  cases  of  peri- 
carditis; and  in  71  per  cent  of  cases  of  endo-pericarditis.  Congestion  of 
the  lung  is  occasionally  found,  and  in  several  cases  has  proved  rapidly 
fatal. 

(4)  Nervous  Complications. — These  are  due,  in  part,  to  the  hyper- 
pyrexia and  in  part  to  the  special  action  upon  the  brain  of  the  toxic  agent 
of  the  disease.  They  may  be  grouped  as  follows:  (a)  Delirium.  This  is 
usually  associated  with  the  hyperpyrexia,  but  may  be  independent  of  it. 
It  may  be  active  and  noisy  in  character;  more  rarely  a  low  muttering 
delirium,  passing  into  stupor  and  coma.  Special  mention  must  be  made 
of  the  delirium  which  occurs  in  connection  with  rheumatic  pericarditis. 
Delirium,  too,  may  be  excited  by  the  salicylate  of  soda,  either  shortly  after 
its  administration,  or  more  commonly  a  week  or  ten  days  later,  (b)  Coma, 
which  is  more  serious,  may  occur  without  preliminary  delirium  or  con- 
vulsions, and  may  prove  rapidly  fatal.  Certain  of  these  cases  are  associ- 
ated with  hyperpyrexia;  but  Southey  has  reported  the  case  of  a  girl  who, 
without  previous  delirium  or  high  fever,  became  comatose,  and  died  in  less 
than  an  hour.  A  certain  number  of  such  cases,  as  those  reported  by  Da 
Costa,  have  been  associated  with  marked  renal  changes  and  were  evidently 
uremic.  The  coma  may  supervene  during  the  attack,  or  after  convales- 
cence has  set  in.  (c)  Convulsions  are  less  common,  though  they  may  precede 
the  coma.  Of  127  observations  cited  by  Besnier,  there  were  37  of  delirium, 
only  7  of  convulsions,  17  of  coma  and  convulsions,  54  of  delirium,  coma, 
and  convulsions,  and  3  of  other  varieties  (Howard),  (d)  CJwrea.  The 
relations  of  this  disease  and  rheumatism  will  be  subsequently  discussed. 
It  is  sufficient  here  to  say  that  in  only  88  out  of  554  cases  which  I  have 
analyzed  from  the  Infirmary  for  Diseases  of  the  Nervous  System,  Phila- 

11 


172  SPECIFIC  INFECTIOUS  DISEASES. 

delphia,  were  chorea  and  rheumatism  associated.  It  is  most  apt  to  develop 
in  the  slighter  attacks  in  childhood,  (e)  Meningitis  is  extremely  rare, 
though  undoubtedly  it  does  occur.  It  must  not  be  forgotten  that  in  ulcer- 
ative endocarditis,  which  is  occasionally  associated  with  acute  rheumatism, 
meningitis  is  frequent,    {f)  Polyneuritis  has  been  described. 

(5)  Cutaneous  Affections. — Sweat-vesicles  have  already  been  mentioned 
as  extremely  common.  A  red  miliary  rash  may  also  develop.  Scarlatini- 
form  eruptions  are  occasionally  seen.  Purpura,  with  or  without  urticaria, 
may  occur,  and  various  forms  of  erythema.  It  is  doubtful  whether  the 
cases  of  extensive  purpura  with  urticaria  and  arthritis — peliosis  rheumatica 
— belong  truly  to  acute  rheumatism. 

(6)  Rheumatic  Nodules. — These  curious  structures,  in  the  form  of  small 
subcutaneous  nodules  attached  to  the  tendons  and  f  ascise,  have  been  known 
for  some  years;  but  special  attention  has  been  paid  to  them  of  late,  since 
their  careful  study  by  Barlow  and  Warner.  While  not  so  common  in  this 
country  as  in  England,  the  cases  are  by  no  means  infrequent  (Futcher. 
J.  H.  H.  Bulletin,  1895).  They  vary  in  size  from  a  small  shot  to  a  large 
pea,  and  are  most  numerous  on  the  fingers,  hands,  and  wrists.  They  also 
occur  about  the  elbows,  knees,  the  spines  of  the  vertebrae,  and  the  scapula. 
They  are  not  often  tender.  They  do  not  necessarily  come  on  during  the 
fever,  but  may  be  found  on  its  decline,  or  even  independently  altogether 
of  an  acute  attack.  The  nodules  may  grow  with  great  rapidity  and  usually 
last  for  weeks  or  months.  They  are  more  common  in  children  than  in 
adults,  and  in  the  former  their  presence  may  be  regarded  as  a  positive  indi- 
cation of  rheumatism.  They  have  been  noted  particularly  in  association 
with  severe  and  chronic  rheumatic  endocarditis.  Subcutaneous  nodules 
occur  also  in  migraine,  gout,  and  arthritis  deformans.  Histologically  they 
are  made  up  of  round  and  spindle-shaped  cells.  In  addition  to  these  firm, 
hard  nodules,  there  occur  in  rheumatism  and  in  chronic  vegetative  endo- 
carditis remarkable  small  bodies,  which  have  been  called  by  Fereol  "  nodo- 
sites  cutanees  ephemeres."  In  a  case  of  chronic  vegetative  endocarditis 
(without  arthritis),  which  I  saw  with  Dr.  J.  K.  Mitchell,  there  were,  in 
addition  to  occasional  elevated  spots  resembling  urticaria,  areas  of  infiltra- 
tion in  the  skin,  from  two  to  three  lines  in  diameter,  not  elevated,  but  pale 
pink,  and  exquisitely  tender  and  painful  even  without  being  touched. 

The  course  of  acute  rheumatism  is  extremely  variable.  It  is,  as  Austin 
Flint  first  showed,  a  self -limited  disease,  and  it  is  not  probable  that  medi- 
cines have  any  special  influence  upon  its  duration  or  course.  Gull  and 
Sutton,  who  likewise  studied  a  series  of  62  cases  without  special  treatment, 
arrived  at  the  same  conclusion. 

Sudden  death  in  rheumatic  fever  is  due  most  frequently  to  myocarditis. 
Herringham  has  reported  a  case  in  which  on  the  fourteenth  day  there  was 
fatty  degeneration  and  acute  inflammation  of  the  myocardium.  In  a  few 
rare  cases  it  results  from  embolism.  I  saw  one  case  at  the  Montreal  Gen- 
eral Hospital  in  which  we  thought  possibly  the  sudden  death  was  due  to 
Fuller's  alkaline  treatment,  which  had  been  kept  up  by  mistake.  There  was 
slight  endocarditis  but  no  myocardial  changes.  Alarming  symptoms  of 
depression  sometimes  follow  excessive  doses  of  the  salicylate  of  soda. 


RHEUMATIC  FEVER.  173 

Diagnosis. — Practically,  the  recognition  of  acute  rheumatism  is  very 
easy;  but  there  are  several  affections  which,  in  some  particulars,  closely 
resemble  it. 

(1)  Multiple  Secondary  Arthritis. — Under  this  term  may  be  embraced 
the  various  forms  of  arthritis  which  come  on  or  follow  in  the  course  of  the 
infective  diseases,  such  as  gonorrhoea,  scarlet  fever,  dysentery,  and  cerebro- 
spinal meningitis.  Of  these  the  gonorrhoeal  form  will  receive  special  con- 
sideration and  is  the  type  of  the  entire  group. 

(2)  Septic  Arthritis,  which  develops  in  the  course  of  pyaemia  from  any 
cause,  and  particularly  in  puerperal  fever.  No  hard  and  fast  line  can  be 
drawn  between  these  and  the  cases  in  the  first  group;  but  the  inflammation 
rapidly  passes  on  to  suppuration  and  there  is  more  or  less  destruction  of 
the  joints.  The  conditions  under  which  the  arthritis  occurs  give  a  clew 
at  once  to  the  nature  of  the  case.  Under  this  section  may  also  be  men- 
tioned: 

(a)  Acute  necrosis  or  acute  osteo-myelitis,  occurring  in  the  lower  end 
of  the  femur,  or  in  the  tibia,  and  which  may  be  mistaken  for  acute  rheu- 
matism. Sometimes,  too,  it  is  multiple.  The  greater  intensity  of  the  local 
symptoms,  the  involvement  of  the  epiphyses  rather  than  the  joints,  and 
the  more  serious  constitutional  disturbances  are  points  to  be  considered. 
The  condition  is  unfortunately  often  mistaken  for  acute  arthritis,  and,  as 
the  treatment  is  essentially  surgical,  the  error  is  one  which  may  cost  the  life 
of  the  patient. 

(&)  The  acute  arthritis  of  infants  must  be  distinguished  from  rheuma- 
tism. It  is  a  disease  which  is  usually  confined  to  one  joint  (the  hip  or 
knee),  the  effusion  in  which  rapidly  becomes  purulent.  The  affection  is 
most  common  in  sucklings  and  is  undoubtedly  pysemic  in  character.  It 
may  also  occur  in  the  gonorrhoeal  ophthalmia  or  vaginitis  of  the  new- 
born, as  pointed  out  by  Clement  Lucas. 

(3)  Gout. — While  the  localization  in  a  single,  usually  a  small,  joint,  the 
age,  the  history,  and  the  mode  of  onset  are  features  which  enable  us  to  recog- 
nize acute  gout,  there  are  in  this  country  many  cases  of  acute  arthritis, 
called  rheumatic  fever,  which  are  in  reality  gout.  The  involvement  of  sev- 
eral of  the  larger  joints  is  not  so  infrequent  in  gout,  and  unless  tophi  are 
present,  or  unless  a  very  accurate  analysis  of  the  urine  is  made,  the  diagnosis 
may  be  difficult. 

Treatment. — The  bed  should  have  a  smooth,  soft,  yet  elastic  mattress. 
The  patient  should  wear  a  fiannel  night-gown,  which  may  be  opened  all  the 
way  down  the  front  and  slit  along  the  outer  margin  of  the  sleeves.  Three 
or  four  of  these  should  be  made,  so  as  to  facilitate  the  frequent  changes 
required  after  the  sweats.  He  may  wear  also  a  light  flannel  cape  about  the 
shoulders.  He  should  sleep  in  blankets,  not  in  sheets,  so  as  to  reduce  tlie 
liability  to  catch  cold  and  obviate  the  unpleasant  clamminess  consequent 
upon  heavy  sweating.  Chambers  insisted  that  the  liability  to  endocarditis 
and  pericarditis  was  much  reduced  when  the  patients  were  in  blankets. 

Milk  is  the  most  suitable  diet.  It  may  be  diluted  with  alkaline  min- 
eral waters.  Lemonade  and  oatmeal  or  barley  water  should  be  freely  given. 
The  thirst  is  usually  great  and  may  be  fully  satisfied.     There  is  no  objec- 


174  SPECIFIC  INFECTIOUS  DISEASES. 

tion  to  broths  and  soups  if  the  milk  is  not  well  borne.  The  food  should 
be  given  at  short  and  stated  intervals.  As  convalescence  is  established  a 
fuller  diet  may  be  allowed,  but  meat  should  be  used  sparingly. 

The  local  treatment  is  of  the  greatest  importance.  It  often  suffices  to 
wrap  the  affected  joints  in  cotton.  If  the  pain  is  severe,  hot  cloths  may 
be  applied,  saturated  with  Fuller's  lotion  (carbonate  of  soda,  6  drachms; 
laudanum,  1  oz.;  glycerine,  2  oz.;  and  water,  9  oz.).  Tincture  of  aconite 
or  chloral  may  be  employed  in  an  alkaline  solution.  Chloroform  liniment 
is  also  a  good  application.  Fixation  of  the  joints  is  of  great  service  in  allay- 
ing the  pain.  I  have  seen,  in  a  German  hospital,  the  joints  enclosed  in 
plaster  of  Paris,  apparently  with  great  relief.  Splints,  padded  and  bandaged 
with  moderate  firmness,  will  often  be  found  to  relieve  pain.  Friction  is 
rarely  well  borne  in  an  acutely  inflamed  joint.  Cold  compresses  are  much 
used  in  Germany.  The  application  of  blisters  above  and  below  the  joint 
often  relieves  the  pain.  This  method,  which  was  used  so  much  a  few  years 
ago,  is  not  to  be  compared  with  the  light  application  of  the  Paquelin 
thermo-cautery. 

The  drug  treatment  of  acute  rheumatism  is  still  far  from  satisfactory, 
though  the  introduction  of  the  salicyl  compounds  has  been  a  great  boon. 
Pribram's  exhaustive  consideration  of  the  question,  extending  over  some 
67  pages  (Nothnagel's  Handbuch,  Bd.  v),  in  which  he  discusses  some  75 
drugs  and  measures,  indicates  perhaps  better  than  anything  else  that  the 
therapeutics  of  the  disease  are  still  far  from  satisfactory. 

Treatment  with  the  Salicyl  Compounds. — Salicin,  introduced  in  1876  by 
Maclagan,  may  be  used  in  doses  of  30  grains  every  hour  or  two  until  the 
pain  is  relieved.  It  has  the  advantage  of  being  less  depressing  than  the 
salicylate  of  soda.  It  is  also  perhaps  the  best  drug  to  use  for  children. 
Salicylic  acid,  15  to  20  grains,  may  be  given  every  two  hours  in  acute  cases 
until  the  pain  is  relieved.  It  is  best  given  in  capsules.  Salicylate  of  soda, 
20-grain  doses  every  two  hours,  is  perhaps  the  best  of  the  drugs  for  gen- 
eral use  in  the  acute  rheumatism  of  adults.  After  the  pain  has  been 
relieved,  the  drug  should  be  given  every  four  or  five  hours  until  the  tem- 
perature begins  to  fall.  The  potassium  bicarbonate  may  be  given  with  it. 
Oil  of  wintergreen,  20  minims  every  two  hours  in  milk,  may  be  used  if  the 
salicylate  of  soda  disagrees.  There  are  many  other  salicyl  compounds  in- 
troduced of  late,  but  the  best  results  are  obtained  from  the  use  of  one  or 
other  of  the  above-named  preparations.  There  can  be  no  question  as  to 
their  efficacy  in  relieving  the  pain  in  the  disease.  A  majority  of  observers 
agree  that  they  also  protect  the  heart,  shorten  the  course,  and  render 
relapse  less  likely. 

The  All-aline  Treatment. — Potassium  bicarbonate  may  be  given  in  half- 
drachm  doses  every  three  hours  with  the  salicylic  acid  or  salicin.  Fuller's 
plan  was  to  give  a  drachm  and  a  half  of  the  sodium  bicarbonate  with  half 
a  drachm  of  potassium  acetate  in  three  ounces  of  water,  rendered  effer- 
vescent at  the  time  of  administration  by  half  a  drachm  of  citric  acid  or  an 
ounce  of  lemon-juice.  "^^Hien  the  urine  is  alkaline  the  amount  may  be 
reduced. 

The  heart  should  be  watched  carefully  during  the  administration  of 
full  doses  of  the  alkalies. 


CHOLERA  ASIATICA.  1Y5 

Opinion  favors  the  view  that  with  the  alkaline  treatment  endocarditis  is 
less  frequent,  but  the  disease  is  not  cut  short,  nor  is  the  pain  allayed.  The 
truth  is  there  are  certain  cases  of  rheumatic  fever  that  resist  all  forms  of 
treatment,  and  persist  for  weeks,  sometimes  with  recrudescences  or  relapses 
of  great  severity. 

To  allay  the  pain  opium  may  be  given  in  the  form  of  Dover's  powder, 
or  morphia  hypodermically.  Antipyrin,  antifebrin,  and  phenacetin  are 
useful  sometimes  for  the  purpose.  During  convalescence  iron  is  indicated 
in  full  doses,  and  quinine  is  a  useful  tonic.  Of  the  complications,  hyper- 
pyrexia should  be  treated  by  the  cold  bath  or  the  cold  pack.  The  treat- 
ment of  endocarditis  and  pericarditis  and  the  pulmonary  complicatious 
will  be  considered  under  their  respective  sections. 

To  prevent  and  arrest  endocarditis  Caton  urges  the  use  of  a  series  of 
small  blisters  along  the  course  of  the  third,  fourth,  fifth,  and  sixth  inter- 
costal nerves  of  the  left  side,  applied  one  at  a  time  and  repeated  at  differ- 
ent points.  Potassium  or  sodium  iodide  is  given  in  addition  to  the  salicyl- 
ates.   The  patients  are  kept  in  bed  for  about  six  weeks. 


XX.    CHOLERA   ASIATICA, 

Definition. — A  specific,  infectious  disease,  caused  by  the  comma  ba- 
cillus of  Koch,  and  characterized  clinically  by  violent  purging  and  rapid 
collapse. 

Historical  Summary. — Cholera  has  been  endemic  in  India  from  a 
remote  period,  but  only  within  the  last  century  did  it  make  inroads  into 
Europe  and  America.  An  extensive  epidemic  occurred  in  1832,  in  which 
year  it  was  brought  in  immigrant  ships  from  Great  Britain  to  Quebec.  It 
travelled  along  the  lines  of  traffic  up  the  Great  Lakes,  and  finally  reached 
as  far  west  as  the  military  posts  of  the  upper  Mississippi.  In  the  same 
year  it  entered  the  United  States  by  way  of  ISTew  York.  There  were  re- 
currences of  the  disease  in  1835-'36.  In  1848  it  entered  the  country  through 
New  Orleans,  and  spread  widely  up  the  Mississippi  Valley  and  across  the 
continent  to  California.  In  1849  it  again  appeared.  In  1854  it  was  intro- 
duced by  immigrant  ships  into  New  York  and  prevailed  widely  through- 
out the  country.  In  1866  and  in  1867  there  were  less  serious  epidemics. 
In  1873  it  again  appeared  in  the  United  States,  but  did  not  prevail  widely. 
In  1884  there  was  an  outbreak  in  Europe,  and  again  in  1892  and  1893. 
Although  occasional  cases  have  been  brought  by  ship  to  the  quarantine 
stations  in  this  country,  the  disease  has  not  gained  a  foothold  here  since 
1873. 

Etiology. — In  1884  Koch  announced  the  discovery  of  the  specific 
organism  of  this  disease.  Subsequent  observations  have  confirmed  his 
statement  that  the  comma  bacillus,  as  it  is  termed,  occurs  constantly  in 
the  true  cholera,  and  in  no  other  disease.  It  has  the  form  of  a  slightly 
bent  rod,  which  is  thicker,  but  not  more  than  about  half  the  length  of  the 
tubercle  bacillus,  and  sometimes  occurs  in  corkscrew-like  or  S  forms.  It  is 
not  a  true  bacillus,  but  really  a  spirochsete.  The  organisms  grow  upon  a 
great  variety  of  media  and  display  distinctive  and  characteristic  appear- 


176  SPECIFIC  INFECTIOUS  DISEASES. 

ances.  Kocli  found  them  in  tlie  water-tanks  in  India,  and  tliey  were  isolated 
from^the  Elbe  water  during  the  Hamburg  epidemic  of  1892.  During  epi- 
demics virulent  bacilli  may  be  found  in  the  tseees  of  healthy  persons.  The 
bacilli  are  found  in  the  intestine,  in  the  stools  from  the  earliest  period  of 
the  disease,  and  very  abundantly  in  the  characteristic  rice-water  evacua- 
tions, in  which  they  may  be  seen  as  an  almost  pure  culture.  They  very 
rarely  occur  in  the  vomit.  Post  mortem,  they  are  found  in  enormous  num- 
bers in  the  intestine.  In  acutely  fatal  cases  they  do  not  seem  to  invade  the 
intestinal  wall,  but  in  those  with  a  more  protracted  course  they  are  found 
in  the  depths  of  the  glands  and  in  the  still  deeper  tissues.  Experimental 
animals  are  not  susceptible  to  cholera  germs  administered  per  os.  But 
if  introduced  after  neutralization  of  the  gastric  contents,  and  if  kept  in 
contact  with  the  intestinal  mucosa  by  controlling  peristalsis  with  opium, 
guinea-pigs  succumb  after  showing  cholera-like  symptoms.  The  intestines 
are  filled  with  thin,  watery  contents,  containing  comma  bacilli  in  almost 
pure  culture. 

Cholera  Toxine. — Koch  in  his  studies  of  cholera  failed  to  find  the 
spirilla  in  the  internal  organs.  He  concluded  that  the  constitutional  symp- 
toms of  the  disease  resulted  from  the  absorption  of  toxic  bodies  from  the 
intestine.  In  old  cholera  cultures  ptomaines  are  contained;  these  probably 
have  nothing  to  do  with  the  intoxication  of  human  cholera.  E.  Pfeiffer 
has  shown  that  the  cholera  toxine  is  intimately  associated  with  the  proteid 
of  the  bacterial  cells,  and,  being  of  a  very  labile  nature,  cannot  be  separated. 
Dead  cultures  are  toxic;  and  the  symptoms  produced  by  the  introduction  of 
even  minimal  amounts  are  often  comparable  with  those  of  the  algid  stage 
of  cholera  asiatica.  The  symptoms  develop  very  rapidly,  and  death  often 
results  in  eight  to  twelve  hours;  in  non-fatal  cases  recovery  is  often  equally 
as  rapid.  The  intracellular  cholera  toxine  is  poisonous  to  animals  if  intro- 
duced into  the  blood,  peritoneal  cavity,  or  subcutaneous  tissues.  JSTo  ab- 
sorption takes  place  from  the  intestine  unless  the  epithelial  layer  has  been 
injured. 

Immunity. — Lazarus  found  that  the  blood-serum  of  human  beings  who 
had  recovered  from  cholera  contained  an  antidotal  substance  which  would 
prevent  the  fatal  result  of  intraperitoneal  injections  of  cholera  vibrios  in 
guinea-pigs.  E.  Pfeiffer  showed,  contrary  to  Lazarus,  that  this  substance 
was  not  of  the  nature  of  an  antitoxine,  but  was  actively  bactericidal,  and 
caused  rapid  disintegration  of  the  introduced  bacilli.  The  blood-serum 
of  animals  rendered  immune  to  the  bacillus  contains  this  body.  Upon  its 
presence  depends  the  success  of  the  "  Pfeiffer  serum  reaction "  for  the 
identification  of  the  true  cholera  vibrio  and  its  differentiation  from  all  other 
forms  which  resemble  it.  Haffkine  has  carried  out  immunizing  injections 
of  cholera  cultures  in  India  on  a  large  scale  with  very  promising  results. 

Modes  of  Infection. — As  in  other  diseases,  individual  peculiarities  count 
for  much,  and  during  epidemics  virulent  cholera  bacilli  have  been  isolated 
from  the  normal  stools  of  healthy  men.  Cholera  cultures  have  also  been 
swallowed  with  impunity. 

The  disease  is  not  highly  contagious;  physicians,  nurses,  and  others  in 
close  contact  with  patients  are  not  often  affected.     On  the  other  hand, 


CHOLERA  ASIATICA.  177 

washerwomen  and  those  who  are  brought  into  very  close  contact  with  the 
linen  of  the  cholera  patients,  or  with  their  stools,  are  particularly  prone  to 
catch  the  disease.  There  have  been  several  instances  of  so-called  "  labora- 
tory cholera/^  in  which  students,  having  been  accidentally  infected  while 
working  with  the  cultures,  have  developed  the  disease,  and  at  least  one 
death  has  resulted  from  this  cause. 

Vegetables  which  have  been  washed  in  the  infected  water,  particularly 
lettuces  and  cresses,  may  convey  the  disease.  Milk  may  also  be  contami- 
nated. The  bacilli  live  on  fresh  bread,  butter,  and  meat,  for  from 
six  to  eight  days.  In  regions  in  which  the  disease  prevails  the  possibil- 
ity of  the  infection  of  food  by  flies  should  be  borne  in  mind,  since  it  has 
been  shown  that  the  bacilli  may  live  for  at  least  three  days  in  their  intes- 
tines. 

Infection  through  the  air  is  not  to  be  much  dreaded,  since  the  germs 
when  dried  die  rapidly. 

The  disease  is  propagated  chieily  by  contaminated  water  used  for  drink- 
ing, cooking,  and  washing.  The  virulence  of  an  epidemic  in  any  region 
is  in  direct  proportion  to  the  imperfection  of  its  water-supply.  In  India 
the  demonstration  of  the  connection  between  drinking-water  and  cholera 
infection  is  complete.  The  Hamburg  epidemic  is  a  most  remarkable  illus- 
tration. The  unfiltered  water  of  the  Elbe  was  the  chief  supply,  although 
taken  from  the  river  in  such  a  situation  that  it  was  of  necessity  directly 
contaminated  by  sewage.  It  is  not  known  accurately  from  what  source  the 
contagion  came,  whether  from  Eussiaor  from  France,  but  in  August,  1892, 
there  was  a  sudden  explosive  epidemic,  and  within  three  months  nearly 
18,000  persons  were  attacked,  with  a  mortality  of  43.3  per  cent.  The  neigh- 
boring city  of  Altona,  which  also  took  its  water  from  the  Elbe,  but  which 
had  a  thoroughly  well-equipped  modern  filtration  system,  had  in  the  same 
period  only  516  cases. 

Two  main  types  of  epidemics  of  cholera  are  recognized:  the  first,  in 
which  many  individuals  are  attacked  simultaneously,  as  in  the  Hamburg 
outbreak,  and  in  which  no  direct  connection  can  be  traced  between  the 
individual  cases.  In  this  type  there  is  widespread  contamination  of  the 
drinking-water.  In  the  other  the  cases  occur  in  groups,  so-called  cholera 
nests;  individuals  are  not  attacked  simultaneously  but  successively.  A 
direct  connection  between  the  cases  may  be  very  difficult  to  trace.  Again, 
both  these  types  may  be  combined,  and  in  an  epidemic  which  has  started 
in  a  widespread  infection  through  water,  there  may  be  other  outbreaks, 
which  are  examples  of  the  second  or  chain-like  type. 

Pettenkofer,  on  the  other  hand,  denies  the  truth  of  this  drinking- 
water  theory,  and  maintains  that  the  conditions  of  the  soil  are  of  the  great- 
est importance;  particularly  a  certain  porosity,  combined  with  moisture 
and  contamination  with  organic  matter,  such  as  sewage.  He  holds  that 
germs  develop  in  the  subsoil  moisture  during  the  warm  months,  and  that 
they  rise  into  the  atmosphere  as  a  miasm. 

The  disease  always  follows  the  lines  of  human  travel.    In  India  it  has, 


178  SPECIFIC  INFECTIOUS  DISEASES. 

in  many  notable  cases,  been  widely  spread  by  pilgrims.  It  is  carried  also 
by  caravans  and  in  ships.    It  is  not  conveyed  through  the  atmosphere. 

Places  situated  at  the  sea-level  are  more  prone  to  the  disease  than  inland 
towns.  In  high  altitudes  the  disease  does  not  prevail  so  extensively.  A 
high  temperature  favors  the  development  of  cholera,  but  in  Europe  and 
America  the  epidemics  have  been  chiefly  in  the  late  summer  and  in  the 
autumn. 

The  disease  affects  persons  of  all  ages.  It  is  particularly  prone  to  attack 
the  intemperate  and  those  debilitated  by  want  of  food  and  by  bad  surround- 
ings. Depressing  emotions,  such  as  fear,  undoubtedly  have  a  marked  influ- 
ence. It  is  doubtful  whether  an  attack  furnishes  immunity  against  a 
second  one. 

Morbid  Anatomy. — There  are  no  characteristic  anatomical  changes 
in  cholera;  but  a  post-mortem  diagnosis  of  the  nature  of  the  disease  could 
be  made  by  any  competent  bacteriologist,  as  the  micro-organisms  are  spe- 
cific and  distinctive.  The  body  has  the  appearances  associated  with  pro- 
found collapse.  There  is  often  marked  post-mortem  elevation  of  tempera- 
ture. The  rigor  mortis  sets  in  early  and  may  produce  displacement  of  the 
limbs.  The  lower  jaw  has  been  seen  to  move  and  the  eyes  to  rotate.  Vari- 
ous movements  of  the  arms  and  legs  have  also  been  noted.  The  blood  is 
thick  and  dark,  and  there  is  a  remarkable  diminution  in  the  amount  of  its 
water  and  salts.  The  peritoneum  is  sticky,  and  the  coils  of  intestines  are 
congested  and  look  thin  and  shrunken.  There  is  nothing  special  in  the 
appearance  of  the  stomach.  The  small  intestine  usually  contains  a  turbid 
serum,  similar  in  appearance  to  that  which  was  passed  in  the  stools.  The 
mucosa  is,  as  a  rule,  swollen,  and  in  very  acute  cases  slightly  hypergemic; 
later  the  congestion,  which  is  not  uniform,  is  more  marked,  especially 
about  the  Peyer's  patches.  Post  mortem  the  epithelial  lining  is  sometimes 
denuded,  but  this  is  probably  not  a  change  which  takes  place  freely  during 
life.  In  the  stools,  however,  large  numbers  of  columnar  epithelial  cells  have 
been  described  by  Horner  and  others.  The  bacilli  are  found  in  the  con- 
tents of  the  intestine  and  in  the  mucous  membrane.  The  spleen  is  usually 
small.  The  liver  and  kidneys  show  cloudy  swelling,  and  the  latter  extensive 
coagulation-necrosis  and  destruction  of  the  epithelial  cells.  The  heart  is 
flabby;  the  right  chambers  are  distended  with  blood  and  the  left  chambers 
are  usually  empty.     The  lungs  are  collapsed,  and  congested  at  the  bases. 

The  above  appearances  are  those  met  with  in  cases  which  prove  rapidly 
fatal.  When  the  patient  survives  and  death  occurs  during  reaction,  there 
may  be  more  definite  inflammatory  appearances  in  the  intestines  leading 
to  extensive  necrosis  and  fibrinous  exudation,  and  more  pronounced  changes 
in  the  kidneys  and  liver. 

In  the  acute  cases  the  rice-water  discharges  contain  the  vibrios  in  prac- 
tically pure  cultures;  at  a  somewhat  later  stage  other  bacteria  make  their 
appearance,  while  in  the  stage  of  cholera-typhoid  the  comma  bacilli  are 
demonstrated  with  difficulty. 

Symptoms. — A  period  of  incubation  of  uncertain  length,  probably 
not  more  than  from  two  to  five  days,  precedes  the  development  of  the 
symptoms. 


CHOLERA  ASIATICA.  179 

Three  stages  may  be  recognized  in  the  attack:  the  preliminary  diar- 
rhoea, the  collapse  stage,  and  the  period  of  reaction. 

(a)  The  preliminary  diarrhoea  may  set  in  abruptly  without  any  previous 
indications.  More  commonly  there  are,  for  one  or  two  days,  colicky  pains 
in  the  abdomen,  with  looseness  of  the  bowels,  perhaps  vomiting,  with  head- 
ache and  depression  of  spirits.    There  may  be  no  fever. 

(&)  Collapse  Stage. — The  diarrhoea  increases,  or,  without  any  of  the 
preliminary  symptoms,  sets  in  with  the  greatest  intensity,  and  profuse 
liquid  evacuations  succeed  each  other  rapidly.  There  are  in  some  instances 
griping  pains  and  tenesmus.  More  commonly  there  is  a  sense  of  exhaustion 
and  collapse.  The  thirst  becomes  extreme,  the  tongue  is  white;  cramps  of 
great  severity  occur  in  the  legs  and  feet.  Within  a  few  hours  vomiting 
sets  in  and  becomes  incessant.  The  patient  rapidly  sinks  into  a  condition 
of  collapse,  the  features  are  shrunken,  the  skin  has  an  ashy  gray  hue,  the 
eyeballs  sink  in  the  sockets,  the  nose  is  pinched,  the  cheeks  are  hollow, 
the  voice  becomes  husky,  the  extremities  are  cyanosed,  and  the  skin  is  shriv- 
elled, wrinkled,  and  covered  with  a  clammy  perspiration.  The  temperature 
sinks.  In  the  axilla  or  in  the  mouth  it  may  be  from  five  to  ten  degrees 
below  normal,  but  in  the  rectum  and  in  the  internal  parts  it  may  be  103° 
or  104°.  The  pulse  becomes  extremely  feeble  and  flickering,  and  the  patient 
gradually  passes  into  a  condition  of  coma,  though  consciousness  is  often 
retained  until  near  the  end. 

The  faeces  are  at  first  yellowish  in  color,  from  the  bile  pigment,  but 
soon  they  become  grayish  white  and  look  like  turbid  whey  or  rice-water; 
whence  the  term  "  rice-water  stools.^'  There  are  found  in  them  numerous 
smair  flakes  of  mucus  and  granular  matter,  and  at  times  blood.  The  re- 
action is  usually  alkaline.  The  fluid  contains  albumin  and  the  chief  min- 
eral ingredient  is  chloride  of  sodium.  Microscopically,  mucus  and  epithelial 
cells  and  innumerable  bacteria  are  seen,  the  majority  of  the  latter  being 
the  comma  bacilli. 

The  condition  of  the  patient  is  largely  the  result  of  the  concentration 
of  the  blood  consequent  upon  the  loss  of  serum  in  the  stools.  There  is 
almost  complete  arrest  of  secretion,  particularly  of  the  saliva  and  the  urine. 
On  the  other  hand,  the  sweat-glands  increase  in  activity,  and  in  nursing 
women  it  has  been  stated  that  the  lacteal  flow  is  unaffected.  This  stage 
sometimes  lasts  not  more  than  two  or  three  hours,  but  more  commonly  from 
twelve  to  twenty-four.  There  are  instances  in  which  the  patient  dies 
before  purging  begins — the  so-called  cholera  sicca. 

(c)  Reaction  Stage". — When  the  patient  survives  the  collapse,  the  cyano- 
sis gradually  disappears,  the  warmth  returns  to  the  skin,  which  may  have 
for  a  time  a  mottled  color  or  present  a  definite  erythematous  rash.  The 
heart's  action  becomes  stronger,  the  urine  increases  in  quantity,  the  irrita- 
bility of  the  stomach  disappears,  the  stools  are  at  longer  intervals,  and  there 
is  no  abdominal  pain.  In  the  reaction  the  temperature  may  not  rise  above 
normal.  Not  infrequently  this  favorable  condition  is  interrupted  by  a  recur- 
rence of  severe  diarrhoea  and  the  patient  is  carried  off  in  a  relapse.  Other 
cases  pass  into  the  condition  of  what  has  been  called  cholera-typhoid,  a 
state  in  which  the  patient  is  delirious,  the  pulse  rapid  and  feeble,  and  the 


180  '  SPECIFIC  INFECTIOUS  DISEASES. 

tongue  dry.  Death  finally  occurs  with  coma.  These  symptoms  have  been 
attributed  to  uraemia. 

During  epidemics  attacks  are  found  of  all  grades  of  severity.  There 
are  cases  of  diarrhoea  with  griping  pains,  liquid,  copious  stools,  vomiting, 
and  cramps,  with  slight  collapse.  To  these  the  term  cholerine  has  been 
applied.  They  resemble  the  milder  cases  of  cholera  nostras.  At  the  oppo- 
site end  of  the  series  there  are  the  instances  of  cholera  sicca,  in  which 
death  may  occur  in  a  few  hours  after  the  onset,  without  diarrhoea.  There 
are  also  cases  in  which  the  patients  are  overwhelmed  with  the  poison  and 
die  comatose,  without  the  preliminary  stage  of  collapse. 

Complications  and  Sequelae.  — The  typhoid  condition  has  al- 
ready been  referred  to.  The  consecutive  nephritis  rarely  induces  dropsy. 
Diphtheritic  colitis  has  been  described.  There  is  a  special  tendency  to 
diphtheritic  inflammation  of  the  mucous  membranes,  particularly  of  the 
throat  and  genitals.  Pneumonia  and  pleurisy  may  develop,  and  destruc- 
tive abscesses  may  occur  in  different  parts.  Suppurative  parotitis  is  not 
very  uncommon.  In  rare  instances  local  gangrene  may  develop.  A  trouble- 
some symptom  of  convalescence  is  cramps  in  the  muscles  of  the  arms  and 
legs. 

Diagnosis. — The  only  affection  with  which  Asiatic  cholera  could  be 
confounded  is  the  cholera  nostras,  the  severe  choleraic  diarrhoea  which 
occurs  during  the  summer  months  in  temperate  climates.  The  clinical 
picture  of  the  two  affections  is  identical.  The  extreme  collapse,  vomiting, 
and  rice-water  stools,  the  cramps,  the  cyanosed  appearance,  are  all  seen  in 
the  worst  forms  of  cholera  nostras.  In  enfeebled  persons  death  may  occur 
within  twelve  hours.  It  is  of  course  extremely  important  to  be  able  to  diag- 
nose between  the  two  affections.  This  can  only  be  done  by  one  thoroughly 
versed  in  bacteriological  methods,  and  conversant  with  the  diversified  flora 
of  the  intestines.  The  comma  bacillus  is  present  in  the  dejections  of  a 
great  majority  of  the  cases  and  can  be  seen  on  cover-glass  preparations. 
Though  the  eye  of  the  expert  may  be  able  to  differentiate  between  the 
bacillus  of  true  cholera  and  that  which  occurs  in  cholera  nostras,  cultures 
should  be  made,  from  which  alone  positive  results  can  be  obtained. 

Attacks  very  similar  to  Asiatic  cholera  are  produced  in  poisoning  by 
arsenic,  corrosive  sublimate,  and  certain  fungi;  but  a  difficulty  in  diagnosis 
could  scarcely  arise. 

The  prognosis  is  always  uncertain,  as  the  mortality  ranges  in  different 
epidemics  from  30  to  80  per  cent.  Intemperance,  debility,  and  old  age 
are  unfavorable  conditions.  The  more  rapidly  the  collapse  sets  in,  the 
greater  is  the  danger,  and  as  Andral  truly  says  of  the  malignant  form,  "  It 
begins  where  other  diseases  end — in  death."  Cases  with  marked  cyanosis 
and  very  low  temperature  rarely  recover. 

Prophylaxis. — Preventive  measures  are  all-important,  and  isolation 
of  the  sick  and  thorough  disinfection  have  effectually  prevented  the  dis- 
ease entering  England  or  the  United  States  since  1873.  On  several  occa- 
sions since  that  date  cholera  has  been  brought  to  various  ports  in  America, 
but  has  been  checked  at  quarantine.  During  epidemics  the  greatest  care 
should  be  exercised  in  the  disinfection  of  the  stools  and  linen  of  the  pa- 


CHOLERA  ASIATIC  A.  181 

tients.  When  an  epidemic  prevails,  persons  should  be  warned  not  to  drink 
water  unless  previously  boiled.  Errors  in  diet  should  be  avoided.  As  the 
disease  is  not  more  contagious  than  typhoid  fever,  the  chance  of  a  person 
passing  safely  through  an  epidemic  depends  very  much  upon  how  far  he 
is  able  to  carry  out  thoroughly  prophylactic  measures.  Digestive  disturb- 
ances are  to  be  treated  promptly,  and  particularly  the  diarrhoea,  which  so 
often  is  a  preliminary  symptom.  For  this,  opium  and  acetate  of  lead  and 
large  doses  of  bismuth  should  be  given. 

Medicinal  Treatment.  — During  the  initial  stage,  when  the  diar- 
rhoea is  not  excessive  but  the  abdominal  pain  is  marked,  opium  is  the  most 
efficient  remedy,  and  it  should  be  given  hypodermically  as  morphia.  It  is 
advisable  to  give  at  once  a  full  dose,  which  may  be  repeated  on  the  return 
of  the  pain.  It  is  best  not  to  attempt  to  give  remedies  by  the  mouth,  as 
they  disturb  the  stomach.  Ice  should  be  given,  and  brandy  or  hot  coffee. 
In  the  collapse  stage,  writers  speak  strongly  against  the  use  of  opium.  Un- 
doubtedly it  must  be  given  with  caution,  but,  judging  from  its  effects  in 
cholera  nostras,  I  should  say  that  collapse  per  se  was  not  a  contra-indica- 
tion.  The  patient  may  be  allowed  to  drink  freely.  For  the  vomiting,  which 
is  very  difficult  to  check,  cocaine  may  be  tried,  and  lavage  with  hot  water. 
Creasote,  hydrocyanic  acid,  and  creolin  have  been  found  useless.  Rumpf 
advises  calomel  (gr.  -|)  every  two  hours. 

External  applications  of  heat  should  be  made  and  a  hot  bath  may  be 
tried.  Warm  applications  to  the  abdomen  are  very  grateful.  Hypodermic 
injections  of  ether  will  be  found  serviceable. 

Irrigation  of  the  bowel — enteroclysis — with  warm  water  and  soap,  or 
tannic  acid  (2  per  cent),  should  be  used.  With  a  long,  soft-rubber  tube, 
as  much  as  3  or  4  litres  may  be  slowly  injected.  Not  only  is  the  colon 
cleansed,  but  the  small  bowel  may  also  be  reached,  as  shown  by  the  fact 
that  the  tannic-acid  solutions  have  been  vomited. 

Owing  to  the  profuse  serous  discharges  the  blood  becomes  concentrated, 
and  absorption  takes  place  rapidly  from  the  lymph-spaces.  To  meet  this, 
intravenous  injections  were  introduced  by  Latta,  of  Leith,  in  the  epidemic 
of  1832.  My  preceptor,  Bovell,  first  practised  the  intravenous  injections 
of  milk  in  Toronto,  in  the  epidemic  of  1854.  A  litre  of  salt  solution  at  107° 
may  be  injected,  and  repeated  in  a  few  hours  if  no  reaction  follows.  Less 
risky  and  equally  efficacious  is  the  subcutaneous  injection  of  a  saline  solu- 
tion. For  this,  common  salt  should  be  used  in  the  proportion  of  about  four 
grammes  to  the  liter.  With  rubber  tubing,  a  cannula  from  an  aspirator,  or 
even  with  a  hypodermic  needle,  the  warm  solution  may  be  allowed  to  run 
by  pressure  beneath  the  skin.  It  is  rapidly  absorbed,  and  the  process  may 
be  continued  until  the  pulse  shows  some  sign  of  improvement.  This  is 
really  a  valuable  method,  thoroughly  physiological,  and  should  be  tried 
in  all  severe  cases. 

In  the  stage  of  reaction  special  pains  should  be  taken  to  regulate  the 
diet  and  to  guard  against  recurrences  of  the  severe  diarrhoea. 


182  SPECIFIC  INFECTIOUS  DISEASES. 

XXI.   YELLOW  FEVER. 

Definition. — A  fever  of  tropical  and  subtropical  countries,  character- 
ized by  a  toxemia  of  varying  intensity,  with  jaundice,  albuminuria,  and  a 
marked  tendency  to  hsemorrhage,  especially  from  the  stomach,  causing  the 
''  black  vomit/'  The  specific  organism  has  not  yet  been  found,  but  the  dis- 
ease is  capable  of  being  transmitted  through  the  bite  of  mosquitoes. 

Etiology. — The  disease  prevails  endemically  in  the  "West  Indies  and 
in  certain  sections  of  the  Spanish  Main.  From  these  regions  it  occasionally 
extends  and,  under  suitable  conditions,  prevails  epidemically  in  the  South- 
ern States.  ISTow  and  then  it  is  brought  to  the  large  seaports  of  the  Atlantic 
coast.  Formerly  it  occurred  extensively  in  the  United  States.  In  the  latter 
part  of  the  eighteenth  century  and  the  beginning  of  the  nineteenth,  frightful 
epidemics  prevailed  in  Philadelphia  and  other  Northern  cities.  The  epi- 
demic of  1793,  in  Philadelphia,  so  graphically  described  by  Matthew  Carey, 
was  the  most  serious  that  has  ever  visited  any  city  of  the  Middle  States.  The 
mortality,  as  given  by  Carey,  during  the  months  of  August,  September, 
October,  and  November,  was  4,041,  of  whom  3,435  died  in  the  months  of 
September  and  October.  The  population  of  the  city  at  the  time  was  only 
40,000.  Epidemics  occurred  in  the  United  States  in  1797,  1798,  1799,  and 
in  1803,  when  the  disease  prevailed  slightly  in  Boston  and  extensively  in 
Baltimore.  In  1803  and  1805  it  again  appeared;  then  for  many  years  the 
outbreaks  were  slight  and  localized.  In  1853  the  disease  raged  throughout 
the  Southern  States.  There  were  moderately  severe  epidemics  in  1867, 
1873,  and  1878;  and  still  milder  ones  in  1897,  1898,  and  1899.  In  July, 
1899,  a  local  outbreak  occurred  in  the  Soldiers'  Home,  at  Hampton,  Va. 
There  were  45  cases,  with  13  deaths.  In  Cuba  the  disease  prevails  during 
the  summer  season,  and  in  Havana  last  year  (1900)  there  was  an  unusually 
severe  outbreak.  In  Europe  it  has  occasionally  gained  a  foothold,  but  there 
have  been  no  widespread  epidemics  except  in  the  Spanish  ports.  The  dis- 
ease exists  on  the  west  coast  of  Africa.  It  is  sometimes  carried  to  ports  in 
Great  Britain  and  France,  but  it  has  never  extended  into  those  countries. 
The  history  of  the  disease  and  its  general  symptomatology  are  exhaustively 
treated  of  in  the  classical  works  of  Eene  La  Eoche  and  Berenger-Feraud. 

Guiteras  recognizes  tliree  areas  of  infection:  (1)  The  focal  zone  in  which 
the  disease  is  never  absent,  including  Havana,  Vera  Cruz,  Eio,  and  other 
Spanish- American  ports.  (2)  The  perifocal  zone  or  regions  of  periodic  epi- 
demics, including  the  ports  of  the  tropical  Atlantic  in  America  and  Africa. 
(3)  The  zone  of  accidental  epidemics,  between  the  parallels  of  45°  north 
and  35°  south  latitude. 

Conditions  favoring  the  Development  of  Epidemics. — ^Yellow  fever  is  a 
disease  of  the  sea-coast,  and  rarely  prevails  in  regions  with  an  elevation 
above  1,000  feet.  Its  ravages  are  most  serious  in  cities,  particularly  when 
the  sanitary  conditions  are  unfavorable.  It  is  always  most  severe  in  the 
badly  drained,  unhealthy  portions  of  a  city,  where  the  population  is  crowded 
together  in  ill-ventilated,  dark  houses.  The  disease  prevails  during  the  hot 
season.  Humidity  and  heat  seem  to  be  the  proper  coefficients  for  the  pres- 
ervation of  the  poison. 


YELLOW  FEVER.  I33 

The  epidemics  in  the  United  States  have  always  been  in  the  summer  and 
autumn  months,  disappearing  rapidly  with  the  onset  of  cold  weather. 

Mode  of  Transmission. — (a)  By  Direct  Contagion. — There  seems 
to  be  very  little  risk  in  nursing  the  disease.  In  Cuba  very  few  of  the 
nurses  or  doctors  in  attendance  upon  yellow-fever  patients  have  been  af- 
fected. "Walter  Eeed  tells  me  that,  so  far  as  he  knows,  not  a  nurse  or  doc- 
tor contracted  the  disease  by  caring  for  the  sick  in  Cuba,  unless  the  nurs- 
ing was  done  in  a  house  known  to  be  infected.  In  one  hospital  in  the 
suburbs  of  Havana  five  non-immune  female  nurses  nursed  more  than  one 
hundred  yellow-fever  cases  during  1900  without  contracting  the  disease. 

(&)  By  Fomites. — No  belief  is  more  strong  among  the  laity  than  that 
the  disease  is  transmitted  by  infected  clothing,  and  quarantine  efforts  are 
chiefly  directed  to  the  disinfection  of  fomites  of  all  sorts  shipped  from 
infected  ports.  A  remarkable  series  of  experiments  have  been  reported  by 
the  Yellow  Fever  Commission  of  the  United  States  Army,  consisting  of 
Drs.  Walter  Eeed,  Carroll,  Lazear,  and  Agramonte,  which  go  far  to  show 
that  the  disease  can  not  be  conveyed  in  this  way.  At  Camp  Lazear,  Cuba, 
a  frame  house  was  so  constructed  as  to  shut  out  the  sunlight  and  fresh  air, 
and  the  vestibule  was  thoroughly  screened.  The  average  temperature  for 
sixty-three  days  was  kept  about  76°  F.  Boxes  filled  with  sheets,  pillow- 
slips, blankets,  etc.,  contaminated  by  contact  with  cases  of  yellow  fever 
and  the  discharges,  were  placed  in  the  house.  Dr.  K.  P.  Cooke  and  two 
privates  of  the  hospital  corps,  all  non-immunes,  entered  this  building  and 
unpacked  the  boxes,  and  for  a  period  of  twenty  days  occupied  the  room, 
each  morning  packing  the  infected  articles  in  the  boxes,  and  at  night  un- 
packing them.  In  their  experiments  with  the  fomites,  in  all  seven  non- 
immune subjects  during  the  period  of  sixty-three  days  lived  in  contact  with 
the  fomites  and  remained  perfectly  well.  These  experiments,  conducted 
in  the  most  rigid  and  scientific  manner,  go  far  to  discredit  the  belief  in  the 
transmission  of  the  disease  by  fomites. 

(c)  Transmission  hy  Mosquitoes. — Carlos  Finlay,  of  Havana,  in  1881 
suggested  that  the  disease  was  transmitted  by  mosquitoes.  Stimulated  by 
the  work  of  Eoss  on  malaria,  the  American  Commission  above-named  has 
demonstrated  conclusively  that  yellow  fever  may  be  transferred  by  the 
mosquito,  culex  fasciatus  (Fabricius),  previously  fed  on  the  blood  of  infected 
persons.  Non-immunes  were  kept  under  the  most  rigid  quarantine  for  a 
period  outside  the  endemic  area,  and  then  exposed  in  a  specially  constructed 
house  to  the  bites  of  mosquitoes  that  had  previously  bitten  cases  of  yellow 
fever.  The  experiment  fulfilled  the  most  exacting  conditions  of  scientific 
accuracy,  and  forms  a  model  of  its  kind. 

The  Commission  showed  also  that  in  non-immunes  the  disease  could 
be  produced  by  either  the  subcutaneous  or  the  intravenous  injection  of 
blood  taken  from  patients  suffering  with  the  disease. 

An  interval  of  about  twelve  days  or  more  after  contamination  appears 
to  be  necessary  before  the  mosquito  is  capable  of  introducing  the  infection. 
The  bite  at  an  early  period  after  contamination  does  not  confer  immunity 
against  a  subsequent  attack.  The  period  of  incubation  in  13  cases  of  ex- 
perimental yellow  fever  varied  from  forty-one  hours  to  five  days  and  seven- 
teen hours. 


184  SPECIFIC  INFECTIOUS  DISEASES. 

"We  must  bear  testimony  to  the  heroism  of  the  young  soldiers  who  vol- 
untarily, without  any  compensation  and  purely  in  the  interests  of  human- 
ity, submitted  to  the  experiments,  and  also  to  the  zeal  and  devotion  with 
which  members  of  our  profession  have,  at  the  greatest  possible  risks, 
attempted  to  solve  the  riddle  of  this  most  serious  disease.  The  death  from 
the  disease  of  Dr.  Lazear,  of  the  American  Commission,  and  of  Dr.  Myers, 
of  the  Liverpool  Commission,  adds  two  more  names  to  the  already  long 
roll  of  the  martyrs  of  science. 

As  Eeed  points  out,  the  mosquito  theory  fits  in  with  well-recognized 
facts  in  connection  with  the  epidemics.  After  the  importation  of  a  case 
into  an  uninfected  region,  a  definite  period  of  time  elapses,  rarely  less  than 
two  weeks,  before  a  second  case  occurs.  Like  malaria,  the  disease  prevails 
most  during  the  mosquito  season,  and  disappears  with  the  appearance  of 
frost.  Probably,  too,  as  in  very  malarious  districts,  the  disease  is  kept  up 
by  its  prevalence  in  a  very  mild  form  among  children.  As  Guiteras  re- 
marks, "  the  foci  of  endemicity  are  essentially  maintained  by  the  Creole 
infant  population,  which  is  subject  to  the  disease  in  a  very  mild  form."  In 
all  probability  the  immunity  which  is  acquired  by  prolonged  residence  in 
a  locality  in  which  the  disease  is  endemic  is  due  to  the  occurrence  of  very 
slight  attacks. 

It  has  been  shown  that  one  attack  does  not  always  confer  immunity. 
Eosenau  reports  two  attacks  within  a  period  of  eight  years,  and  Libby  two 
attacks  within  a  period  of  two  years. 

The  Specific  Germ. — The  transmission  by  the  mosquito  makes  it  very 
probable,  reasoning  from  analogy,  that  the  germ  of  the  disease  is  a  proto- 
zoon;  but  of  this  there  is  no  evidence  as  yet.  There  are  three  views  at 
present  held: 

1.  Bacillus  icteroides  of  Sanarelli,  which  he  claims  is  found  in  more 
than  half  of  the  cases,  and  produces  what  he  calls  an  amaril  poison  with 
three  special  properties — emetic,  hsemorrhagic,  and  steatogenic.  The 
claims  of  Sanarelli  have  been  disputed  by  Novy,  and  also  by  the  Yellow 
Fever  Commission  of  the  United  States  Army,  which  in  1900,  in  18 
cases  of  typical  yellow  fever,  failed  to  find  bacillus  icteroides  in  the 
blood  in  a  single  case,  and  the  same  negative  results  were  obtained  in 
11  autopsies. 

2.  From  what  I  can  gather,  a  majority  of  those  whose  bacteriological 
training  makes  them  fit  judges,  incline  strongly  to  the  belief  that  the 
specific  organism  of  the  disease  has  not  yet  been  discovered. 

3.  Quite  recently  Durham  and  Myers,  of  the  Liverpool  Yellow  Fever 
Commission,  have  found  a  small,  fine  infiuenza-like  bacillus  in  scanty  num- 
bers in  organs  of  perfectly  fresh  cadavers.  They  confirm  Sternberg's  state- 
ment of  the  extraordinary  numbers  of  similar  small  bacilli  in  mucus  of 
evacuations  and  of  intestinal  contents.  It  did  not  grow  upon  ordinary 
media. 

Morbid  Anatomy. — The  skin  is  more  or  less  jaundiced,  even  though 
the  patient  did  not  appear  yellow  before  death.  Cutaneous  hjemorrhages 
may  be  present.  No  specific  or  distinctive  internal  lesions  have  been  found. 
The  blood-serum  may  contain  haemoglobin,  owing  to  destruction  of  the 


YELLOW  FEVER.  185 

red  cells,  just  as  in  pernicious  malaria.  The  heart  sometimes,  not  invaria- 
bly, shows  fatty  change;  the  stomach  presents  more  or  less  hyperasmia  of 
the  mucosa  with  catarrhal  swelling.  It  contains  the  material  which,  ejected 
during  life,  is  known  as  the  hlach  vomit.  The  essential  ingredient  in  this  is 
transformed  blood-pigment.  There  is  no  proof  that  this  black  material 
depends  upon  the  growth  of  a  micro-organism.  There  is  often  general 
glandular  enlargement;  the  cervical  axillary  and  mesenteric  groups  are 
most  involved.  The  liver  is  usually  of  a  pale  yelloAV  or  brownish-yellow 
color,  and  the  cells  are  in  various  stages  of  fatty  degeneration.  From  the 
date  of  Louis'  observations  at  Gibraltar  in  1828,  the  appearances  of  this 
organ  have  been  very  carefully  studied,  and  some  have  thought  the  changes 
in  it  to  be  characteristic.  Councilman  has  described  remarkable  aj)pear- 
ances  in  the  liver-cells  which  he  believes  are  distinctive  and  peculiar.  Fatty 
degeneration  and  regions  of  necrosis  are  present  in  all  cases.  The  kidneys 
always  show  traces  of  diffuse  nephritis.  The  epithelium  of  the  convoluted 
tubules  is  swollen  and  very  granular;  there  may  also  be  necrotic  changes. 
In  both  liver  and  kidneys  bacteria  of  various  sorts  have  been  described. 

Symptoms. — The  incubation  is  usually  three  or  four  days;  in  13 
experimental  cases  it  ranged  from  forty-one  hours  to  five  days  seventeen 
hours.  The  onset  is  sudden,  as  a  rule,  without  premonitory  symptoms,  and 
in  the  early  hours  of  the  morning.  Chilly  feelings  are  common,  and  are 
usually  associated  with  headache  and  very  severe  pains  in  the  back  and 
limbs.  The  fever  rises  rapidly  and  the  skin  feels  very  hot  and  dry.  The 
tongue  is  furred,  but  moist;  the  throat  sore.  Nausea  and  vomiting  are  not 
constant,  and  become  more  intense  on  the  second  or  third  day.  The 
bowels  are  usually  constipated.  The  following,  in  detail,  are  the  more 
important  characteristics: 

Fades. — Even  as  early  as  the  first  morning  the  patient  may  present  a 
very  characteristic  facies,  according  to  Guiteras,  one  of  the  three  distin- 
guishing features  of  the  disease.  The  following  description  is  taken  from 
him:  The  face  is  decidedly  flushed,  more  so  than  in  any  other  acute  infec- 
tious disease  at  such  an  early  period.  The  eyes  are  injected,  the  color  is 
a  bright  red,  and  there  may  be  a  slight  tumefaction  of  the  eyelids  and  of 
the  lips.  Even  at  this  early  date  there  is  to  be  noticed  in  connection  with 
the  injection  of  the  superficial  capillaries  of  the  face  and  conjunctivae  an 
element  of  icterus,  and  "  the  early  manifestation  of  jaundice  is  undoubtedly 
the  most  characteristic  feature  of  the  facies  of  yellow  fever."  It  has  to  be 
looked  for  very  carefully. 

The  Fever. — On  the  morning  of  the~first  day  the  temperature  may  vary 
between  100°  and  106°,  usually  between  103°  and  103°.  During  the  even- 
ing of  the  first  day  and  the  morning  of  the  second  day  the  temperature 
keeps  about  the  same.  There  is  a  slight  diurnal  variation  on  the  secoud 
and  third  day.  In  very  mild  cases  the  fever  may  fall  on  the  evening  of  the 
second  or  on  the  morning  of  the  third  day,  or  in  abortive  cases  or  in  unde- 
veloped cases  in  children  even  at  the  end  of  twenty-four  hours.  In  cases 
that  are  to  terminate  favorably  the  defervescence  takes  place  by  lysis  during 
a  period  of  two  or  three  days.  The  remission  or  stage  of  calm,  as  it  has  been 
called,  is  succeeded  by  a  febrile  reaction  or  secondary  fever,  which  lasts  one, 


186  SPECIFIC  INFECTIOUS  DISEASES. 

two,  or  three  days,  and  in  favorable  cases  falls  by  a  short  lysis.  On  the 
other  hand,  in  fatal  cases  the  temperature  is  continuous,  becomes  higher 
than  in  the  initial  fever,  and  death  follows  shortly. 

The  Pulse. — On  the  first  day  the  pulse  is  rarely  more  than  100  or  110. 
On  the  second  or  third  day,  while  the  fever  still  keeps  up,  the  pulse  begins 
to  fall,  and  may  have  become  slower  by  as  much  as  20  beats  while  the  tem- 
perature has  risen  1.5°  or  2°.  On  the  evening  of  the  third  day  there  may  be 
a  temperature  range  of  103°  and  a  pulse  of  only  75,  or  "  a  temperature 
between  103°  and  104°  with  a  pulse  running  from  70  to  80."  This  impor- 
tant diagnostic  feature  was  first  described  by  Faget,  of  New  Orleans.  Dur- 
ing the  defervescence  the  pulse  may  become  still  slower,  down  to  50,  48,  or 
45,  or  even  as  low  as  30.  A  slow  pulse  with  the  defervescence  is  not  the 
special  circulatory  feature  of  the  disease,  but  ihe  slowing  of  the  pulse  with 
a  steady  or  even  rising  temperature. 

Albuminuria. — This,  regarded  by  Guiteras  as  the  third  characteristic 
symptom  of  the  disease,  occurs  as  early  as  the  evening  of  the  third  day.  He 
says  very  truly  that  it  is  very  rare  so  early  in  other  fevers  except  those  of  an 
unusually  severe  type.  "  Even  in  the  mild  cases  that  do  not  go  to  bed — 
cases  of  '  walking  yellow  fever ' — on  the  second,  third,  or  fourth  day  of 
the  disease  albuminuria  will  show  itself."  It  may  be  quite  transient.  In 
the  severer  cases  the  amount  of  albumin  is  very  large,  and  there  may  be 
numerous  tube-casts  and  all  the  signs  of  an  intense  acute  nephritis;  or 
complete  suppression  of  the  urine  may  supervene,  and  death  may  occur  in 
uremic  convulsions  or  coma  within  twenty-four  or  thirty-six  hours.  Gui- 
teras  insists  that  the  evening  urine  should  be  specially  examined.  He 
states  that  the  presence  of  albumin  on  the  first  day  and  its  persistence  on 
the  second  indicate  a  severe  case.  With  the  secondary  rise  in  temperature 
the  jaundice  becomes  more  intense. 

Gastric  Features. — ''Black  Vomit." — Irritability  of  the ^  stomach  is 
present  from  the  very  outset,  and  the  vomited  matter  consists  of  the  con- 
tents of  the  stomach,  and  subsequently  of  mucus  and  a  grayish  fluid.  In 
the  third  stage  of  the  disease  the  vomiting  becomes  more  pronounced  and 
in  the  severe  cases  is  characterized  by  the  presence  of  blood.  It  may  be 
copious  and  forcible,  producing  much  pain  in  the  abdomen  and  along  the 
gullet.  There  is  nothing  specific  in  the  "  black  vomit "  of  yellow  fever. 
It  consists  of  altered  blood.  "  Black  vomit "  is  not  necessarily  a  fatal 
symptom,  though  it  occurs  only  in  the  severer  forms  of  the  disease.  Other 
hsemorrhagic  features  may  be  present — petechias  on  the  skin  and  bleeding 
from  the  gums  or  from  other  mucous  membranes.  The  bowels  are  usually 
constipated,  the  stools  not  clay-colored,  except  late  in  the  disease.  They 
are  sometimes  tarry  from  the  presence  of  altered  blood. 

Mental  Features. — In  very  severe  cases  the  onset  may  be  with  active 
delirium.  "  As  a  rule,  in  a  majority  of  cases,  even  wben  there  is  black 
vomit,  there  is  a  peculiar  alertness;  the  patient  watches  everything  going 
on  about  him  with  a  peculiar  intensity  and  liveliness.  This  may  be  due 
in  part  to  the  terror  the  disease  inspires  "  (Guiteras).  The  first  signs  of 
mental  cloudiness  may  be  due  to  the  ura;mic  coma. 

Eelapses  occasionally  occur.    Among  the  varieties  of  the  disease  it  is 


YELLOW  FEVER.  187 

important  to  recognize  the  mild  cases.  These  are  characterized  by  slight 
fever,  continuing  for  one  or  two  days,  and  succeeded  by  a  rapid  convales- 
cence. Such  cases  would  not  be  recognized  as  yellow  fever  in  the  absence 
of  a  prevailing  epidemic.  Cases  of  greater  severity  have  high  fever  and 
the  features  of  the  disease  are  well  marked — vomiting,  extreme  prostra- 
tion, and  hemorrhages.  And  lastly,  there  are  malignant  cases  in  which 
the  patient  is  overwhelmed  by  the  intensity  of  the  fever,  and  death  takes 
place  in  two  or  three  days. 

In  severe  cases  convalescence  may  be  complicated  by  the  occurrence  of 
parotitis,  abscesses  in  various  parts  of  the  body,  and  diarrhoea.  An  attack 
confers  an  immunity  which  persists,  as  a  rule,  through  life. 

Diagnosis. — (a)  From  Dengue. — The  difficulty  in  the  differential 
diagnosis  of  these  two  diseases  lies  in  their  frequent  coexistence,  as  during 
the  epidemic  of  1897  in  parts  of  the  Southern  States.  During  the  autumn 
of  1897  the  profession  of  Texas  was  divided  on  the  question  of  the  exist- 
ence of  yellow  fever  in  the  State,  some  claiming  that  the  disease  was 
dengue,  others,  including  Guiteras  and  West,  that  yellow  fever  also  existed. 
If  the  suspicious  cases  were  dengue,  break-bone  fever  is  a  much  more 
serious  disease  than  writers  state,  and  certain  of  the  symptoms,  particu- 
larly haemorrhages,  occur  in  a  larger  proportion  of  cases  than  has  been 
heretofore  acknowledged.  Of  the  other  symptoms,  too,  one  writer  states 
that  jaundice  of  mild  grade  was  the  rule  from  first  to  last.  Albumin  was 
not  infrequently  present  in  the  urine,  and  the  lack  of  correlation  between 
the  pulse  and  the  temperature  was  so  frequent  as  to  be  almost  the  rule. 
There  was  no  case  of  black  vomit.  Dengue,  as  I  have  stated  in  the  article 
on  that  disease,  prevailed  to  a  remarkable  extent  in  the  city  of  Galveston. 
On  the  other  hand,  if  the  cases  examined  by  Guiteras  and  declared  by  hun 
to  be  yellow  fever  were  truly  examples  of  that  disease,  there  is  the  anoma- 
lous— indeed,  unique — fact  of  an  outbreak  of  yellow  fever  in  a  city  which 
had  not  had  the  disease  in  epidemic  form  since  1867,  and  in  which  it  did 
not  assume  epidemic  proportions  and  did  not  increase  the  death-rate,  which 
for  the  months  of  August,  September,  and  October  of  1897  was  lower  than 
for  the  corresponding  three  months  in  1896  and  1895.  After  a  review 
of  the  local  literature  on  the  question,  I  confess  myself  to  be  quite  unable 
to  decide  upon  the  points  at  issue.  I  have  dwelt  upon  this  matter  in  order 
that  practitioners  may  realize  how  difficult  the  diagnosis  may  be  under 
certain  circumstances.  It  is  quite  useless  to  emphasize  in  parallel  columns 
the  differential  points  between  the  two  diseases.  Doubtless  in  a  majority 
of  all  the  cases  the  three  diagnostic  points  upon  which  Guiteras  lays  stress 
— the  facies,  the  albuminuria,  and  the  slowing  of  the  pulse  with  mainte- 
nance or  elevation  of  the  fever — are  sufficient  for  the  diagnosis.  He  states, 
too,  that  jaundice,  which  does  sometimes  occur  in  dengue,  rarely  appears  as 
early  as  the  second  or  third  day  of  the  disease,  and  on  this  much  stress 
should  be  laid.  Haemorrhages  are  much  less  common  in  dengue,  but  that 
they  do  occur  has  been  recognized  by  authorities  ever  since  the  time  of 
Eush.  It  is  a  pity  that  we  can  not  be  more  positive  on  this  all-important 
point,  but  when  an  expert  like  Dr.  John  Guiteras  is  in  doubt  it  behooves 
the  average  practitioner  to  be  humble. 
12 


188  '  SPECIFIC  INFECTIOUS  DISEASES. 

(b)  From  Malarial  Fever. — In  the  early  stages  of  an  epidemic  cases  are 
very  apt  to  be  mistaken  for  forms  of  malarial  fever.  In  the  Southern  States 
the  outbreaks  have  usually  been  in  the  late  summer  months,  the  very  season 
in  which  the  astivo-autumnal  irregular  malarial  fever  prevails.  Among 
the  points  to  be  specially  noted  are  the  absence  of  early  jaundice  in  ma- 
larial fever.  Even  in  the  most  intense  types  of  infection  the  color  of  the 
skin  is  rarely  changed  within  four  or  five  days.  To  the  experienced  eye 
the  facies  would  be  of  considerable  help  if  the  ease  was  seen  from  the 
outset.  Albumin  is  rarely  present  in  the  urine  so  early  as  the  second  day 
in  a  malarial  infection.  Other  important  points  are  the  marked  swelling 
of  the  spleen  in  malaria,  while  in  pure  yellow  fever  it  is  not  enlarged. 
Haemorrhages,  and  particularly  the  black  vomit,  epistaxis,  and  bleeding 
gums  are  very  rare  in  malarial  infection.  In  the  so-called  hsemorrhagic 
malarial  fever  the  patient  has  usually  had  previous  attacks  of  malaria. 
Hsematuria  is  a  prominent  feature,  while  in  yellow  fever  it  is  by  no  means 
frequent.  A  special  point  of  greater  importance,  perhaps,  than  any  of 
these  general  symptomatic  features  is  the  careful  examination  of  the  blood 
for  malarial  parasites.  The  forms  to  be  looked  for  are  the  small,  ring- 
shaped  organisms  of  the  asstivo-autumnal  infections.  As  a  rule,  their 
presence  is  readily  determined  by  any  one  familiar  with  their  general 
characters.  They  are,  however,  of  all  forms  the  most  difficult  to  recog- 
nize, and,  while  they  may  be  very  abundant,  there  are  cases  in  which  the 
organisms  are  extremely  scanty  in  the  peripheral  circulation.  The  work 
of  the  army  surgeons  in  Cuba  shows  that  in  a  large  proportion  of  cases  there 
is  not  much  difficulty  in  recognizing  the  sestivo-autumnal  fever  from 
yellow  fever. 

Prognosis. — In  its  graver  forms,  yellow  fever  is  one  of  the  most 
fatal  of  epidemic  diseases.  The  mortality  has  ranged,  in  various  epidemics, 
from  15  to  85  per  cent.  In  heavy  drinkers  and  those  who  have  been  ex- 
posed to  hardships  the  death-rate  is  much  higher  than  among  the  better 
classes.  In  the  epidemic  of  1878,  in  New  Orleans,  while  the  mortality  in 
hospitals  was  over  50  per  cent  of  the  white  and  21  per  cent  of  the  colored 
patients,  in  private  practice  it  was  not  more  than  10  per  cent  among  the 
white  patients.  The  death-rate  was  very  low  in  the  epidemic  of  1897. 
Favorable  symptoms  are  a  low  grade  of  fever,  slight  jaundice,  absence  of 
hasmorrhages,  and  a  free  secretion  of  urine.  If  the  temperature  rise  above 
103°  or  104°  during  the  first  two  days,  the  outlook  is  serious.  Black  vomit 
is  not  an  invariably  fatal  symptom.  Cases  with  suppression  of  urine,  de- 
lirium, coma,  and  convulsions  rarely  recover. 

Prophylaxis. — It  is  scarcely  likely  that  quarantine  measures  will  be 
abandoned  before  full  confirmation  of  the  work  of  the  United  States  Yellow 
Fever  Commission;  but  meanwhile  every  means  should  be  taken  to  prevent 
the  spread  of  the  disease  through  infected  mosquitoes.  There  are  three 
important  measures:  (1)  the  protection  of  the  sick  from  the  bites  of  mosqui- 
toes; (2)  the  screening  of  houses,  the  use  of  mosquito  nets,  and  the  destruc- 
tion of  the  insects  in  the  house;  (3)  measures  such  as  already  referred  to 
under  malaria,  which  diminish  the  possibility  of  the  mosquito  breeding  in 
the  neighborhood  of  dwellings.     New-comers  should  be  particularly  careful 


THE  PLAGUE.  189 

in  infected  regions,  and  medical  officers  in  charge  of  camps  should  exercise 
the  most  scrupulous  care  to  prevent  the  spread  of  infection  through 
mosquitoes. 

Treatment. — Careful  nursing  and  a  symptomatic  plan  of  treatment 
probably  give  the  best  results.  The  patient  should  be  removed  at  once 
from  the  infected  house.  Care  should  be  taken  to  prevent  chilling  of  the 
skin,  and  sweating  should  be  promoted.  Bleeding  has  long  since  been 
abandoned.  An  early  purge,  followed  by  phenacetin  to  relieve  the  back- 
ache, is  recommended  by  Geddings.  Of  special  remedies  quinine  is  warmly 
recommended,  and,  when  hsemorrhage  sets  in,  the  perchloride  of  iron. 
Digitalis,  aconite,  and  jaborandi  have  been  employed.  Sternberg  advises 
the  following  mixture:  Bicarbonate  of  soda,  150  grains;  bichloride  of  mer- 
cury, ^  grain;  pure  water,  1  quart.  Three  tablespoonfuls  every  hour.  This 
is  given  on  the  view  that  the  specific  agent  is  in  the  intestine,  and  that 
its  growth  may  possibly  be  restrained  by  this  antacid  and  antiseptic  mix- 
ture. The  lever  is  best  treated  by  hydrotherapy.  There  are  several  reports 
of  the  good'  effects  of  cold  baths,  sponging,  and  the  application  of  ice-cold 
water  to  the  head  and  the  extremities  in  this  disease.  Vomiting  is  a  very 
difficult  symptom  to  control.  Ice  in  small  quantities  is  probably  the  best 
remedy.  Cocaine  may  be  tried  in  doses  of  |— J  gr.  every  hour  or  two  (Ged- 
dings). 

We  have  no  drug  which  can  be  depended  upon  to  check  the  haem- 
orrhages. Ergot  and  acetate  of  lead  and  opium  are  recommended.  The 
urgemic  symptoms  are  best  treated  by  the  hot  bath.  Stimulants  should  be 
given  freely  during  the  second  stage,  when  the  heart's  action  becomes 
feeble  and  there  is  a  tendency  to  collapse.  The  patient  should  be  carefully 
fed;  but  when  the  vomiting  is  incessant  it  is  best  not  to  irritate  the  stom- 
ach, but  to  give  nutritive  enemata  until  the  gastric  irritation  is  allayed. 
Washing  out  the  lower  bowel  is  very  advantageous,  and  in  the  cases  with 
extreme  toxaemia  the  subcutaneous  or  intravenous  injection  of  saline  solu- 
tion may  be  tried. 

The  serum  treatment  introduced  by  Sanarelli  does  not  appear  to  have 
come  into  general  use. 


XXII.   THE  PLAGUE. 

Definition. — A  specific,  infectious  disease  of  extraordinary  virulence 

and  very  rapid  course,  caused  by  bacillus  pestis,  characterized  by  in- 
flammation of  the  lymphatic  glands  (buboes),  carbuncles,  and  often  haem- 
orrhages. 

History  and  Geographical  Distribution.— The  disease  was 
probably  not  known  to  the  classical  Greek  writers.  The  earliest  positive 
account  dates  from  the  second  century  of  our  era.  The  plague  of  Athens 
and  the  pestilence  of  the  reign  of  Marcus  Aurelius  were  apparently  not  this 
disease  (Payne).  From  the  great  plague  in  the  days  of  Justinian  (sixth 
century)  to  the  middle  of  the  seventeenth  century  epidemics  of  varying 
severity  occurred  in  Europe.    Among  the  most  disastrous  was  the  famous 


190  SPECIFIC  INFECTIOUS  DISEASES. 

"  black  death '''  of  the  fourteenth  century,  which  overran  Europe  and  de- 
stroyed a  fourth  of  the  population.  In  the  seventeenth  century  it  raged 
virulently,  and  during  the  great  plague  of  London,  in  1665,  about  70,000 
people  died.  During  the  eighteenth  and  nineteenth  centuries  the  ravages 
of  the  disease  lessened.  . 

The  revival  of  the  plague  within  the  past  ten  years  has  aroused  uni- 
versal interest.  Since  the  outbreak  at  Hong-Kong,  in  1894,  the  disease 
has  appeared  in  many  parts  of  the  world.  The  most  serious  outbreak  has 
been  in  India,  particularly  in  the  Presidency  of  Bombay.  In  the  city  of 
Bombay  itself  within  nine  months  after  the  onset  at  least  20,000  people 
died  of  the  disease.  It  continues  to  spread  in  India.  In  Africa  outbreaks 
have  occurred  in  Egypt,  and  lately  at  the  Cape.  In  Europe  cases  have 
been  carried  to  different  ports  on  the  Mediterranean,  and  there  was  a  local 
outbreak  at  Oporto.  After  an  absence  of  more  than  two  hundred  years, 
plague  obtained  a  foothold  in  Great  Britain,  and  in  Glasgow  there  was  a 
small  epidemic  in  the  autumn  of  1900.  A  few  cases  have  been  carried 
also  to  other  ports.  In  South  America  there  have  been  a  few  cases  at 
Brazilian  ports.  The  disease  reached  quarantine  in  New  York  in  Novem- 
ber, 1899.  In  San  Francisco  there  has  been  a  localized  epidemic  among 
the  Chinese.  In  Australia  the  disease  has  prevailed  in  Sydney  and  one 
"or  two  other  towns. 

A  most  encouraging  circumstance  is  the  fact,  well  illustrated  in  Glas- 
gow and  San  Francisco,  that  the  disease  is  readily  held  in  check  by  proper 
sanitary  measures. 

Etiology. — ^The  specific  organism  of  the  disease  is  a  bacillus  discov- 
ered by  Kitasato  and  carefully  studied  by  Yersin  and  others.  It  resembles 
somewhat  the  bacillus  of  chicken  cholera,  and  grows  in  a  perfectly  char- 
acteristic manner.  The  bacillus  pestis  occurs  in  the  blood  and  in  the 
organs  of  the  body,  and  has  also  been  found  in  the  dust  and  in  the  soil  of 
houses  in  which  the  patients  have  lived.  Flies  and  fleas  die  from  the  dis- 
ease, and  may  convey  the  infection.  Rats,  mice,  and  dogs  are  readily  in- 
fected, and  diseased  animals  will  convey  the  plague  to  healthy  ones.  Prior 
to  the  onset  of  epidemics  in  man  the  disease  has  prevailed  extensively 
among  the  rats. 

The  disease  prevails  most  frequently  in  hot  seasons,  though  an  out- 
break may  occur  during  the  coldest  weather  of  winter.  Persons  of  all  ages 
are  attacked.  It  spreads  chiefly  among  the  poorer  classes,  in  the  slums  of 
the  great  cities,  and,  in  fact,  wherever  the  hygienic  conditions  are  most 
faulty.  There  is  much  in  favor  of  the  view  that  the  plague  is  a  soil  disease, 
the  virus  of  which,  like  that  of  anthrax  and  tetanus,  resides  permanently 
in  the  soil  of  the  affected  districts  (see  Payne  in  Allbutt's  System).  The 
method  of  spread  was  well  recognized  by  De  Foe:  "No  one  in  this  whole 
nation  ever  received  the  sickness  or  infection  but  who  received  it  in  the 
ordinary  way  of  infection  from  somebody,  or  the  clothes,  or  touch,  or 
stench  of  somebody  that  was  infected  before." 

While  the  virus  of  the  plague  may  be  communicated  from  one  person 
to  another  through  the  air,  the  disease  has  not  the  extreme  contagiousness 
of  small-pox  or  of  scarlet  fever.    It  attaches  itself  particularly  to  houses 


THE   PLAGUE.  191 

and  to  the  clothing  and  bedding.  In  the  Bombay  epidemic  few  attendants 
upon  the  sick — nurses  and  physicians — have  been  attacked,  and  a  writer 
states  that  among  the  hundreds  of  British  troops  daily  employed  on  cordon 
duty  and  search  parties  and  in  the  disinfection  of  houses  not  a  single  case 
occurred. 

Clinical  Forms. — Pestis  Minor. — In  this  variety,  also  known  as  the 
ambulant,  the  patient  has  a  few  days  of  fever,  with  swelling  of  the  glands 
of  the  groin,  and  possibly  suppuration.  He  may  not  be  ill  enough  to  seek 
medical  relief.  These  cases,  often  found  at  the  beginning  and  end  of  an 
epidemic,  are  a  very  serious  danger  in  a  community,  as  the  urine  and  fgeces 
contain  bacilli. 

Bubonic  Plague. — This  constitutes  the  common  variety,  77.65  per  cent 
of  11,600  cases  of  plague  treated  in  the  Arthur  Eoad  Hospital,  Bombay 
(N.  H.  Choksy).  The  stage  of  invasion  is  characterized  by  headache,  back- 
ache, stiffness  of  the  limbs,  a  feeling  of  anxiety  and  restlessness,  and  great 
depression  of  spirits.  There  is  a  steady  rise  in  the  fever  until  the  evening 
of  the  third  or  fourth  day,  when  there  is  a  drop  of  two  or  three  degrees. 
There  is  then  a  secondary  fever,  as  some  writers  describe  it,  in  which  the 
temperature  reaches  a  still  higher  point.  The  tongue  becomes  brown, 
collapse  symptoms  are  apt  to  supervene,  and  in  very  severe  infections  the 
patient  may  die  at  this  stage.  In  at  least  two-thirds  of  all  cases  there  are 
glandular  swellings  or  buboes.  An  analysis  of  9,500  cases  of  buboes  gave 
more  than  54  per  cent  with  the  glands  of  the  groin  affected.  The  swelling 
appears  usually  from  the  third  to  the  fifth  day.  Kesolution  may  occur, 
or  suppuration,  or  in  rare  cases  gangrene.  Suppuration  is  a  favorable 
feature,  as  noted  by  De  Foe  in  his  graphic  account  of  the  London  plague. 

Petechise  very  commonly  show  themselves,  and  may  be  very  extensive. 
These  have  been  called  the  "  plague  spots,"  or  the  "  tokens  of  the  disease," 
and  gave  to  it  in  the  middle  ages  the  name  of  the  Black  Death.  Haemor- 
rhages from  the  mucous  membranes  may  also  occur;  in  some  epidemics 
haemoptysis  has  been  especially  frequent. 

SepticaBmic  Plague. — In  this  form,  which  is  the  most  rapid,  the  patient 
succumbs  in  three  or  four  days  with  a  virulent  infection  before  the  buboes 
appear.  This  form  constituted  14.25  per  cent  of  the  11,600  cases.  Haem- 
orrhages are  common.    The  bacilli  can  be  obtained  from  the  blood. 

Pneumonic  Plague. — This  remarkable  variety  presents  the  features  of 
a  pneumonia,  and  the  sputum  contains  the  bacilli  in  enormous  numbers. 
It  is  even  more  fatal  than  the  septicaemic  type.  The  mortality  in  514 
cases  was  96.69  per  cent.  It  is  of  short  duration.  The  fever  is  high,  the 
respirations  rapid,  the  pneumonia  is  chiefly  lobular,  the  sputa  ha3mor- 
rhagic,  and  contain  the  bacilli  in  almost  pure  culture. 

In  other  varieties  the  chief  manifestations  may  be  in  the  skin  and 
subcutaneous  tissues,  or  in  the  intestines,  causing  diarrhoea  and  sometimes 
the  features  of  typhoid  fever. 

Prophylaxis. — Careful  hygienic  measures  should  be  carried  out,  and 
all  persons  sick  of  the  disease  should  be  isolated.  The  most  thorough 
disinfection  of  the  evacuations  should  be  carried  out.  The  bodies  of  vic- 
tims should  be  cremated.    Patients  who  have  recovered  should  be  kept  in 


192  SPECIFIC  INFECTIOUS  DISEASES. 

isolation  for  at  least  a  month.  A  most  important  prophylactic  measure 
relates  to  the  destruction  of  rats,  which  are  probably  the  chief  agents  in 
the  distribution  of  the  disease.  As  Dr.  Ashburton  Thompson  remarks  (Ee- 
port  on  Plague  at  Sydney),  "  during  an  epidemic  the  only  proceeding  of 
much  value  is  destruction  of  rats  and  of  their  nests,  burrows,  and  habitual 
haunts,  and  those  others  which  are  calculated  to  prevent  access  of  surviving 
rats  to  proximity  with  human  beings — in  other  words,  to  expel  them  from 
occupied  premises,  and  to  keep  them  outside.  ...  On  premises  where  in- 
digenous cases  had  occurred,  moreover,  the  presence  of  freshly  deceased 
rats  was  discovered  quite  often  enough  to  support  the  general  proposition 
that  the  danger  of  contracting  plague  stood  in  relation  to  the  presence  of 
rats  in  dwellings  or  inclosed  premises.  A  general  slaughter  of  rats  would 
answer  the  purpose,  if  it  could  be  carried  out  quickly  and  with  tolerable 
completeness." 

Diagnosis. — At  the  early  stage  of  an  outbreak  plague  cases  are  easily 
overlooked,  but  if  the  suspicious  cases  are  carefully  studied  by  a  compe- 
tent bacteriologist,  there  is  no  disease  which  can  be  more  positively  identi- 
fied. The  San  Francisco  epidemic  illustrates  this.  The  nature  of  the  cases 
was  recognized  by  Kellog  and  by  Kinyoun,  but  with  an  amazing  stupidity 
(which  was  shared  by  not  a  few  physicians,  who  should  have  known  better) 
the  Governor  of  the  State  refused  to  recognize  the  presence  of  plague,  and 
the  United  States  Government  had  to  intervene  and  send  a  board  of  experts 
to  settle  the  question.  In  the  early  Glasgow  cases  Dr.  Colvin,  while  sus- 
pecting typhoid  fever,  saw  that  there  was  something  unusual,  and  at  once 
took  precautionary  measures.  Probably,  too,  the  association  of  four  cases 
in  one  family  made  him  suspicious.  The  limitation  of  the  outbreak  was 
due  to  the  prompt  and  effective  measures  taken  by  Dr.  A.  K.  Chalmers 
and  his  associates.  The  widespread  prevalence  of  the  disease  makes  it 
the  imperative  duty  of  the  health  authorities  to  have  on  hand,  in  con- 
nection with  large  ports,  skilled  men  who  can  promptly^make  the  bac- 
teriological diagnosis.  There  are  dangers  from  the  cultures  in  laboratories, 
as  shown  by  the  sad  experiences  of  Vienna,  but  with  proper  precautions 
they  may  be  reduced  to  a  minimum. 

Treatment.  ^ — In  a  disease  the  mortality  of  which  may  reach  as  high 
as  80  or  90  per  cent  the  question  of  treatment  resolves  itself  into  making 
the  patient  as  comfortable  as  possibly  and  following  out  certain  general 
principles  such  as  guide  us  in  the  care  of  fever  patients.  Cantlie  recom- 
mends purgation  and  stimulation  from  the  outset,  and  the  use  of  morphia 
for  the  pain.  The  local  treatment  of  the  buboes  is  important.  Ice  may  be 
applied  to  them,  and  good  results  apparently  follow  the  injection  of  the 
bichloride  of  mercury.  The  pyrexia  of  the  disease  is  best  treated  by 
systematic  hydrotherapy.  Antipyrin  and  depressing  drugs  should  be 
avoided. 

Preventive  Inoculation. — Haffkine  uses  sterilized  bouillon  cultures  of 
the  bacillus,  which  appear  to  confer  immunity  lasting  for  a  month  or 
more.  The  reports  on  the  whole  are  favorable.  Yersin  has  prepared  an 
antitoxic  serum,  which  has  been  used  extensively  in  the  East,  sometimes 
with  favorable  results.    Roux  has  also  prepared  a  serum,  which  is  on  the 


DYSENTERY.  I93 

market,  and  which  is  used  for  immunizing  as  for  a  therapeutic  agent. 
Lustig's  serum  has  been  used  extensively  in  India,  and  there  are  reports 
from  Bombay  which  indicate  that  it  has  a  distinctly  favorable  influence 
on  the  course  of  the  disease. 


XXIII.    DYSENTERY. 

Definition. — A  clinical  term  embracing  several  varieties  of  intestinal 
flux — the  acute  forms  characterized  by  pain,  frequent  passages  of  blood 
and  mucus,  the  more  chronic  by  diarrhoea  alternating  with 'constipation, 
and  a  tendency  to  recurrence.  Anatomically  there  is  inflammation,  and 
in  the  chronic  cases  ulceration,  of  the  large  bowel. 

General  Etiology. — Owing  to  improved  sanitation,  the  diseases  de- 
scribed under  dysentery  have  become  less  frequent.  In  temperate  climates 
sporadic  cases  occur  from  time  to  time,  and  at  intervals  epidemics  prevail, 
particularly  in  overcrowded  institutions.  The  statistics  of  general  hos- 
pitals for  the  past  twenty  years  show  a  decided  decrease  in  the  number 
of  cases  admitted.  Eecords  of  widespread  epidemics  have  been  collected 
by  Woodward.  The  most  serious  was  that  which  prevailed  from  1847  to 
1856.  In  Great  Britain  and  Ireland  epidemicg  of  the  disease  have  become 
less  frequent.  In  institutions,  particularly  in  overcrowded  asylums,  dysen- 
tery is  very  common,  and  this  form  has  been  made  the  subject  of  a  valuable 
report  by  Mott  and  Durham.  In  the  tropics  "  dysentery  is  a  destructive 
giant  compared  to  which  strong  drink  is  a  mere  phantom  "  (Macgregor). 
Dysentery  is  one  of  the  great  camp  diseases,  and  it  has  been  more  destruc- 
tive to  armies  than  powder  and  shot.  In  the  Federal  service  during  the 
civil  war,  according  to  Woodward,*  there  were  259,071  cases  of  acute 
and  28,451  cases  of  chronic,  dysentery.  The  last  report  (1900)  of  Surgeon- 
General  Sternberg  shows  that  the  disease  has  prevailed  in  Porto  Eico,  the 
Philippines,  and  to  a  less  extent  in  Cuba.  In  the  South  African  campaign 
dysentery  has  prevailed  widely. 

A  careful  study  is  needed  of  the  acute  dysenteries  of  temperate  regions, 
more  particularly  of  the  outbreaks  which  occur  from  time  to  time.  Pro- 
visionally the  following  forms  may  be  described: 

Acute  Specific  Dysentery. — For  many  years  a  very  fatal  form  of 
dysentery  has  prevailed  in  Japan,  particularly  in  the  summer  and  autumn 
months,  having  a  mortality  of  from  26  to  27  per  cent;  in  1899  there  were 
125,989  cases,  with  26,709  deaths  (Eldridge).  A  Japanese  observer,  Shiga, 
found  in  connection  with  it  a  bacillus  with  special  characters.  Flexner 
and  Barker,  of  the  Johns  Hopkins  Commission  for  the  Study  of  Tropical 
Diseases,  found  in  the  dysentery  in  the  Philippine  Islands  an  identical 
organism,  and  it  has  been  made  the  subject  of  very  careful  study  by 
Flexner,  and  also  by  E.  P.  Strong,  Musgrave,  and  Craig,  of  the  United 
States  army.    It  has  also  been  found  in  cases  of  dysentery  from  Porto  Eico. 

*  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Medical,  vol.  ii.  The 
most  exhaustive  treatise  extant  on  intestinal  fluxes— an  enduring  monument  to  the  indus- 
try and  ability  of  the  author. 


194  SPECIFIC  INFECTIOUS  DISEASES. 

The  organism  appears  to  be  constantly  present  in  the  acute  dysentery  of 
the  tropics.  It  is  pathogenic  to  animals,  and  Flexner  has  produced  in 
rabbits  a  typical  acute  colitis  by  subcutaneous  inoculation  of  cultures.  The 
organism  agglutinates  with  the  blood-serum  of  cases  of  acute  dysentery. 

B.  dysenterice. — Bacillus  of  average  length  of  B.  typhosus.  Grows 
readily  upon  all  culture  media.  Colonies  upon  gelatin,  when  fully  devel- 
oped, show  a  grape-leaf  appearance.  There  is  no  liquefaction  of  gelatin. 
Sugars  are  not  -fermented  and  milk  is  not  coagulated.  In  litmus  milk 
there  is  at  first  a  small  amount  of  acid  production  which  is  followed  by 
alkalinizatioB.  The  bacillus  when  first  isolated  is  slightly  motile,  but 
quickly  loses  its  motility  in  artificial  cultivations.  Flagella  have  not  been 
demonstrated.  Feeding  animals  on  the  bacilli,  unless  the  intestinal  tract 
is  previous^  irritated  with  chemicals,  has  no  effect.  Feeding  after  irrita- 
tion sets  up  colitis  in  cats  and  dogs.  Intraperitoneal  and  subcutaneous 
injections  into  mice,  rabbits,  and  guinea-pigs  are  lethal.  In  the  rabbit, 
subcutaneous  injections  have,  in  some  instances,  given  rise  to  extensive 
pseudo-membranous  inflammations  of  the  caecum  (Flexner). 

In  Manila,  according  to  the  figures  by  Strong  and  Musgrave,  of  1,328 
cases  712  were  of  the  acute  specific  variety,  55  suspected  specific  cases, 
and  561  of  amoebic  dysentery.  Kruse,  in  an  outbreak  at  Laar  in  Grcrmany, 
in  which  300  persons  were  stacked,  has  isolated  an  identical  bacillus.  In 
the  epidemic  in  the  Lancaster  County  Asylum,  so  fully  reported  by  Gem- 
mel,  Goodliffe  found  an  organism  which  evidently  has  close  affinities  with 
Shiga's  bacillus.  As  the  presence  of  Shiga's  bacillus  has  been  demonstrated 
in  local  epidemics  in  this  country,  it  seems  probable  that  a  disease  exists 
which  is  identical  with  the  acute  specific  dysentery  of  the  tropics  (Flexner). 

Clinical  Features. — It  ocurs  sporadically,  and  at  intervals  prevails  in 
epidemic  form.  For  many  years  now  it  has  recurred  in  the  autumn  in 
Japan  with  great  severity.  In  the  Philippines  it  is  widely  spread  over 
the  islands,  and  appears  chiefly  toward  the  end  of  the  rainy  season.  The 
precise  channel  of  infection  is  not  known,  but  it  is  possibly  through  the 
drinking-water.  According  to  Strong  and  Musgrave,  the  period  of  incu- 
bation is  not  more  than  forty-eight  hours. 

The  onset,  which  is  usually  sudden,  is  characterized  by  slight  fever, 
pain  in  the  abdomen,  and  frequent  stools.  At  first  mucus  is  passed,  but 
within  twenty-four  hours  blood  appears  with  it,  or  there  is  pure  blood. 
There  is  a  constant  desire  to  go  to  stool,  with  great  straining  and  tenes- 
mus; every  hour  or  half  hour  there  may  be  a  small  amount  of  blood  and 
mucus  passed.  The  temperature  rises  and  may  reach  103°  or  104°.  The 
pulse  increases  in  frequency,  and  in  the  severer  cases  becomes  very  small. 
The  tongue  is  coated  with  a  white  fur,  and  there  is  excessive  thirst.  In 
the  very  acute  cases  the  patient  becomes  seriously  ill  within  forty-eight 
hours,  the  movements  increase  in  frequency,  the  pain  is  of  great  intensity, 
the  patient  becomes  delirious,  and  death  may  occur  on  the  third  or  fourth 
day.  In  cases  of  moderate  severity  the  urgency  of  the  symptoms  abates, 
the  stools  lessen,  the  temperature  falls,  and  within  two  or  three  weeks 
the  patient  is  convalescent.  The  mortality  in  the  severe  forms  is  very 
high,  and  the  Japanese  records  show  how  fatal  the  disease  is.    There  is  a 


DYSENTERY.  I95 

subacute  form  which  lasts  for  many  weeks  or  months.  The  patients  be- 
come greatly  emaciated,  having  from  three  to  five  stools  in  the  twenty- 
four  hours.  In  this  form,  too,  the  bacillus  dysenterise  is  found,  and  it 
agglutinates  readily  with  the  blood  serum.  Strong  and  Musgrave  have 
found  it  as  early  as  the  third  day.     Amoebae  are  not  found  in  the  stools. 

Morbid  Anatomy. — In  the  acute  cases,  when  death  has  occurred  on 
the  fourth  to  the  seventh  day,  the  mucous  membrane  of  the  large  intes- 
tine is  swollen,  of  a  deep-red  color,  and  presents  elevated,  coarse  corruga- 
tions and  folds.  In  addition  to  the  intense  hypersemia  there  are  spots  of 
haemorrhage  scattered  through  the  swollen  mucosa.  Over  the  surface 
there  is  usually  a  superficial  necrotic  layer,  which  can  be  brushed  off  lightly 
with  the  finger.  This  may  be  in  patches,  or  uniform  over  large  areas. 
There  is  no  ulceration,  only  the  superficial,  general  necrosis  of  the  mucosa. 
The  solitary  follicles  are  swollen  and  red,  but  the  prominence  is  obscured 
in  the  involvement  of  the  entire  mucosa.  In  cases  of  great  intensity  the 
entire  coats  of  the  colon  may  be  stiff  and  thick,  and  the  mucous  memlDrane 
enormously  increased  in  thickness,  grayish  black  in  color,  extensively 
necrotic,  and,  in  places,  gangrenous.  The  serous  surface  is  often  deeply 
injected.  The  ileum  is,  in  many  cases,  involved,  having  a  deeply  haemor- 
rhagic  mucosa,  with  a  superficial  necrosis.  In  the  subacute  cases  there 
is  not  the  same  great  thickening  of  the  intestinal  wall,  the  solitary  fol- 
licles are  more  swollen,  there  is  less  necrosis,  and,  while  there  are  no 
ulcers,  there  are  superficial  erosions. 

Amoebic  Dysentery. — This  is  a  widely  prevalent  form,  which  has 
been  described  in  Egypt,  in  India,  and  in  the  tropics.  It  is  the  commonest 
variety  throughout  the  United  States,  and  is  exceedingly  common  in  the 
Philippine  Islands.  It  is  endemic,  the  cases  sometimes  increasing  to  such 
an  extent  as  to  form  an  epidemic.  Sporadic  instances  apparently  occur 
in  all  temperate  regions. 

Amoeba  Dysenterice. — The  organism  was  first  described  by  Lambl  in 
1859,  and  subsequently  by  Losh.  Kartulis  found  them  in  the  stools  of 
the  endemic  dysentery  in  Egypt,  and  in  the  liver  abscesses.  In  1890 
I  found  them  in  a  case  of  dysentery  with  abscess  of  the  liver  originating  in 
Panama.  Subsequently  from  my  wards  a  series  of  cases  was  described 
by  Councilman  and  Lafleur.  Since  then  numbers  of  observations  have 
been  made  by  Dock  in  this  country,  by  Quincke  and  Eoos  in  Germany,  and 
by  many  others.  The  little  flakes  of  mucus  or  pus  in  the  stools  should  be 
selected  for  examination  or  the  mucus  obtained  by  passing  a  soft-rubber 
catheter.  Students  must  learn  to  distinguish  from  amoeba  the  swollen, 
altered  epithelial  cells,  which  are  round,  with  granular  protoplasm. 

Amoeba  dysenterias  is  from  fifteen  to  twenty  /*  in  diameter,  and  con- 
sist of  a  clear  outer  zone  (ectosarc),  and  a  granular  inner  zone  (endosarc), 
and  contain  a  nucleus  and  one  or  two  vacuoles.  The  movements  are 
very  similar  to  those  of  the  ordinary  amoeba,  consisting  of  sliglit 
protrusions  of  the  protoplasm.  They  vary  a  good  deal,  and  usually  may 
be  intensified  by  having  the  slide  heated.  Not  infrequently  the  amoeba 
contain  red  blood-corpuscles  which  they  have  included.  In  the  tissues  they 
are  very  readily  recognized  by  suitable  stains.    They  may  be  in  enormous 


196  SPECIFIC  INFECTIOUS  DISEASES. 

numbers,  and  sometimes  the  field  of  the  microscope  is  completely  occupied 
by  them.  In  the  pus  of  a  liver  abscess  they  may  be  very  abundant,  though 
in  large,  long-standing  abscesses  they  may  not  be  found  until  after  a  few 
days,  when  the  pus  begins  to  discharge  from  the  wall  of  the  abscess  cavity. 
In  the  sputum  in  the  cases  of  pulmono-hepatic  abscess  they  are  readily 
recognized.  There  are  probably  different  varieties  of  amoebae.  They  have 
been  found  in  the  stools  of  perfectly  healthy  persons.  Quincke  and  Eoos 
recognize  three  varieties,  and  Strong  describes  two  distinct  forms  in 
Manila,  only  one  of  which  is  pathogenic. 

The  relative  frequency  of  this  form  of  dysentery  in  the  tropics  is  well 
illustrated  by  the  experience  of  the  United  States  army  in  Manila.  As 
already  stated,  the  figures  given  by  Strong  are  of  1,328  cases;  561  were  of 
the  amoebic  variety. 

In  this  region  the  amoebic  dysentery  is  the  common  variety,  and  the 
cases  of  acute  and  chronic  dysentery  admitted  to  my  wards  during  the  past 
twelve  years  have  been  almost  exclusively  of  this  form. 

Morbid  Anatomy. — The  lesions  are  found  in  the  large  intestine,  some- 
times in  the  lower  portion  of  the  ileum.  Abscess  of  the  liver  is  very  com- 
mon, and  occurred  in  25  of  100  cases  in  my  wards. 

Intestines. — The  lesions  consist  of  ulceration,  produced  by  preceding 
infiltration,  general  or  local,  of  the  submucosa,  due  to  an  oedematous  con- 
dition and  to  multiplication  of  the  fixed  cells  of  the  tissue.  In  the  earliest 
stage  these  local  infiltrations  appear  as  hemispherical  elevations  above  the 
general  level  of  the  mucosa.  The  mucous  membrane  over  these  soon  be- 
comes necrotic  and  is  cast  off,  exposing  the  infiltrated  submucous  tissue  as 
a  grayish-yellow  gelatinous  mass,  which  at  first  forms  the  floor  of  the 
ulcer,  but  is  subsequently  cast  off  as  a  slough. 

The  individual  ulcers  are  round,  oval,  or  irregular,  with  infiltrated, 
undermined  edges.  The  visible  aperture  is  often  small  compared  to  the 
loss  of  tissue  beneath  it,  the  ulcers  undermining  the  mucosa,  coalescing, 
and  forming  sinuous  tracts  bridged  over  by  apparently  normal  mucous 
membrane.  According  to  the  stage  at  which  the  lesions  are  observed,  the 
floor  of  the  ulcer  may  be  formed  by  the  submucous,  the  muscular,  or  the 
serous  coat  of  the  intestine.  The  ulceration  may  affect  the  whole  or  some 
portion  only  of  the  large  intestine,  particularly  the  caBcum,  the  hepatic 
and  sigmoid  flexures,  and  the  rectum.  In  severe  cases  the  whole  of  the 
intestine  is  much  thickened  and  riddled  with  ulcers,  with  only  here  and 
there  islands  of  intact  mucous  membrane. 

The  disease  advances  by  progressive  infiltration  of  the  connective-tissue- 
layers  of  the  intestine,  which  produces  necrosis  of  the  overlying  structures. 
Thus,  in  severe  cases  there  may  be  in  different  parts  of  the  bowel  slough- 
ing en  masse  of  the  mucosa  or  of  the  muscularis,  and  the  same  process  is 
observed,  but  not  so  conspicuously,  in  the  less  severe  forms. 

In  some  cases  a  secondary  diphtheritic  inflammation  complicates  the 
original  lesions. 

Healing  takes  place  by  the  gradual  formation  of  fibrous  tissue  in  the 
floor  and  at  the  edges  of  the  ulcers,  which  may  ultimately  result  in  partial 
and  irregular  strictures  of  the  bowel. 


DYSENTERY.  I97 

Microscopical  examination  shows  a  notable  absence  of  the  products  of 
purulent  inflammation.  In  the  infiltrated  tissues  polynuclear  leucocytes 
are  seldom  found,  and  never  constitute  purulent  collections.  On  the  other 
hand,  there  is  proliferation  of  the  fixed  connective-tissue  cells.  Amoebse 
are  found  more  or  less  abundantly  in  the  tissues  at  the  base  of  and  around 
the  ulcers,  in  the  lymphatic  spaces,  and  occasionally  in  the  blood-vessels. 

The  lesions  in  the  liver  are  of  two  kinds:  firstly,  local  necroses  of  the 
parenchyma,  scattered  throughout  the  organ  and  possibly  due  to  the  action 
of  chemical  products  of  the  amoebae;  and,  secondly,  abscesses.  These  may 
be  single  or  multiple.  When  single  they  are  generally  in  the  right  lobe, 
either  toward  the  convex  surface  near  its  diaphragmatic  attachment,  or 
on  the  concave  surface  in  proximity  to  the  bowel.  Multiple  abscesses  are 
small  and  generally  superficial.  In  an  early  stage  the  abscesses  are  grayish- 
yellow,  with  sharply  defined  contours,  and  contain  a  spongy  necrotic  ma- 
terial, with  more  or  less  fluid  in  its  interstices.  The  larger  abscesses  have 
ragged  necrotic  walls,  and  contain  a  more  or  less  viscid,  greenish-yellow 
or  reddish-yellow  purulent  material  mixed  with  blood  and  shreds  of  liver- 
tissue.  The  older  abscesses  have  fibrous  walls  of  a  dense,  almost  carti- 
laginous toughness.  A  section  of  the  abscess  wall  shows  an  inner  necrotic 
zone,  a  middle  zone  in  which  there  is  great  proliferation  of  the  connective- 
tissue  cells  and  compression  and  atrophy  of  the  liver-cells,  and  an  outer 
zone  of  intense  hypergemia.  There  is  the  same  absence  of  purulent  inflam- 
mation as  in  the  intestine,  except  in  those  cases  in  which  a  secondary  in- 
fection with  pyogenic  organisms  has  taken  place.  The  material  from  the 
abscess  cavity  shows  chiefly  fatty  and  granular  detritus,  few  cellular  ele- 
ments, and  amoebae  in  variable  numbers,  which  are  also  found  in  the  abscess 
walls,  chiefly  in  the  inner  necrotic  zone.  Mallory  has  devised  a  differential 
stain,  by  which  they  can  be  distinguished  in  tissues.  Cultures  are  usually 
sterile.  Lesions  in  the  lungs  are  seen  when  an  abscess  of  the  liver — as  so 
frequently  happens — points  toward  the  diaphragm  and  extends  by  con- 
tinuity through  it  into  the  lower  lobe  of  the  right  lung. 

Symptoms. — The  cases  may  be  divided  into  the  acute  and  chronic 
forms. 

Acute  Amoebic  Dysentery. — Many  cases  have  an  acute  onset.  Pain  and 
tenesmus  are  severe.  The  stools  are  bloody,  or  mucus  and  blood.  In  very 
severe  cases  there  may  be  constant  tenesmus,  with  pain  of  the  greatest 
intensity,  and  the  passage  every  few  minutes  of  a  little  blood  and  mucus. 
In  some  cases  large  sloughs  are  passed.  The  temperature  as  a  rule  is  not 
high.  The  patient  may  become  rapidly  emaciated;  the  heart's  action  be- 
comes feeble,  and  death  may  occur  within  a  week  of  the  onset.  Among  the 
other  symptoms  to  be  mentioned  are  haemorrhage  from  the  bowels,  which 
occurred  in  seven  cases;  perforation  of  an  ulcer,  which  occurred  in  four 
cases,  with  general  peritonitis.  While  in  a  majority  of  the  instances  the 
patient  recovers,  in  others  the  disease  drags  on  and  becomes  chronic.  In 
a  few  cases,  after  the  separation  of  the  sloughs,  there  is  extensive  ulcera- 
tion remaining,  with  thickening  and  induration  of  the  colon,  and  the 
patient  has  constant  diarrhoea,  loses  weight,  and  ultimately  dies  exhausted, 
usually  within  three  months  of  the  onset.    With  the  exception  of  cancer 


198    '  SPECIFIC  INFECTIOUS  DISEASES. 

of  the  oesophagus  and  anorexia  nervosa,  no  such  extreme  grade  of  emacia- 
tion is  seen  as  in  these  cases.  Extensive  ulceration  of  the  cornea  may 
occur. 

Chronic  Amoebic  Dysentery. — The  disease  may  be  subacute  from  the 
onset,  and  gradually  passes  into  a  chronic  stage,  the  special  characteristic 
of  which  is  alternating  periods  of  constipation  with  diarrhoea.  These  may 
occur  over  a  period  of  from  six  months  to  a  year  or  more.  Some  of  our 
patients  have  been  admitted  to  the  hospital  five  or  six  times  within  a 
period  of  two  years.  During  the  exacerbations  there  are  pain,  frequent 
passages  of  mucus  and  blood,  and  a  slight  rise  of  temperature.  Many  of 
these  patients  do  not  feel  very  ill,  and  retain  their  nutrition  in  a  remark- 
able way;  indeed,  in  this  region  it  is  rare  in  the  chronic  amoebic  form  to  see 
the  extreme  emaciation  so  common  in  the  chronic  cases  from  the  tropics. 
In  them  the  alternating  periods  of  improvement  with  attacks  of  diarrhoea 
are  the  rule.  The  appetite  is  capricious,  the  digestion  disordered,  and 
slight  errors  in  diet  are  apt  to  be  followed  at  once  by  an  increase  in  the 
number  of  stools.  The  tongue  is  often  red,  glazed,  and  beefy.  In  pro- 
tracted cases  the  emaciation  may  be  extreme. 

Acute  Catarrhal  Dysentery,  Acute  Ileo-colitis. — This  may  occur  spo- 
radically or  endemically,  and  is  the  variety  most  frequently  found  in  tem- 
perate climates  and  in  children. 

Morbid  Anatomy. — The  lesions  are  confined  to  the  large  bowel;  some- 
times the  ileum  also  is  involved.  The  mucous  membrane  is  injected, 
swollen,  and  often  covered  with  tenacious  blood-stained  mucus.  The  most 
striking  feature  is  the  enlargement  of  the  solitary  follicles,  which  stand 
out  prominently  from  the  mucous  membrane.  In  very  acute  forms,  as  in 
children,  the  picture  is  that  of  an  acute  follicular  colitis.  In  more  pro- 
tracted cases  the  follicles  suppurate  or  are  capped  with  an  area  of  necrotic 
tissue.  In  other  instances  the  sloughs  have  separated  and  the  entire  colon 
presents  numerous  ulcers,  most  of  which  have  developed  from  the  follicles, 
while  others  have  resulted  from  necrosis  and  sloughing  of  the  intervening 
tissue. 

Symptoms. — There  may  be  preliminary  dyspepsia  or  slight  pains  in  the 
abdomen.  Chills  are  rare.  Diarrhoea  is  the  most  constant  initial  symp- 
tom, and  at  first  is  not  painful.  Usually  within  thirty-six  hours  the  char- 
acteristic features  of  the  disease  develop — abdominal  pain  of  a  colicky, 
griping  character  and  frequent  stools,  which  are  passed  with  straining  and 
tenesmus;  the  constitutional  disturbance  is  variable,  and  in  mUd  cases 
may  be  slight.  The  temperature  is  not  high;  at  the  outset  the  range  may 
be  102°  or  103°.  The  tongue  is  furred  and  moist,  and  as  the  disease  pro- 
gresses becomes  red  and  glazed.  Nausea  and  vomiting  may  be  present, 
but,  as  a  rule,  the  patient  retains  nourishment.  The  constant  desire  to  go 
to  stool  and  the  straining  or  tenesmus  are  the  most  distressing  symptoms. 
The  abdomen  may  be  flat  and  hard.  The  thirst  is  often  excessive.  The 
stools  in  this  variety  of  dysentery  have  the  following  characters:  During 
the  first  twenty-four  or  forty-eight  hours  they  consist  of  more  or  less  clear 
mucus  and  blood  mixed  with  small  faecal  scybala.  After  this  they  become 
purely  gelatinous  and  bloody,  and  are  small  and  frequent,  from  fifteen  to 


DYSENTERY.  199 

two  hundred  in  tTrent5^-foiir  hours,  according  to  the  severitj'  of  the  case. 
About  the  end  of  the  first  week  the  mucus  becomes  opaque,  the  proportion 
of  blood  diminishes,  and  grayish  or  brownish  shreddy  material  appears  in 
the  stools,  which  become  gradually  reduced  in  frequency.  At  this  time 
they  may  be  wholly  composed  of  a  greenish  pultaceous  material  with  mucus. 
As  the  disease  subsides,  fascal  matter  again  appears  in  the  stools,  increasing 
in  amount  until  they  become  normal.  Microscopical  examination  of  the 
glairy  bloody  stools  shows  red  blood-corpuscles,  few  or  many  leucocytes, 
and  constantly  large,  swollen,  round  or  oval  epithelioid  cells,  containing 
fat-drops  and  vacuoles.  These  are  not  infrequently  mistaken  for  amoeba. 
Occasionally  the  cercomonas  intestinalis  is  seen  in  large  numbers.  The  ba- 
cillus pyoeyaneus  has  been  found  by  F.  C.  Curtis  in  a  recent  epidemic  at 
Hartwick,  N.  Y.  Not  only  was  it  present  in  the  stools  in  large  numbers, 
but  it  was  isolated  from  the  drinking-water  in  almost  pure  culture. 

DipMlieritic  Dysentery.— A  form  of  colitis  or  entero-colitis  in  which 
areas  of  necrosis  occur  in  the  mucous  membranes,  which  on  separation 
leave  ulcers.  This  occurs:  (a)  As  a  primary  disease  coming  on  acutely 
and  sometimes  proving  fatal.  In  its  milder  grades  the  tops  of  the  folds 
of  the  colon  are  capped  with  a  thin,  yellow  exudate.  In  severer  forms 
the  colon  is  enormously  enlarged,  the  walls  are  thickened,  stiff,  and  infil- 
trated, and  the  mucosa,  from  the  ileo-csecal  valve  to  the  rectum,  is  repre- 
sented by  a  tough,  yellowish  material,  in  which  on  section  no  trace  of  the 
glandular  elements  can  be  seen.  The  condition  is  one  of  extensive  necrosis 
of  the  mucosa.  There  are  cases  in  which  this  necrosis  is  superficial,  in- 
volving only  the  upper  layers  of  the  mucous  membrane;  but  in  the  most 
advanced  forms  it  may  be,  as  in  the  description  by  Eokitansky,  "  a  black, 
rotten,  friable,  charred  mass."  The  areas  of  necrosis  may  be  more  local- 
ized, and  large  sloughs  are  formed  which  may  be  a  half  to  three  fourths 
of  an  inch  in  thickness  and  extend  to  the  serosa.  There  are  instances  in 
which  this  condition  is  confined  to  the  lower  portion  of  the  large  bowel. 
In  cases  which  last  for  many  weeks  the  sloughs  separate  and  may  be 
thrown  off,  sometimes  in  large  tubular  pieces.  The  relation  of  this  form 
to  the  specific  dysentery  of  the  tropics  remains  to  be  determined. 

(b)  Secondary  Diphtheritic  Dysentery. — This  occurs  as  a  terminal  event 
in  many  acute  and  chronic  diseases.  It  is  not  infrequent  in  chronic  heart 
affections,  in  Bright's  disease,  and  in  cachectic  states  generally.  In  acute 
diseases  it  is,  as  pointed  out  by  Bristowe,  most  frequently  associated  with 
pneumonia.  Anatomically  there  may  be  only  a  thin,  superficial  infiltra- 
tion of  the  upper  layer  of  the  mucosa  in  localized  regions,  particularly  along 
the  ridges  and  folds  of  the  colon,  often  extending  into  the  ileum.  In 
severer  forms  the  entire  mucosa  may  be  involved  and  necrotic,  sometimes 
having  a  rough,  granular  appearance.  In  the  secondary  colitis  of  pneu- 
monia the  exudation  may  be  pseudo-membranous  and  form  a  firm,  thin, 
.white  pellicle  which  seems  to  lie  upon,  not  within,  the  mucous  membrane. 

Symptoms. — The  clinical  features  of  diphtheritic  dysentery  are  very 
varied.  In  the  acute  primary  cases  the  patient  from  the  outset  is  often 
extremely  ill,  with  high  fever,  great  prostration,  pain  in  the  abdomen,  and 
frequent  discharges.    Delirium  may  be  early  and  the  clinical  features  may 


200  SPECIFIC  INFECTIOUS  DISEASES. 

closely  resemble  those  of  severe  typhoid.  I  have,  on  more  than  one  occa- 
sion, known  this  mistake  to  be  made.  The  abdomen  is  distended  and  often 
tender.  The  discharges  are  frequent  and  diarrhoeal  in  character,  and  tenes- 
mus may  not  be  a  striking  symptom.  Blood  and  mucus  may  be  found  early, 
but  are  not  such  constant  features  as  in  the  follicular  disease.  This  pri- 
mary form  is  very  fatal,  but  the  sloughs  may  separate  and  the  condition 
become  chronic.  In  the  secondary  form  there  may  have  been  no  symptoms 
to  attract  attention  to  the  large  bowel.  In  a  majority  of  the  cases  the 
patient  has  a  diarrhoea — three,  four,  or  more  movements  in  the  day,  which 
are  often  profuse  and  weakening.  A  little  blood  and  mucus  may  be  passed 
at  first,  but  they  are  not  specially  characteristic  elements  in  the  stools. 

In  all  forms  of  dysentery  death  usually  results  from  asthenia.  The 
pulse  becomes  weaker  and  more  rapid,  the  tongue  dry,  the  face  pinched, 
the  skin  cool  and  covered  with  sweat,  and  the  patient  falls  into  a  drowsy, 
torpid  condition.  Consciousness  may  be  retained  until  the  last,  but  in 
the  protracted  cases  there  is  a  low  delirium  deepening  into  collapse. 

Complications  and  Sequelse  of  the  Various  Forms.— A 
local  peritonitis  may  arise  by  extension,  or  a  diffuse  inflammation  may  fol- 
low perforation,  which  is  usually  fatal.  When  this  occurs  about  the  esecal 
region,  perityphlitis  results;  when  low  down  in  the  rectum,  periproctitis. 
In  108  autopsies  collected  by  "Woodward  perforation  occurred  in  11.  By  far 
the  most  serious  complication  is  abscess  of  the  liver,  which  occurs  fre- 
quently in  the  tropics  and  is  not  very  uncommon  in  this  country.  It  was 
not,  however,  a  frequent  complication  in  dysentery  during  the  civil  war.  In 
this  latitude  it  is  certainly  not  uncommon.  It  usually  comes  on  insidiously. 
The  symptoms  will  be  discussed  in  connection  with  hepatic  abscess. 

In  extensive  epidemics,  however,  Woodward  states  that  cases  of  ordinary 
dysentery  occur  associated  with  all  the  phenomena  of  malaria.  We  have 
had  a  number  of  instances  of  the  coexistence  of  the  two  diseases.  With 
reference  to  typhoid  fever,  as  a  complication,  this  author  mentions  that  the 
combination  was  exceedingly  frequent  during  the  civil  war,  and  charac- 
teristic lesions  of  both  diseases  coexisted.  In  civil  practice  it  is  extremely 
rare. 

Sydenham  noted  that  dysentery  was  sometimes  associated  with  rheu- 
matic pains,  and  in  certain  epidemics  joint  swellings  have  been  especially 
prevalent.  They  are  probably  not  of  the  nature  of  true  rheumatism,  but 
rather  analogous  to  those  of  gonorrhoeal  arthritis.  In  severe,  protracted 
cases  there  may  be  pleurisy,  pericarditis,  endocarditis,  and  occasionally  pyse- 
mic  manifestations,  among  which  may  be  mentioned  pylephlebitis.  Chronic 
Bright's  disease  is  also  an  occasional  sequel.  In  protracted  cases  there  may 
be  an  anaemic  oedema.  An  interesting  sequel  of  dysentery  is  paralysis. 
Woodward  reports  8  cases.  Weir  Mitchell  mentions  it  as  not  uncommon, 
occurring  chiefly  in  the  form  of  paraplegia.  As  in  other  acute  fevers,  this 
is  due  probably  to  a  neuritis.  Intestinal  stricture  is  a  rare  sequence — so-^ 
rare  that  no  case  was  reported  at  the  Surgeon-General's  office  during  the 
war.  Among  the  sequelse  of  chronic  dysentery,  in  persons  who  have  recov- 
ered a  certain  measure  of  health,  may  be  mentioned  persistent  dyspepsia 
and  irritability  of  the  bowels. 


DYSENTERY.  201 

Diagnosis. — The  recognition  of  the  acute  follicular  form  is  easy;  the 
frequency  of  the  passages,  the  presence  of  blood  and  mucus,  and  the  tenes- 
mus forming  a  very  characteristic  picture.  Local  affections  of  the  rectum, 
particularly  syphilis  and  epithelioma,  may  produce  tenesmus  with  the 
passage  of  mucoid  and  bloody  stools.  The  acute  diphtheritic  form,  coming 
on  with  great  intensity  and  with  severe  constitutional  disturbances,  is  not 
infrequently  mistaken  for  typhoid  fever,  to  which  indeed  in  many  cases 
the  resemblance  is  extremely  close.  The  higher  grade  of  fever,  the  more 
pronounced  intestinal  symptoms,  the  presence,  particularly  in  the  early 
stage,  of  a  small  amount  of  blood  in  the  stools,  the  absence  of  enlargement 
of  the  spleen,  the  rose  rash,  and  the  Widal  reaction  should  lead  to  a  correct 
diagnosis.  In  the  amoebic  form  the  diagnosis  can  readily  be  made  by  ex- 
amination of  the  stools.  A  characteristic  feature  of  these  cases  is  their 
irregular,  chronic  course.  A  patient  may  be  about  and  in  fairly  good  con- 
dition, with  well-formed  stools  and  very  slight  intestinal  disturbance,  in 
whose  faeces  the  amoebge  may  still  be  discovered,  and  in  whom  the  disease 
is  at  any  time  likely  to  recur  with  intensity.  In  some  cases,  complicated 
by  abscess  of  the  liver  and  lung  discharging  through  a  bronchus,  the  diag- 
nosis may  rest  on  the  detection  of  amoebae  in  the  sputa,  when  they  can  not 
be  found  in  the  stools  owing  to  the  latency  of  the  intestinal  disturbance. 
Leucocytosis  is  rare  except  when  complications  arise.  In  the  acute  specific 
form  the  blood-serum  agglutinates  the  Shiga  bacillus. 

Treatment. — Flint  has  shown  that  sporadic  dysentery  is,  in  its 
slighter  grades  at  least,  a  self -limited  disease,  which  runs  its  course  in  eight 
or  nine  days.  Heading  a  report  of  his  cases,  one  is  struck,  however,  with 
their  comparative  mildness. 

The  enormous  surface  involved,  amounting  to  many  square  feet,  the 
constant  presence  of  irritating  particles  of  food,  and  the  impossibility  of 
getting  absolute  rest,  are  conditions  which  render  the  treatment  of  dysen- 
tery peculiarly  difficult.  Moreover,  in  the  severer  cases,  when  necrosis  of 
the  mucosa  has  occurred,  ulceration  necessarily  follows,  and  can  not  in  any 
way  be  obviated.  When  a  case  is  seen  early,  particularly  if  there  has  been 
constipation,  a  saline  purge  should  be  given.  The  free  watery  evacuations 
produced  by  a  dose  of  salts  cleanse  the  large  bowel  with  the  least  possible 
irritation,  and  if  necessary,  in  the  course  of  the  disease,  particularly  if 
scybala  are  present,  the  dose  may  be  repeated.  The  saline  treatment  is 
much  commended.  W.  J.  Buchanan  has  treated  855  cases  with  only  9 
deaths.  He  gives  a  drachm  of  sodium  sulphate,  four,  six,  or  eight  times  a 
day,  and  continues  until  all  blood  and  mucus  have  disappeared,  usually 
for  two  or  three  days.  Of  medicines  which  are  supposed  to  have  a  direct 
effect  upon  the  disease,  ipecacuanha  still  maintains  its  reputation  in  the 
tropics.  Ko  food- is  taken  for  three  hours,  then  twenty  drops  of  laudanum, 
and  half  an  hour  after  from  20  to  60  grains  of  ipecacuanha.  If  rejected 
by  vomiting,  the  dose  is  repeated  in  a  few  hours.  Washbourn  and  Kichards, 
in  the  South  African  campaign,  speak  of  the  good  results  of  ipecacuanha 
combined  with  the  saline  treatment. 

Minute  doses  of  corrosive  sublimate,  one  hundredth  of  a  grain  every 
two  hours,  are  warmly  recommended  by  Einger.    Large  doses  of  bismuth, 


202  SPECIFIC  INFECTIOUS  DISEASES. 

half  a  drachm  to  a  drachm  eyerj  two  hours,  so  that  the  patient  may  take 
from  12  to  15  drachms  in  a  day,  have  in  many  cases  had  a  beneficial  effect. 
To  do  good  it  must  be  given  in  large  doses,  as  recommended  by  Monneret, 
who  gave  as  high  as  70  grammes  a  day.  It  certainly  is  more  useful  in  the 
chronic  than  the  acute  cases.  It  is  best  given  alone.  Opium  is  an  invalu- 
able remedy  for  the  relief  of  the  pain  and  to  quiet  the  peristalsis.  It  should 
be  given  as  morphia,  hypodermieally,  according  to  the  needs  of  the  patient. 

The  treatment  of  dysentery  by  topical  applications  is  by  far  the  most 
rational  plan.  A  serious  obstacle,  however,  in  the  acute  cases,  is  the  ex- 
treme irritability  of  the  rectum  and  the  tenesmus  which  follows  any  at- 
tempt to  irrigate  the  colon.  A  preliminary  cocaine  suppository  or  the  in- 
jection of  a  small  quantity  of  the  4-per-cent  solution  will  sometimes  re- 
lieve this,  and  then  with  a  long  tube  the  solution  can  be  allowed  to  flow 
in  slowly.  The  patient  should  be  in  the  dorsal  position  with  a  pillow  under 
the  hips,  so  as  to  get  the  effect  of  gravitation.  TTater  at  the  temperature 
of  100°  is  very  soothing,  but  the  irritability  of  the  bowel  is  such  that  large 
quantities  can  rarely  be  retained  for  any  time.  When  the  acute  symptoms 
subside,  the  injections  are  better  borne.  Various  astringents  may  be  used — 
alum,  acetate  of  lead,  sulphate  of  zinc  and  copper,  and  nitrate  of  silver. 
Of  these  remedies  the  nitrate  of  silver  is  the  best,  though,  I  think,  not  in 
very  acute  cases.  In  the  chronic  form  it  is  perhaps  the  most  satisfactory 
method  of  treatment  which  we  have.  It  is  useless  to  give  it  in  the  small 
injections  of  two  or  three  ounces  with  1  to  2  grains  of  the  salt  to  the 
ounce.  It  must  be  a  large  irrigating  injection,  which  will  reach  all  parts 
of  the  colon.  This  plan  was  introduced  by  Hare,  of  Edinburgh,  and  is 
highly  recommended  by  Stephen  Mackenzie  and  H.  C.  Wood.  The  solu- 
tion must  be  fairly  strong,  20  to  30  grains  to  the  pint,  and  if  possible  from 
3  to  6  pints  of  fluid  must  be  injected.  To  begin  with  it  is  well  to  use 
not  more  than  a  drachm  to  the  2  pints  or  2^  pints,  and  to  let  the  warm 
fluid  run  in  slowly  through  a  tube  passed  far  into  the  bowel.  It  is  at  times 
intensely  painful  and  is  rejected  at  once.  Argyria,  so  far  as  I  know,  has 
never  followed  the  prolonged  use  of  nitrate-of -silver  injections  in  chronic 
dysentery.  In  the  cases  of  amoebic  dysentery  we  have  been  using  at  the 
Johns  Hopkins  Hospital  with  great  benefit  warm  injections  of  quinine  in 
strength  of  1  to  5,000,  1  to  2,500,  and  1  to  1,000.  The  amcebae  are  rapidly 
destroyed  by  the  drug.  These  large  injections  are  said  not  to  be  without 
a  certain  degree  of  danger.  I  have  never  seen  any  ill  effects,  even  with 
the  very  large  amounts.  When  there  is  not  much  tenesmus,  a  small  in- 
jection of  thin  starch  with  half  a  drachm  to  a  drachm  of  laudanum  gives 
great  relief,  but  for  the  tormina  and  tenesmus,  the  two  most  distressing 
symptoms,  a  hj'podermic  of  morphia  is  the  only  satisfactory  remedy.  Local 
applications  to  the  abdomen,  in  the  form  of  light  poultices  or  turpentine 
stupes,  are  very  grateful. 

The  diet  in  acute  cases  must  be  restricted  to  milk,  whey,  and  broths, 
and  during  convalescence  the  greatest  care  must  be  taken  to  provide  only 
the  most  digestible  articles  of  food.  In  chronic  dysentery,  diet  is  perhaps 
the  most  important  element  in  the  treatment.  The  number  of  stools  can 
frequently  be  reduced  from  ten  or  twelve  in  the  day  to  two  or  three,  by 


MALARIAL   FEVER.  203 

placing  the  patient  in  bed  and  restricting  the  diet.  Many  cases  do  well 
on  milk  alone,  hut  the  stools  should  be  carefully  watched  and  the  amount 
limited  to  that  which  can  be  digested.  If  curds  appear,  or  if  much  oily 
matter  is  seen  on  microscopical  examination,  it  is  best  to  reduce  the 
amount  of  milk  and  to  supplement  it  with  beef-juice  or,  better  still,  egg- 
albumen.  The  large  doses  of  bismuth  seem  specially  suitable  in  the  chronic 
cases,  and  the  injections  of  nitrate  of  silver,  in  the  way  already  mentioned, 
should  always  be  given  a  trial. 

XXIV.    MALARIAL  FEVER. 

Definition. — An  infectious  disease  characterized  by:  (a)  paroxysms  of 
intermittent  fever  of  quotidian,  tertian,  or  quartan  type;  (b)  a  continued 
fever  with  marked  remissions;  (c)  certain  pernicious,  rapidly  fatal  forms; 
and  (d)  a  chronic  cachexia,  with  anaemia  and  an  enlarged  spleen. 

With  the  disease  are  invariably  associated  the  hsemocytozoa  described 
by  Laveran,  which  are  transmitted  to  man  by  the  bite  of  the  mosquito. 

Etiology. —  (1)  Geographical  Distribution. — In  Europe,  southern 
Eussia  and  certain  parts  of  Italy  are  now  the  chief  seats  of  the  disease.  It 
is  rare  in  Germany,  France,  and  England,  and  the  foci  of  epidemics  are 
becoming  yearly  more  restricted. 

In  the  United  States  malaria  has  progressively  diminished  in  extent 
and  severity  during  the  past  fifty  years.  The  records  of  the  health  boards 
of  the  larger  cities  on  the  Atlantic  coast  which  give  a  high  mortality  from 
the  disease  are  quite  untrustworthy.  From  New  England,  where  it  once 
prevailed  extensively,  it  has  gradually  disappeared,  but  there  has  of  late 
years  been  a  slight  return  in  some  places.  In  the  city  of  New  York  the 
milder  forms  of  the  disease  are  not  uncommon.  In  Philadelphia  and  along 
the  valleys  of  the  Delaware  and  Schuylkill  Elvers,  formerly  hot-beds  of 
malaria,  the  disease  has  become  much  restricted.  In  Baltimore  a  few  cases 
develop  in  the  autumn,  but  a  majority  of  the  patients  seeking  relief  are 
from  the  outlying  districts  and  one  or  two  of  the  inlets  of  Chesapeake  Bay. 
Throughout  the  Southern  States  there  are  many  regions  in  which  malaria 
prevails;  but  here,  too,  the  disease  has  diminished  in  prevalence  and  in- 
tensity. In  the  Northwestern  States  malaria  is  almost  unknown.  It  is  rare 
on  the  Pacific  coast.  In  the  region  of  the  Great  Lakes  malaria  prevails 
only  in  the  Lake  Erie  and  Lake  St.  Clair  regions.  The  St.  Lawrence 
basin  remains  free  from  the  disease. 

In  India  malaria  is  very  prevalent,  particularly  in  the  great  river  basins. 
In  Burma  and  Assam  severe  types  are  met  with,  and  recently  the  anomalous 
form  of  fever  known  as  the  Kdla-dzar  of  Assam  has  been  shown  to  be  ma- 
larial (Eogers). 

In  Africa  the  malarial  fevers  form  the  great  obstacle  to  European  set- 
tlements on  the  coast  and  along  the  river  basins.  The  Hack-water  or  West 
African  fever  of  the  Gold  Coast  is  a  very  fatal  type  of  malarial  hemo- 
globinuria. 

(2)  Season.— In  the  tropics  there  are  minimal  and  maximal  periods, 
the  former  corresponding  to  the  summer  and  winter,  the  latter  to  the 
13 


204  ,  SPECIFIC  INFECTIOUS  DISEASES. 

spring  and  autumn  months.  In  temperate  regions,  like  the  central  Atlan- 
tic States,  there  are  only  a  few  cases  in  the  spring,  usually  in  the  month  of 
May,  and  a  large  number  of  cases  in  September  and  October,  and  some- 
times in  November. 

(3)  The  Parasite. — Parasites  of  the  red  blood-corpuscles — hsemocy- 
tozoa  or  haemosporidia — are  very  widespread  throughout  the  animal  series. 
They  are  met  with  in  the  blood  of  frogs,  fish,  birds,  and  among  mammals 
in  monkeys,  bats,  cattle,  and  man.  In  birds  and  in  frogs  the  parasites 
appear  to  do  no  harm  except  when  present  in  very  large  numbers. 

In  1880  Laveran,  a  French  army  surgeon  stationed  at  Algiers,  noted  in 
the  blood  of  patients  with  malarial  fever  pigmented  bodies,  which  he 
regarded  as  parasites,  and  as  the  cause  of  the  disease.  Eichard,  another 
French  army  surgeon,  confirmed  these  observations.  In  1885  Marchiafava 
and  Celli  described  the  parasites  with  great  accuracy,  and  in  the  same 
year  Golgi  made  the  all-important  observation  that  the  paroxysm  of  fever 
invariably  coincided  with  the  sporulation  or  segmentation  of  a  group  of 
the  parasites.  In  the  following  year  (1886)  Laveran's  observations  were 
brought  before  the  profession  in  this  country  by  Sternberg.  Councilman 
and  Abbott  had  already,  in  the  previous  year,  described  the  remarkable  pig- 
mented bodies  in  the  red  blood-corpuscles  in  the  blood-vessels  of  the  brain 
in  a  fatal  case,  and  in  1886  Councilman  confirmed  the  observations  of 
Laveran  in  clinical  cases.  Stimulated  by  his  work,  I  began  studying  the 
malarial  cases  in  the  Philadelphia  Hospital,  and  soon  became  convinced  of 
the  truth  of  Laveran's  discovery,  and  was  able  to  confirm  Golgi's  statement 
as  to  the  coincidence  of  the  sporulation  with  the  paroxysm.  The  work 
was  taken  up  actively  in  this  country  by  Walter  James,  Dock,  Koplik, 
Thayer,  Hewetson,  and  others,  and  in  a  number  of  subsequent  communica- 
tions I  tried  to  emphasize  the  extraordinary  clinical  importance  of  Lav- 
eran's discovery.* 

Among  British  observers,  Vandyke  Carter  alone,  in  India,  seems  to  have 
appreciated  at  an  early  date  the  profound  significance  of  Laveran's  work. 

The  next  important  observation  was  the  discovery  by  Golgi  that  the 
parasite  of  quartan  malarial  fever  was  different  from  the  tertian.  From  this 
time  on  the  Italian  observers  took  up  the  work  with  great  energy,  and  in 
1889  Marchiafava  and  Celli  determined  that  the  organism  of  the  severer 
forms  of  malarial  fever  differed  from  the  parasite  of  the  tertian  and  quar- 
tan varieties.  During  the  past  ten  years  the  work  of  observers  in  many 
lands  has  confirmed  these  essential  features,  and  has  added  greatly  to  our 
knowledge  of  the  structure  and  modes  of  development  of  the  parasites. 

*  The  following  references  to  work  on  malaria  which  has  been  done  in  connection 
with  my  clinic,  chiefly  under  the  supervision  of  my  colleague,  Professor  Thayer,  may  be 
of  interest :  Philadelphia  Medical  Times,  1886 ;  British  Medical  Journal,  March,  1887 ; 
Medical  News,  1889,  vol.  i ;  Johns  Hopkins  Hospital  Bulletin,  1889 ;  the  first  edition  of 
my  Text-Book  of  Medicine,  1892 ;  Thayer  and  Hewetson,  Johns  Hopkins  Hospital  Reports, 
1895  ;  Thayer,  Lectures  on  Malarial  Fever,  1897 ;  W.  G.  MacCallura,  Hsmatozoa  of  Birds, 
Jour,  of  Exp.  Med.,  1898 ;  Opie,  On  the  Haematozoa  of  Birds,  1898 ;  Barker,  On  Fatal  Cases 
of  Malaria,  Johns  Hopkins  Hospital  Reports,  1899 ;  MacCallum,  On  the  Significance  of  the 
Flagella,  Lancet,  1897 ;  Thayer,  Transactions  American  Medical  Congress,  vol.  iv,  1900. 


_  MALARIAL  FEVER.  205 

The  next  important  step  related  to  the  question  of  the  mode  of  infec- 
tion. It  had  been  suggested  by  King,  of  Washington,  and  others,  that  the 
disease  was  transmitted  by  the  mosquitoes.  The  important  role  played 
by  insects  as  an  intermediate  host  had  been  shown  in  the  case  of  the  Texas 
cattle  fever,  in  which  Theobald  Smith  demonstrated  that  the  hsematozoa 
developed  in,  and  the  disease  was  transmitted  by,  ticks;  but  it  remained 
for  Manson  to  formulate  in  a  clear  and  scientific  way  the  theory  of  infec- 
tion in  malaria  by  the  mosquito.  Impressed  with  the  truth  of  this,  Eoss 
studied  the  problem  in  India,  and  showed  that  the  parasites  developed  in 
the  bodies  of  the  mosquitoes,  and  demonstrated  conclusively  that  the 
infection  in  birds  was  transmitted  by  the  mosquito.  W.  G.  MacCallum 
suggested  that  the  flagella  were  sexual  elements,  and  he  actually  saw  the 
process  of  fertilization  by  them. 

In  many  countries  the  forms  of  mosquitoes  were  studied,  and  it  was 
demonstrated  that  the  malarial  infection  was  associated  with  special  vari- 
eties, and  Grassi  and  others  confirmed  Eoss's  discovery  of  development  of 
the  parasites  in  the  body  of  the  mosquito.  Then  came  the  practical 
demonstration  by  Italian  observers,  and  by  the  interesting  experiments  on 
Manson,  Jr.,  of  the  direct  transmission  of  the  disease  to  man  by  the  bite 
of  infected  mosquitoes.  And  lastly,  as  a  practical  conclusion  of  the  whole 
matter,  is  the  war  against  the  mosquito  and  the  recognition  of  the  means 
whereby  infection  may  be  prevented. 

General  Morphology  of  the  Parasite. — Belonging  to  the  sporozoa,  it  has 
received  a  large  number  of  names,  of  which,  perhaps,  hsemamoeba  is  at 
present  the  most  satisfactory.  The  term  plasmodium  malariee  has  also  been 
applied  to  the  parasite  as  it  exists  in  the  human  blood.  There  are  three, 
possibly  more,  well-marked  varieties  of  the  parasite,  and  they  exist  in  two 
separate  phases  or  stages:  (a)  the  parasite  in  man,  who  acts  as  the  interme- 
diate host,  and  in  whom,  in  the  cycle  of  its  development,  it  causes  symptoms 
of  malaria;  and  (&)  an  extracorporeal  cycle,  in  which  it  lives  and  develops  in 
the  body  of  the  mosquito,  which  is  its  definitive  host. 

I.  The  Parasite  in  Man. — (a)  The  Parasite  of  Tertian  Fever. — The  ear- 
liest form  seen  in  the  red  blood-corpuscle  is  oval  or  irregular  in  shape,  about 
2  /A  in  diameter  and  unpigmented.  It  corresponds  very  much  in  appear- 
ance with  the  spore  bodies  of  the  rosettes  formed  during  the  chill.  A  few 
hours  later  the  body  has  increased  in  size,  is  still  ring-shaped,  and  there 
is  pigment  in  the  form  of  fine  grains.  It  has  a  relatively  large  nuclear  body, 
consisting  of  a  well-defined,  clear  area,  in  part  almost  transparent,  in  part 
consisting  of  a  milk-white  substance,  in  which  there  lies  a  small,  deeply 
staining  chromatin  mass,  as  shown  by  Eomanowsky's  method  of  staining. 
At  this  period  it  usually  shows  active  amoeboid  movements,  with  tongue- 
like protrusions.  The  pigment  increases  in  amount  and  the  corpuscle  be- 
comes larger  and  paler,  owing  to  a  progressive  diminution  of  its  haemo- 
globin. There  is  a  gradual  growth  of  the  parasite,  which,  toward  the  end 
of  twenty-four  hours,  occupies  almost  all  of  the  swollen  red  corpuscle. 
It  is  now  much  pigmented,  and  is  in  the  stage  of  what  is  often  called  the 
full-grown  parasite.  Between  the  twentieth  and  twenty-fourth  hours  many 
of  the  parasites  are  seen  to  have  undergone  the  remarkable  change  known 


206  SPECIFIC  INFECTIOUS  DISEASES. 

as  segmentation,  in  which  the  pigment  becomes  collected  into  a  single  mass 
or  block,  and  the  protoplasm  divides  into  a  series  of  from  fifteen  to  twenty 
spores,  often  showing  a  radial  arrangement.  Certain  full-grown  tertian 
parasites,  however,  do  not  undergo  segmentation.  These  forms,  which  are 
larger  than  the  sporulating  bodies,  and  contain  very  actively  dancing  pig- 
ment granules,  represent  the  sexually  differentiated  form  of  the  parasite — 
gametocytes. 

(6)  The  Parasite  of  Quartan  Fever. — The  earlieaj  form  is  very  like  the 
tertian  in  appearance,  but  as  it  increases  in  size  the  earlier  granules  are 
coarser  and  darker  and  the  movement  is  not  nearly  so  marked.  By  the 
third  day  the  parasite  is  still  larger,  rounded  in  shape,  scarcely  at  all 
amoeboid,  and  the  pigment  is  more  often  arranged  at  the  periphery  of  the 
parasite.  The  rim  of  protoplasm  about  it  is  often  of  a  deep  yellowish- 
green  color  or  of  a  dark  brassy  tint.  On  the  fourth  day  the  segment- 
ing bodies  become  abundant,  the  pigment  flowing  in  toward  the  centre 
of  the  parasite  in  radial  lines  so  as  to  gWe  a  star-shaped  appearance.  The 
parasites  finally  break  up  into  from  six  to  twelve  spores.  Here  also,  as 
in  the  case  of  the  tertian  parasite,  some  full-grown  bodies  persist  without 
sporulating,  representing  the  gametocytes. 

(c)  The  parasite  of  the  cestivo-autumnal  fever  is  considerably  smaller  than 
the  other  varieties;  at  full  development  it  is  often  less  than  one  half 
the  size  of  a  red  blood-corpuscle.  The  pigment  is  much  scantier,  often 
consisting  of  a  few  minute  granules.  At  first  only  the  earlier  stages  of 
development,  small,  hyaline  bodies,  sometimes  with  one  or  two  pigment 
granules,  are  to  be  found  in  the  peripheral  circulation;  the  later  stages  are 
ordinarily  only  to  be  seen  in  the  blood  of  certain  internal  organs,  the  spleen 
and  bone  marrow  particularly.  The  corpuscles  containing  the  parasites 
become  not  infrequently  shrunken,  erenated,  and  brassy-colored.  After 
the  process  has  existed  for  about  a  week,  larger,  refractive,  crescentic, 
ovoid,  and  round  bodies,  with  central  clumps  of  coarse  pigment  granules, 
begin  to  appear.  These  bodies  are  characteristic  of  sestivo-autumnal  fever. 
The  crescentic  and  ovoid  forms  are  incapable  of  sporulation;  they  are 
analogous  to  the  large,  full-grown,  non-sporulating  bodies  of  the  tertian 
and  quartan  parasites  which  have  been  above  mentioned,  and  represent 
sexually  difierentiated  forms — gametocytes.  Within  the  human  host  they 
are  incapable  of  further  development,  but  upon  the  slide,  or  within  the 
stomach  of  the  normal  intermediate  host,  the  mosquito,  the  male  ele- 
ments (micro-gametocytes)  give  rise  to  a  number  of  long,  actively  motile 
flagella  (micro-gametes)  which  break  loose,  penetrating  and  fecundating 
the  female  forms — macro-gametes  (W.  G.  MacCallum).  The  fecundated 
female  form  enters  into  the  stomach  wall  of  the  intermediate  host,  the 
mosquito,  where  it  undergoes  a  definite  cycle  of  existence. 

II.'  The  Parasite  ivithin  the  Body  of  the  Mosquito. — The  brilliant  re- 
searches of  Eoss,  followed  by  the  work  of  Grassi,  Bastianelli,  Bignami, 
Stephens,  Christophers,  and  Daniels,  have  proved  that  a  certain  genus 
of  mosquito — anopheles — is  not  only  the  intermediate  host  of  the  malarial 
parasite,  but  also  the  sole  source  of  infection.  In  the  present  state  of  our 
knowledge  it  would  appear  that  all  species  of  the  genus  anopheles  may  act 


MALARIAL  FEVER.  207 

as  hosts  of  the  parasite.  The  more  common  genera  of  mosquito  in  tem- 
perate climates  are  culex  and  anopheles.  The  different  species  of  culex 
form  the  great  majority  of  our  ordinary  house  mosquitoes,  and  are  appar- 
ently incapable  of  acting  as  hosts  of  the  malarial  parasite.  All  malarial 
regions,  however,  which  have  been  investigated  contain  anopheles.  Al- 
though this  is  apparently  a  positive  rule,  anopheles  may,  however,  be  pres- 
ent without  the  existence  of  malaria  under  two  circumstances:  firstly, 
when  the  climate  is  too  cold  for  the  development  of  the  malarial  parasite; 
and  secondly,  in  a  region  which  has  not  yet  been  infected.  So  far  as  is 
known,  the  parasite  exists  only  in  the  mosquito  and  in  man.  It  is  apparently 
fair  to  state  that  regions  in  which  mosquitoes  of  the  genus  anopheles  are 
present  may  become  malarious  during  the  warm  season.  A  large  number 
of  species  of  anopheles  have  been  described.  In  this  country,  however,  only 
three  have  been  positively  recognized — A.  pundipennis  (Say),  A.  quadri- 
maculatus  (Say),  A.  crucians  (Wied).  The  commonest  variety,  and  that 
which  in  all  probability  is  most  concerned  in  the  spread  of  the  disease  in 
this  country,  is  A.  quadrimaculatus,  which  has  been  shown  to  be  identical 
with  A.  claviger  (A.  maculipennis),  which  is  the  most  important  agent  in 
the  spread  of  the  disease  on  the  Continent. 

Mr.  Howard,  of  the  Entomological  Department  at  Washington,  has 
issued  a  very  useful  pamphlet  on  the  varieties  and  the  methods  of 
identification.  In  Africa  the  distribution  of  the  forms  has  been  studied  by 
Stephens,  Christophers,  and  Daniels.  To  those  interested  in  the  subject, 
Christophers'  careful  study  of  the  Anatomy  and  Histology  of  the  Adult 
Female  Mosquito  (Eeport  of  Malaria  Committee,  Eoyal  Society,  No.  IV) 
will  prove  of  great  help. 

The  palpi  in  the  mature  culex  are  extremely  short,  only  to  be  seen  on 
careful  observation  at  the  base  of  the  proboscis,  while  in  the  anopheles 
they  are  nearly  of  equal  length  with  the  proboscis,  so  that  on  superficial 
observation  the  insect  would  appear  to  have  three  proboscides.  The  wings 
of  the  common  species  of  culex  show  no  markings  beyond  the  ordinary 
veins.  The  wings  of  all  our  American  species  of  anopheles  show  distinct 
mottling.  The  culex,  when  sitting  upon  the  wall  or  ceiling,  holds  its  pos- 
terior pair  of  legs  turned  up  above  its  back,  while  the  body  lies  nearly 
parallel  to  the  wall.  In  some  instances,  when  it  is  full  of  blood,  and  sit- 
ting upon  the  ceiling,  the  body  may  sag  downward  considerably.  The 
anopheles,  when  sitting  upon  the  wall  or  ceiling,  holds  its  posterior  pair 
of  legs  commonly  either  against  the  wall  or  hanging  downward,  though  in 
some  instances  they  may  be  lifted  above  the  back.  The  body,  however,  in- 
stead of  lying  parallel  to  the  wall  or  ceiling,  protrudes  at  an  angle  of  45° 
or  more.  These  simple  points  are  sufficient  to  permit  the  ready  distinction 
of  species  by  almost  any  individual. 

The  culex  lays  its  eggs  in  sinks,  tanks,  cisterns,  and  any  collection  of 
water  about  or  in  houses,  while  anopheles  lays  its  eggs  in  small,  shallow 
puddles  or  slowly  running  streams,  especially  those  in  which  certain  forms 
of  algai  exist.  The  culex  is  essentially  a  city  mosquito,  the  anopheles  a 
country  insect. 

Evolution  in  the  Body  of  the  Mosquito. — When   a  mosquito   of   the 


208  SPECIFIC  INFECTIOUS  DISEASES. 

genus  anopheles  bites  an  individual  whose  blood  contains  sex-ripe  forms 
(gametocjtes)  of  the  malarial  parasite,  flagellation  and  fecundation  of  the 
female  element  occurs  within  the  stomach  of  the  insect.  The  fecundated 
element  then  penetrates  the  wall  of  the  mosquito's  stomach  and  begins  a 
definite  cycle  of  development  in  the  muscular  coat.  Two  days  after  biting 
there  begin  to  appear  small,  round,  refractive,  granular  bodies  in  the 
stomach  wall  of  the  mosquito,  which  contain  pigment  granules  clearly 
identical  with  those  previously  contained  in  the  malarial  parasite.  These 
develop  until  at  the  end  of  seven  days  they  have  reached  a  diameter  of 
from  60  to  70  /t.  At  this  period  they  may  be  observed  to  show  a  delicate 
radial  striation  due  to  the  presence  of  great  numbers  of  small  sporoblasts. 
The  mother  oocyst  (zygote)  then  bursts,  setting  free  into  the  body  cavity 
of  the  mosquito  an  enormous  number  of  delicate  spindle-shaped  sporo- 
zoids.  These  accumulate  in  the  cells  of  the  veneno-salivary  glands  of  the 
mosquito,  and,  escaping  into  the  ducts,  are  inoculated  with  subsequent 
bites  of  the  insect.  These  little  spindle-shaped  sporozoids  develop,  after 
inoculation  into  the  warm-blooded  host,  into  fresh  young  parasites.  The 
sporozoid  which  has  developed  in  the  oocyst  in  the  stomach  wall  of  the  mos- 
quito is  then  the  equivalent  of  the  spore  resulting  from  the  asexual  seg- 
mentation of  the  full-grown  parasite  in  the  circulation.  Either  one,  on 
entering  a  red  blood-corpuscle,  may  give  rise  to  the  asexual  or  sexual  cycle. 
As  a  rule  the  first  several  generations  of  parasites  in  the  human  body  pur- 
sue the  asexual  cycle,  the  sexual  forms  developing  later.  These  sexual 
forms,  sterile  while  in  the  human  host,  serve  as  the  means  of  preserving 
the  life  of  the  parasite  and  spreading  infection  when  the  individual  is 
subjected  to  bites  of  anopheles. 

Morbid  Anatomy. — The  changes  result  from  the  disintegration  of 
the  red  blood-corpuscles,  accumulation  of  the  pigment  thereby  formed,  and 
possibly  the  influence  of  toxic  materials  produced  by  the  parasite.  Cases 
of  simple  malarial  infection,  the  ague,  are  rarely  fatal,  and  our  knowledge 
of  the  morbid  anatomy  of  the  disease  is  drawn  from  the  pernicious  malaria 
or  the  chronic  cachexia.  Eupture  of  the  enlarged  spleen  may  occur  spon- 
taneously, but  more  commonly  from  trauma.  A  case  of  the  kind  was  ad- 
mitted under  my  colleague,  Halsted,  in  June,  1889,  and  Dock  has  reported 
two  cases. 

(1)  Pernicious  Malaria. — The  blood  is  hydremic  and  the  serum  may 
even  be  tinged  with  haemoglobin.  The  red  blood-corpuscles  present  the 
endoglobular  forms  of  the  parasite  and  are  in  all  stages  of  destruction. 
The  spleen  is  enlarged,  often  only  moderately;  thus,  of  two  fatal  cases 
in  my  wards  the  spleens  measured  13  X  8  cm.  and  14  X  8  cm.  respec- 
tively. In  a  fresh  infection,  the  spleen  is  usually  very  soft,  and  the  pulp 
lake-colored  and  turbid.    The  liver  is  swollen  and  turbid. 

In  some  acute  pernicious  cases  with  choleraic  symptoms,  the  capillaries 
of  the  gastro-intestinal  mucosa  may  be  packed  with  parasites. 

(2)  Malarial  Cachexia. — In  fatal  cases  of  chronic  paludism  death  occurs 
usually  from  anaemia  or  the  hsemorrhage  associated  with  it. 

The  anasmia  is  profound,  particularly  if  the  patient  has  died  of  fever. 
The  spleen  is  greatly  enlarged,  and  may  weigh  from  seven  to  ten  pounds. 


MALARIAL  FEVER.  209 

The  lirer  may  be  greatly  enlarged,  and  presents  to  the  naked  eye  a 
grayish-brown  or  slate  color,  due  to  the  large  amount  of  pigment.  In 
the  portal  canals  and  beneath  the  capsule  the  connective  tissue  is  im- 
pregnated with  melanin.  The  pigment  is  seen  in  the  Kupffer's  cells  and 
the  perivascular  tissue. 

The  kidneys  may  be  enlarged  and  present  a  grajdsh-red  color,  or  areas 
of  pigmentation  may  be  seen.  The  peritonaeum  is  usually  of  a  deep  slate- 
color.  The  mucous  membrane  of  the  stomach  and  intestines  may  have 
the  same  hue,  due  to  the  pigment  in  and  about  the  blood-vessels.  In 
some  cases  this  is  confined  to  the  lymph  nodules  of  Peyer's  patches,  caus- 
ing the  shaven-beard  appearance. 

(3)  The  Accidental  and  Late  Lesions  of  Malarial  Fever. — (a)  The  Liver. — 
Paludal  hepatitis  plays  a  very  important  role  in  the  history  of  malaria,  as 
described  by  French  writers.  Only  those  cases  in  which  the  history  of 
chronic  malaria  is  definite,  and  in  which  the  melanosis  of  both  liver  and 
spleen  coexist,  should  be  regarded  as  of  paludal  origin. 

(b)  Pneumonia  is  believed  by  many  authors  to  be  common  in  malaria, 
and  even  to  depend  directly  upon  the  malarial  poison,  occurring  either  in 
the  acute  or  in  the  chronic  forms  of  the  disease.  I  have  no  personal 
knowledge  of  such  a  special  pneumonia. 

(c)  Nepliritis. — Moderate  albuminuria  is  a  frequent  occurrence,  having 
occurred  in  46.4  per  cent  of  the  cases  in  my  wards.  Acute  nephritis  is 
relatively  frequent  in  asstivo-autumnal  infections,  having  occurred  in  over 
4.5  per  cent  of  my  cases.  Chronic  nephritis  occasionally  follows  long- 
continued  or  frequently  repeated  infections. 

Clinical  Forms  of  Malarial  Fever.— (1)  The  Regularly  Inter- 
mittent  Fevers. — (a)  Tertian  fever;  (b)  quartan  fever.  These  forms  are 
characterized  by  recurring  paroxysms  of  what  are  known  as  ague,  in  which, 
as  a  rule,  chill,  fever,  and  sweat  follow  each  other  in  orderly  sequence.  The 
stage  of  incubation  is  not  definitely  known;  it  probably  varies  much  ac- 
cording to  the  amount  of  the  infectious  material  absorbed.  Experimentally 
the  period  of  incubation  varies  from  thirty-six  hours  to  fifteen  days,  being 
a  trifle  longer  in  quartan  than  in  tertian  infections.  Attacks  have  been 
reported  within  a  very  short  time  after  the  apparent  exposure.  On  the 
other  hand,  the  ague  may  be,  as  is  said,  "  in  the  system,"  and  the  patient 
may  have  a  paroxysm  months  after  he  has  removed  from  a  malarial  region, 
though  of  course  this  can  not  be  the  case  unless  he  has  had  the  disease 
when  living  there. 

Description  of  the  Paroxysm. — The  patient  generally  knows  he  is  going 
to  have  a  chill  a  few  hours  before  its  advent  by  unpleasant  feelings  and 
uneasy  sensations,  sometimes  by  headache.  The  paroxysm  is  divided  into 
three  stages — cold,  hot,  and  sweating. 

Cold  Stage. — The  onset  is  indicated  by  a  feeling  of  lassitude  and  a 
desire  to  yawn  and  stretch,  by  headache,  uneasy  sensations  in  the  epigas- 
trium, sometimes  by  nausea  and  vomiting.  Even  before  the  chill  begins 
the  thermometer  indicates  some  rise  in  temperature.  Gradually  the  pa- 
tient begins  to  shiver,  the  face  looks  cold,  and  in  the  fully  developed  rigor 
the  whole  body  shakes,  the  teeth  chatter,  and  the  movements  may  often 


210 


SPECIFIC  INFECTIOUS  DISEASES.. 


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Chaet  XI 6. — ^stivo-autumnal  infection. — Remittent  fever. 
The  case  was  treated  for  a  week  as  one  of  typhoid  fever. 


MALARIAL  FEVER. 


211 


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Chart  XI  d. — Quartan  fever. 


212  SPECIFIC  INFECTIOUS  DISEASES. 

be  violent  enough  to  shake  the  bed.  Not  only  does  the  patient  look  cold 
and  blue,  but  a  surface  thermometer  will  indicate  a  reduction  of  the  skin 
temperature.  On  the  other  hand,  the  axillary  or  rectal  temperature  may, 
during  the  chill,  be  greatly  increased,  and,  as  shown  in  the  chart,  the  fever 
may  rise  meanwhile  even  to  105°  or  106°.  Of  symptoms  associated  with 
the  chill,  nausea  and  vomiting  are  common.  There  may  be  intense  head- 
ache. The  pulse  is  quick,  small,  and  hard.  The  urine  is  increased  in 
quantity.  The  chill  lasts  for  a  variable  time,  from  ten  or  twelve  minutes 
to  an  hour,  or  even  longer. 

The  hot  stage  is  ushered  in  by  transient  flushes  of  heat;  gradually  the 
coldness  of  the  surface  disappears  and  the  skin  becomes  intensely  hot. 
The  contrast  in  the  patient's  appearance  is  striking:  the  face  is  flushed, 
the  hands  are  congested,  the  skin  is  reddened,  the  pulse  is  full  and  bound- 
ing, the  heart's  action  is  forcible,  and  the  patient  may  complain  of  a  throb- 
bing headache.  There  may  be  active  delirium.  A  patient  in  this  stage 
Jumped  through  a  ward  window  and  sustained  fatal  injuries.  The  rectal 
temperature  may  not  increase  much  during  this  stage;  in  fact,  by  the 
termination  of  the  chill  the  fever  may  have  reached  its  maximum.  The 
duration  of  the  hot  stage  varies  from  half  an  hour  to  three  or  four  hours. 
The  patient  is  intensely  thirsty  and  drinks  eagerly  of  cold  water. 

Sweating  Stage. — Beads  of  perspiration  appear  upon  the  face  and  grad- 
ually the  entire  body  is  bathed  in  a  copious  sweat.  The  uncomfortable 
feeling  associated  with  the  fever  disappears,  the  headache  is  relieved,  and 
within  an  hour  or  two  the  paroxysm  is  over  and  the  patient  usually  sinks 
into  a  refreshing  sleep.  The  sweating  varies  much.  It  may  be  drenching 
in  character  or  it  may  be  slight. 

Chart  XI  a  is  from  a  case  of  double  tertian  infection  with  resulting 
quotidian  paroxysms.  Charts  XI  &  and  XI  c  give  temperature  curves  in 
sestivo-autumnal  forms.     Chart  Xld  shows  a  quartan  ague. 

The  total  duration  of  the  paroxysm  averages  from  ten  to  twelve  hours, 
but  may  be  shorter.  Variations  in  the  paroxysm  are  common.  Thus  the 
patient  may,  instead  of  a  chill,  experience  only  a  slight  feeling  of  coldness. 
The  most  common  variation  is  the  occurrence  of  a  hot  stage  alone,  or  with 
very  slight  sweating.  During  the  paroxysm  the  spleen  is  enlarged  and 
the  edge  can  iTSually  be  felt  below  the  costal  margin.  In  the  interval  or 
intermission  of  the  paroxysm  the  patient  feels  very  well,  and,  unless  the 
disease  is  unusually  severe,  he  is  able  to  be  up.  Bronchitis  is  a  common 
symptom.  Herpes,  usually  labial,  is  almost  as  frequent  in  ague  as  in  pneu- 
monia. 

Types  of  the  Regularly  Intermittent  Fevers. — As  has  been  stated  in  the 
description  of  the  parasites,  two  distinct  types  of  the  regularly  intermit- 
tent fevers  have  been  separated.  These  are  (a)  tertian  fever  and  (6)  quartan 
fever. 

{a)  Tertian  Fever. — This  type  of  fever  depends  upon  the  presence  in 
the  blood  of  the  tertian  parasite,  an  organism  which,  as  stated  above,  is 
usually  present  in  sharj^ly  defined  groups,  whose  cycle  of  development  lasts 
approximately  forty-eight  hours,  sporulation  occurring  every  third  day. 
In  infections  with  one  group  of  the  tertian  parasite  the  paroxysms  occur 


MALARIAL  FEVER.  213 

synchronously  with  sporulation  at  remarkably  regular  intervals  of  about 
forty-eight  hours,  every  third  day — hence  the  name  tertian.  Very  com- 
monly, however,  there  may  be  two  groups  of  parasites  which  reach  maturity 
on  alternate  days,  resulting  thus  in  daily  {quotidian)  paroxysms — double 
tertian  infection.  Quotidian  fever,  depending  upon  double  tertian  infec- 
tion, is  the  most  frequent  type  in  the  acute  intermittent  fevers  in  this 
latitude. 

(b)  Quartan  Fever. — This  type  of  fever  depends  upon  infection  with 
the  quartan  parasite,  an  organism  which  occurs  in  well-defined  groups, 
whose  cycle  of  existence  lasts  about  seventy-two  hours.  In  infection  with 
one  group  of  parasites  the  paroxysm  occurs  every  fourth  day;  hence  the 
term  quartan.  At  times,  however,  two  groups  of  the  parasites  may  be 
present;  under  these  circumstances  paroxysms  occur  on  two  successive 
days,  with  a  day  of  intermission  following.  In  infection  with  three  groups 
of  parasites  there  are  daily  paroxysms. 

Thus  a  quotidian  intermittent  fever  may  be  due  to  infection  with 
either  the  tertian  or  quartan  parasites. 

Course  of  the  Disease. — After  a  few.  paroxysms,  or  after  the  disease  has 
persisted  for  ten  days  or  two  weeks,  the  patient  may  get  well  without  any 
special  medication.  I  have  repeatedly  known  the  chills  to  stop  spontane- 
ously. Such  cases,  however,  are  very  liable  to  recurrence.  Persistence  of 
the  fever  leads  to  ansemia  and  hsematogenous  jaundice,  owing  to  the  de- 
-struction  of  the  red  blood-disks  by  the  parasites.  Ultimately  the  condition 
may  become  chronic,  and  will  be  described  under  malarial  cachexia.  The 
regularly  intermittent  fevers  yield  promptly  and  immediately  to  treatment 
with  quinine. 

(3)  The  more  Irregular,  Remittent,  or  Continued  Fevers.  —  ^Estivo 
autumnal  Fever. — This  type  of  fever  occurs  in  temperate  climates,  chiefly 
in  the  later  summer  and  fall;  hence  the  term  given  to  it  by  Marchiafava 
and  Celli,  cestivo-autumnal  fever.  The  severer  forms  of  it  prevail  in  the 
Southern  States  and  in  tropical  countries,  where  it  is  known  chiefly  as 
bilious  remittent  fever.  The  entire  group  of  cases  included  under  the  terms 
remittent  fever,  bilious  remittent,  and  typho-malarial  fevers  requires  to  be 
studied  anew. 

This  type  of  fever  is  associated  with  the  presence  in  the  blood  of  the 
sestivo-autumnal  parasite,  an  organism  the  length  of  whose  cycle  of  de- 
velopment is  probably  subject  to  variations,  while  the  existence  of  multiple 
groups  of  the  parasite,  or  the  absence  of  arrangement  into  definite  groups, 
is  not  infrequent. 

The  symptoms  are  therefore,  as  might  be  expected,  often  irregular.  In 
some  instances  there  may  be  regular  intermittent  fever  occurring  at  uncer- 
tain intervals  of  from  twenty-four  to  forty-eight  hours,  or  even  more.  In 
the  cases  with  longer  remissions  the  paroxysms  are  longer.  Some  of  the 
quotidian  intermittent  cases  may  closely  resemble  the  quotidian  fever  de- 
pending upon  double  tertian  or  triple  quartan  infection.  Commonly,  how- 
ever, the  paroxysms  show  material  differences;  their  length  averages  over 
twenty  hours,  instead  of  from  ten  or  twelve;  the  onset  occurs  often  with- 
out chills  and  even  without  chilly  sensations.     The  rise  in  temperature  is 


214  SPECIFIC  INFECTIOUS  DISEASES. 

frequently  gradual  and  slow,  instead  of  sudden,  while  the  fall  may  occur 
by  lysis  instead  of  by  crisis.  There  is  a  marked  tendency  toward  anticipa- 
tion in  the  paroxysms,  while  frequently,  from  the  anticipation  of  one  parox- 
ysm or  the  retardation  of  another,  more  or  less  continuous  fever  may 
result.  Sometimes  there  is  continuous  fever  without  sharp  paroxysms.  In 
these  cases  of  continuous  and  remittent  fever  the  patient,  seen  fairly  early 
in  the  disease,  has  a  flushed  face  and  looks  ill.  The  tongue  is  furred,  the 
pulse  is  full  and  bounding,  but  rarely  dicrotic.  The  temperature  may  range 
from  102°  to  103°,  or  is  in  some  instances  higher.  The  general  appear- 
ance of  the  patient  is  strongly  suggestive  of  typhoid  fever — a  suggestion 
still  further  borne  out  by  the  existence  of  acute  splenic  enlargement  of 
moderate  grade.  As  in  intermittent  fever,  an  initial  bronchitis  may  be 
present.  The  course  of  these  cases  is  variable.  The  fever  may  be  con- 
tinuous, with  remissions  more  or  less  marked;  definite  paroxysms  with  or 
without  chills  may  occur,  in  which  the  temperature  rises  to  105°  or  106°. 
Intestinal  symptoms  are  usually  absent.  A  slight  h^ematogenous  jaundice 
may  develop  early.  Delirium  of  a  mild  type  may  occur.  The  cases  vary 
very  greatly  in  severity.  In  some  the  fever  subsides  at  the  end  of  the  week, 
and  the  practitioner  is  in  doubt  whether  he  has  had  to  do  with  a  mild 
typhoid  or  a  simple  febricula.  In  other  instances  the  fever  persists  for 
from  ten  days  to  two  weeks;  there  are  marked  remissions,  perhaps  chills, 
with  a  furred  tongue  and  low  delirium.  Jaundice  is  not  infrequent.  These 
are  the  cases  to  which  the  term  hilious  remittent  and  typho-malarial  fevers 
are  applied.  In  other  instances  the  symptoms  become  grave  and  assume 
the  character  of  the  pernicious  type.  It  is  in  this  form  of  malarial  fever  that 
so  much  confusion  still  exists.  The  similarity  of  the  cases  to  typhoid  fever 
is  most  striking,  more  particularly  the  appearance  of  the  facies,  and  the 
patient  looks  very  ill.  The  cases  develop,  too,  in  the  autumn,  at  the  very 
time  when  typhoid  fever  occurs.  The  fever  yields,  as  a  rule,  promptly 
to  quinine,  though  here  and  there  cases  are  met  with — rarely  indeed  in  my 
experience — ^which  are  refractory.  It  is  just  in  this  group  that  the  observa- 
tions of  Laveran  will  be  found  of  the  greatest  value.  Several  of  the  charts 
in  Thayer  and  Hewetson's  report  show  how  closely,  in  some  instances, 
the  disease  may  simulate  typhoid  fever. 

The  diagnosis  of  malarial  remittent  fever  may  be  definitely  made  by 
the  examination  of  the  blood.  The  small,  actively  motile,  hyaline  forms 
of  the  sestivo-autumnal  parasite  are  to  be  found,  while,  if  the  case  has 
lasted  over  a  week,  the  larger  crescentic  and  ovoid  bodies  are  usually  seen. 
In  many  cases  here  we  are  at  first  unable  to  distinguish  between  typhoid 
and  continued  malarial  fever  without  a  blood  examination.  A  more  wide- 
spread use  of  this  means  of  diagnosis  will  enable  us  to  bring  some  order 
out  of  the  confusion  which  exists  in  the  classification  of  the  fevers  of  the 
South.  At  present  the  following  febrile  affections  are  recognized  by  vari- 
ous physicians  as  occurring  in  the  subtropical  regions  of  this  continent: 
(a)  Typhoid  fever;  (h)  typho-malarial  fever — a  typhoid  modified  by  ma- 
larial infection,  or  the  result  of  a  combined  infection;  (c)  the  malarial 
remittent  fever;  and  (d)  continued  thermic  fever  (Guiteras).  In  these 
various  forms,  all  of  which  may  be  characterized  by  a  continued  pyrexia 


MALARIAL  FEVER.  215 

with  remissions  or  with  chills  and  sweats  (for  we  must  remember  that  chills 
and  sweats  in  typhoid  fever  are  by  no  means  rare),  the  blood  examination 
will  enable  us  to  discover  those  which  depend  upon  the  malarial  poison. 
In  many  of  these  cases  of  continued  or  remittent  fever  careful  inquiry 
will  show  that  at  the  beginning  the  patient  had  several  intermittent  parox- 
ysms. In  this  latitude  we  have  not  the  opportunity  of  seeing  many  of 
the  protracted  and  severe  cases,  but  I  am  inclined  to  think  that  future 
observations  will  show  that,  apart  from  the  thermic  fever,  there  are  only 
two  forms  of  these  continued  fevers  in  the  South — the  one  due  to  the 
typhoid  and  the  other  to  the  malarial  infection.  The  typhoid  fever  of 
Philadelphia  and  Baltimore  presents  no  essential  difEerence  from  the  dis- 
ease as  it  occurs  in  Montreal,  a  city  practically  free  from  malaria.  Dock 
has  shown  conclusively  that  cases  diagnosed  in  Texas  as  continued  malarial 
fever  were  really  true  typhoid.  The  Widal  reaction  is  now  an  important 
aid  in  diagnosis. 

Pernicious  Malarial  Fever. — This  is  fortunately  rare  in  temperate  cli- 
mates, and  the  number  of  cases  which  now  occur^  for  example,  in  Phila- 
delphia and  Baltimore,  is  very  much  less  than  it  was  thirty  or  forty  years 
ago.  Among  the  cases  of  malaria  which  have  been  under  observation  during 
the  past  eight  years  there  were  only  seven  of  the  pernicious  form.  Per- 
nicious fever  is  always  associated  with  the  sestivo-autumnal  parasite.  The 
following  are  the  most  important  types: 

(a)  The  comatose  form,  in  which  a  patient  is  struck  down  with  symp- 
toms of  the  most  intense  cerebral  disturbance,  either  acute  delirium  or, 
more  frequently,  a  rapidly  developing  coma.  A  chill  may  or  may  not  pre- 
cede the  attack.  The  fever  is  usually  high,  and  the  skin  hot  and  dry. 
The  unconsciousness  may  persist  for  from  twelve  to  twenty-four  hours,  or 
the  patient  may  sink  and  die.  After  regaining  consciousness  a  second 
attack  may  come  on  and  prove  fatal.  In  these  instances,  as  has  been  stated, 
the  special  localization  of  the  infection  is  in  the  brain,  where  actual  thrombi 
of  parasites  with  marked  secondary  changes  in  the  surrounding  tissues  have 
been  found. 

(&)  Algid  Form. — In  this,  the  attack  sets  in  usually  with. gastric  symp- 
toms; there  are  vomiting,  intense  prostration,  and  feebleness  out  of  all 
proportion  to  the  local  disturbance.  The  patient  complains  of  feeling  cold, 
although  there  may  be  no  actual  chill.  The  temperature  may  be  normal, 
or  even  subnormal;  consciousness  may  be  retained.  The  pulse  is  feeble 
and  small,  and  the  respirations  are  increased.  There  may  be  most  severe 
diarrhoea,  the  attack  assuming  a  choleriform  nature.  The  urine  is  often 
diminished,  or  even  suppressed.  This  condition  may  persist  with  slight 
exacerbations  of  fever  for  several  days  and  the  patient  may  die  in  a  condi- 
tion of  profound  asthenia.  This  is  essentially  the  same  as  described  as 
the  asthenic  or  adynamic  form  of  the  disease.  In  the  cases  with  vomiting 
and  diarrhoea,  Marchiafava  has  shown  that  the  gastro-intestinal  mucosa  is 
often  the  seat  of  a  special  invasion  by  the  parasites,  actual  thrombosis  of 
the  small  vessels  with  superficial  ulceration  and  necrosis  occurring.  Simi- 
lar lesions  were  found  by  Barker  in  the  gastro-intestinal  tract  of  a  case 
from  my  wards. 


216  SPECIFIC   [NFECTIOUS  DISEASES. 

(c)  HcemorrJiagic  Forms — Black-water  Fever — Rcemogldbinuric  Fever — 
Malarial  Hcemoglohinuria. — In  temperate  regions  these  forms  are  rare;  in 
the  tropics  they  are  common.  In  the  Southern  States  there  are  many 
districts  in  which  there  is  endemic  hsemoglobinuria^  believed  to  he  of  ma- 
larial origin,  while  in  parts  of  Africa  there  is  the  much-dispnted  malady 
known  as  black-water  fever.  There  seems  to  be  no  essential  difference  be- 
tween the  malarial  hsemoglobinuria  of  the  Southern  States  and  the  African 
black-water  fever.  As  described  by  Stephens  and  Christophers  (Report  of 
Malaria  Committee,  Fifth  Series),  for  two  or  three  days  the  patient  has 
a  rise  of  temperature,  and  if  the  blood  is  examined  before  the  black-water 
the  parasites  are  almost  invariably  present.  If  examined  after  the  ad- 
ministration of  quinine  parasites  are  absent  from  the  blood.  These  authors 
agree  with  the  generally  expressed  opinion  of  physicians  in  the  Southern 
States,  that  there  is  a  causal  connection  between  the  quinine  and  the 
black-water.  It  is  impossible  to  say  why  quinine  at  one  time  can  produce 
black-water,  and  at  another,  even  a  few  hours  or  days  later,  it  can  not.  Of 
the  16  cases  of  black-water  examined  by  Stephens  and  Christophers,  15 
presented  evidence  of  malarial  infection.  The  conclusions  of  the  com- 
mittee are  worth  quoting: 

1.  That  black-water  is  malarial  in  origin,  yet  can  not  be  considered  as 
an  attack  of  malaria. 

2.  That  quinine  is,  in  a  great  majority  of  cases,  the  proximate  cause. 

3.  That  there  is  not  a  single  fact  in  evidence  of  a  special  parasite  being 
the  cause  of  black-water. 

Malarial  Cachexia. — Following  constant  exposure  to  malaria  and  re- 
peated attacks  of  any  one  of  the  forms,  there  may  be  a  condition  charac- 
terized by  anaemia  with  enlarged  spleen. 

The  general  symptoms  are  those  of  ordinary  angemia — ^breathlessness 
on  exertion,  oedema  of  the  ankles,  haemorrhages,  particularly  into  the  ret- 
ina, as  noted  by  Stephen  Mackenzie.  Occasionally  the  bleeding  is  severe, 
and  I  have  twice  known  fatal  haematemesis  to  occur  in  association  with 
the  enlarged  spleen.  The  fever  is  variable.  The  temperature  may  be  low 
for  days,  not  going  above  99.5°.  In  other  instances  there  may  be  irregular 
fever,  and  the  temperature  rises  gradually  to  102.5°  or  103°.  The  cases 
present  a  picture  of  secondary  anaemia. 

With  careful  treatment  the  outlook  is  good,  and  a  majority  of  cases 
recover.  The  spleen  is  gradually  reduced  in  size,  but  it  may  take  several 
months  or,  indeed,  in  some  instances,  several  years  before  the  ague-cake 
entirely  disappears. 

Rarer  Complications. — Among  nervous  sequelse  and  complications 
may  be  mentioned  paraplegia,  which  may  be  due  to  a  peripheral  neuritis 
or  to  changes  in  the  cord,  and  hemiplegia,  which  may  occur  in  the  per- 
nicious comatose  form,  or  occasionally  at  the  very  height  of  a  paroxysm. 
Acute  ataxia  has  been  described,  and  there  are  remarkable  cases  with  the 
symptoms  of  disseminated  sclerosis  (Spiller).  Multiple  gangrene  may  oc- 
cur, as  in  an  instance  recently  described  by  me,  in  which  a  patient  with 
sestivo-autumnal  infection  presented  many  areas  of  multiple  gangrene. 
OrcMtis  has  been  described  as  developing  in  malaria  by  Charvot  in  Algiers 
and  Fedeli  in  Eome. 


MALARIAL  FEY.ER.  217 

Prophylaxis. — In  the  discovery  of  Laveran  there  lay  the  promise 
of  benefits  more  potent  than  any  gift  the  laboratory  had  ever  offered 
to  mankind — viz.,  the  possibility  of  the  extermination  of  malaria.  By  the 
work  of  Manson,  Eoss,  and  others  this  promise  has  reached  the  stage 
of  practical  fulfilment,  and  one  of  the  greatest  scourges  of  the  race  is 
now  at  our  command.     The  measures  of  prophylaxis  are  in  the  main  three: 

(1)  The  rigid  protection  of  houses  against  mosquitoes  by  screens  and 
the  use  of  mosquito  nets.  The  accounts  of  Grassi  and  Celli  of  experiments 
made  to  protect  the  workers  on  the  railways  show  how  extraordinary 
are  the  results  of  these  simple  measures.  The  protection  of  the  sleeper 
at  night  is  one  of  the  most  essential  measures. 

(2)  An  earnest  warfare  against  the  mosquito  on  the  part  of  sanitary 
authorities.  Instruction  should  be  furnished  to  the  people  upon  the  habits 
and  life  history  of  the  insect,  and  of  its  relation  to  the  disease.  Pools, 
ponds,  and  marshy  districts  should  be  drained,  and  in  the  malaria  season 
petroleum  should  be  used  freely,  as  it  prevents  the  development  of  the 
larvEe.  Every  case  of  malaria  should  be  regarded  as  a  centre  of  infection, 
and  in  a  systematic  warfare  against  the  disease  should  be  reported  to  the 
health  authorities.  In  the  tropics,  segregation  of  Europeans  may  do  much 
to  lessen  the  chances  of  infection. 

(3)  Lastly,  every  case  should  receive  thorough  and  prolonged  treatment 
with  quinine.  There  is  far  too  much  carelessness  on  this  point  in  the 
profession.  Malarial  infection  is  a  difficult  one  to  eradicate.  Quinine  is 
the  only  known  drug  which  is  an  effective  parasiticide.  Patients  should 
be  told  to  resume  the  treatment  in  the  spring  and  autumn  for  several  years 
after  the  primary  infection.  In  very  malarial  districts,  as  many  persons 
harbor  the  parasites,  who  do  not  show  any  (or  at  the  most  very  few)  signs, 
a  systematic  treatment  with  quinine  should  be  instituted,  particularly  of 
the  young  children. 

Diagnosis. — The  recognition  of  the  various  forms  of  malarial  fever 
is  now  very  easy.  The  chief  difficulty  is  in  the  sestivo-autumnal  variety 
which  may  simulate  typhoid  fever.  Practitioners  should  appreciate  the  fact 
that  in  obscure  cases  a  well  prepared  cover-slip  preparation  of  the  blood, 
which  can  be  stained  and  carefully  studied,  gives  more  trustworthy  results 
than  fresh  specimens.  To  become  an  expert  on  the  blood  in  malarial  fever 
requires  a  long  and  careful  training. 

Many  forms  of  intermittent  pyrexia  are  mistaken  for  malarial  fever.  In 
these  instances  the  blood  shows  leucocytosis,  which  is  rare  in  malaria.  If 
the  practitioner  will  take  to  heart  the  lesson  that  an  intermittent  fever 
which  resists  quinine  is  not  malarial,  he  will  avoid  many  errors  in  diag- 
nosis. In  the  so-called  masked  intermittent  or  dumb  ague,  the  febrile 
manifestations  are  more  irregular  and  the  symptoms  less  pronounced;  but 
occasionally  chills  occur,  and  the  therapeutical  test  usually  removes  every 
doubt  in  the  diagnosis. 

The  malarial  poison  is  supposed  to  influence  many  affections  in  a  re- 
markable way,  giving  to  them  a  paroxysmal  character.  A  whole  series  of 
minor  ailments  and  some  more  severe  ones,  such  as  neuralgia,  are  attrib- 
uted to  certain  occult  effects  of  paludism.  The  more  closely  such  cases 
are  investigated  the  less  definite  appears  the  connection  with  malaria. 


'218  SPECIFIC  INFECTIOUS   DISEASES. 

Treatment.  — We  do  not  know  as  yet  how  the  poison  reaches  the  sys- 
tem. Infection  seems  most  liable  to  occur  at  night.  In  regions  in  which 
the  disease  prevails  extensively  mosquito  netting  should  be  used,  as  the 
researches  of  Eoss  render  it  highly  probable  that  the  disease  is  trans- 
mitted in  this  way.  Persons  going  to  a  malarial  region  should  take 
about  10  grains  of  quinine  daily,  though  Sezary  found  that  2  grains  three 
times  a  day  was  a  sufficient  protection  against  the  disease.  During  the 
-paroxysm  the  patient  should,  in  the  cold  stage,  be  wrapped  in  blankets  and 
■given  hot  drinks.  The  reactionary  fever  is  rarely  dangerous  even  if  it 
reaches  a  high  grade.  The  body  may,  however,  be  sponged.  In  quinine 
we  possess  a  specific  remedy  against  malarial  infection.  Experiment  has 
shown  that  the  parasites  are  most  easily  destroyed  by  quinine  at  the  stage 
when  they  are  free  in  the  circulation — that  is,  during  and  Just  after  sporu- 
lation.  While  in  most  instances  the  parasites  of  the  regularly  intermittent 
fevers  may  be  destroyed,  even  in  the  intra-corpuscular  stage,  in  sestivo-au- 
tumnal  fever  this  is  much  more  difficult.  It  should,  then,  be  our  object, 
if  we  wish  to  most  effectually  eradicate  the  infection,  to  have  as  much 
quinine  in  circulation  at  the  time  of  the  paroxysm  and  shortly  before  as  is 
possible,  for  this  is  the  period  at  which  sporulation  occurs.  In  the  regu- 
larly intermittent  fevers  from  10  to  30  grains  in  divided  doses  throughout 
the  day  will  in  many  instances  prevent  any  fresh  paroxysms.  If  the  patient 
comes  under  observation  shortly  before  an  expected  paroxysm,  the  admin- 
istration of  a  good  dose  of  quinine  just  before  its  onset  may  be  advisable 
to  obtain  a  maximum  effect  upon  that  group  of  parasites.  The  quinine 
will  not  prevent  the  paroxysm,  but  will  destroy  the  greater  part  of  the 
group  of  organisms  and  prevent  its  further  recurrence.  It  is  safer  to  give 
at  least  20  to  30  grains  daily  for  the  first  three  days,  and  then  to  continue 
the  remedy  in  smaller  doses  for  the  next  two  or  three  weeks.  In  sstivo- 
autumnal  fever  larger  doses  may  be  necessary,  though  in  relatively  few  in- 
stances is  it  necessary  to  give  more  than  30  to  40  grains  in  the  twenty-four 
hours. 

The  quinine  should  be  ordered  in  solution  or  in  capsules.  The  pills 
and  compressed  tablets  are  more  uncertain,  as  they  may  not  be  dissolved. 

A  question  of  interest  is  the  efficient  dose  of  quinine  necessary  to  cure 
the  disease.  I  have  a  number  of  charts  showing  that  grain  doses  three 
times  a  day  will  in  many  cases  prevent  the  paroxysm,  but  not  always  with 
the  certainty  of  the  larger  doses.  In  cases  of  aestivo-autumnal  fever  with 
pernicious  symptoms  it  is  necessary  to  get  the  system  under  the  influence 
of  quinine  as  rapidly  as  possible.  In  these  instances  the  drug  should  be 
administered  hypodermically  as  the  bisulphate  in  30-grain  doses,  with  5 
grains  of  tartaric  acid,  every  two  or  three  hours.  The  muriate  of  quinine 
and  urea  is  also  a  good  form  in  which  to  administer  the  drug  hypoder- 
mically; 10,  15,  or  20  grain  doses  may  be  necessary.  In  the  most  severe 
instances  some  observers  advise  the  intravenous  administration  of  quinine, 
for  which  the  very  soluble  bimuriate  is  well  adapted.  Fifteen  grains  with 
a  grain  of  sodium  chloride  may  be  injected  in  about  2  drachms  of  distilled 
water.  For  extreme  restlessness  in  these  cases  opium  is  indicated,  and  car- 
diac stimulants,  such  as  alcohol  and  strychnine,  are  necessary.     If  in  the 


MALTA  FEVER.  219 

comatose  form  the  internal  temperature  is  raised,  the  patient  should  be 
put  in  a  bath  and  doused  with  cold  water.  For  malarial  anaemia,  iron  and 
arsenic  are  indicated. 

An  interesting  question  is  much  discussed,  whether  quinine  does  not 
cause  or  at  any  rate  aggravate  the  hsemoglobinuria.  We  have  not  yet  seen 
a  case  in  which  this  condition  has  occurred  as  a  result  of  the  use  of  the 
drug.  It  seems  localized  in  certain  sections;  and  Bastianelli  states  that  it 
is  not  seen  in  the  Roman  malarial  fevers.  He  recommends  that  in  any  case 
of  hsemoglobinuria  if  the  blood  shows  parasites  quinine  should  be  admin- 
istered freely.  In  the  post-malarial  forms  quinine  aggravates  the  attack.  In 
an  active  malarial  infection  the  patient  runs  less  risk  with  the  quinine. 

XXV.    MALTA    FEVER. 

{Undulant  Fever.) 

Definition. — An  endemic  fever,  characterized  by  an  irregular  course, 
undulatory  pyrexial  relapses,  profuse  sweats,  rheumatic  pains,  arthritis, 
and  an  enlarged  spleen.  An  organism.  Micrococcus  melitensis,  is  present 
in  all  cases. 

The  greater  part  of  our  knowledge  of  this  remarkable  disease  we  owe 
to  the  work  of  the  army  surgeons  stationed  at  Gibraltar  and  Malta,  par- 
ticularly to  Marston,  to  Bruce,  and  recently  to  Hughes,  whose  important 
work  on  the  subject  I  have  used  freely  for  this  article. 

Distribution. — The  disease  prevails  extensively  at  Malta,  and  is  also 
met  with  in  the  countries  bordering  on  the  Mediterranean;  hence  the  name 
Mediterranean  fever.  In  Gibraltar  it  is  called  Rock  fever,  and  in  Sicily 
and  Italy  it  is  known  as  Neapolitan  fever.  It  is  also  met  with  in  India 
and  China,  and  occurs  in  Porto  Rico  (Musser  and  Sailer,  W.  Cox),  and  in 
Manila  (Strong  and  Musgrave).  Only  imported  cases  have  been  recognized 
in  this  country. 

Etiology. — The  disease  is  not  contagious.  It  prevails  in  summer,  and 
in  infected  regions  is  endemic,  occasionally  assuming  epidemic  characters. 
Insanitary  conditions  favor  its  spread,  but  we  can  not  as  yet  say  whether  the 
poison  is  air-borne  or  water-borne.  Hughes  thinks  that  the  former  is  the 
more  probable  view,  Bruce  the  latter.  Young,  healthy  adults  are  chiefly 
attacked. 

Micrococcus  melitensis,  discovered  by  Bruce,  has  not  yet  been  isolated 
from  the  blood,  but  occurs  in  large  numbers  in  the  spleen.  It  is  constantly 
present  in  fatal  cases.  The  morphological  and  cultural  characters  have 
been  accurately  studied  by  H.  E.  Durham.  The  micrococcus  is  pathogenic 
for  monkeys.  Four  instances  of  accidental  laboratory  infection  in  man 
have  been  reported,  the  portal  of  entry  in  Strong's  case  being  the  con- 
junctiva. 

Symptoms. — There  is  no  specific  fever  which  presents  the  same  re- 
markable group  of  phenomena.  The  period  of  incubation  is  from  six  to  ten 
days.  "  Clinically  the  fever  has  a  peculiarly  irregular  temperature  curve, 
consisting  of  intermittent  waves  or  undulations  of  pyrexia,  of  a  distinctly 
remittent  character.  These  pyrexial  waves  or  undulations  last,  as  a  rule, 
14 


220  SPECIFIC  INFECTIOUS  DISEASES. 

from  one  to  three  weeks,  with  an  apyrexial  interval,  or  period  of  temporary 
abatement  of  pyrexial  intensity  between,  lasting  for  two  or  more  days. 
In  rare  cases  the  remissions  may  become  so  marked  as  to  give  an  almost 
intermittent  character  to  the  febrile  curve,  clearly  distinguishable,  how- 
ever, from  the  paroxysms  of  paludic  infection.  This  pyrexial  condition  is 
usually  much  prolonged,  ha\dng  an  uncertain  duration,  lasting  for  even 
six  months  or  more.  Unlike  paludism,  its  course  is  not  markedly  affected 
by  the  administration  of  quinine  or  arsenic.  Its  course  is  often  irregular 
and  even  erratic  in  nature.  This  pyrexia  is  usually  accompanied  by  obsti- 
nate constipation,  progressive  anaemia,  and  debility.  It  is  often  compli- 
cated with  and  followed  by  neuralgic  symptoms  referred  to  the  peripheral 
or  central  nervous  svstem,  arthritic  effusions,  painful  inflammatory  condi- 
tions of  certain  fibrous  structures,  of  a  localized  nature,  or  swelling  of  the 
testicles  "  (Hughes).  This  author  recognizes  a  malignant  type,  in  which 
the'  disease  may  prove  fatal  within  a  week  or  ten  days;  an  undulatory  type 
— the  common  variety — in  which  the  fever  is  marked  by  intermittent  waves 
or  undulations  of  variable  length,  separated  by  periods  of  apyrexia  and  free- 
dom from  symptoms.  In  this  really  lie  the  peculiar  features  of  the  dis- 
ease, and  the  unfortunate  victim  may  suffer  a  series  of  relapses  which  may 
extend  from  three  months,  the  average  time,  to  two  years.  Lastly,  there 
is  an  intermittent  type,  in  which  the  patient  may  simply  have  daily  pyrexia 
toward  evening,  without  any  special  complications,  and  may  do  well  and 
be  able  to  go  about  his  work,  and  yet  at  any  time  the  other  serious  features 
of  the  disease  may  develop. 

The  mortality  is  slight,  only  about  2  per  cent.  There  are  no  character- 
istic morbid  lesions.  The  seriousness  of  the  disease  is  in  its  protracted 
course,  so  that  in  the  army  the  loss  of  time  is  a  very  grave  item.  Malta 
fever  has  to  be  distinguished  carefully  from  typhoid  fever  and  from  ma- 
laria. From  the  latter  it  can  be  now  readily  differentiated  by  the  examina- 
tion of  the  blood.  The  agglutinative  serum  reaction  is  diagnostic.  From 
Durham's  observations  on  animals  it  is  probable  that  the  organism  may  be 
isolated  from  the  urine  even  after  apparent  recovery. 

Treatment. — General  measures  suitable  to  typhoid  fever  are  indi- 
cated. Fluid  food  should  be  given  during  the  febrile  period.  Hydro- 
therapy, either  the  bath  or  the  cold  pack,  should  be  used  every  third  hour 
when  the  temperature  is  above  103°  F.  Otherwise  the  treatment  is  symp- 
tomatic. No  drugs  appear  to  have  any  special  influence  on  the  fever.  A 
change  of  climate  seems  to  promote  convalescence. 


XXVI.    BERIBERI. 

Definition. — An  endemic  and  epidemic  multiple  neuritis  of  unknown 
etiology,  occurring  in  tropical  and  subtropical  countries,  characterized  by 
motor  and  sensory  paralysis  and  anasarca. 

History. — The  disease  is  believed  to  be  of  great  antiquity  in  China, 
and  is  possibly  mentioned  in  the  oldest  known  medical  treatise.  In  the 
early  years  of  this  century  it  attracted  much  attention  among  the  Anglo- 


BERI-BERI.  221 

T[iidian  surgeons,  and  we  may  date  the  modern  scientific  study  of  the  dis- 
ease from  Malcolmson's  monograph,  published  in  Madras  in  1835.  The 
opening  of  Japan  gave  an  opportunity  to  the  German  physicians  holding 
university  positions,  particularly  Baelz,  Scheube,  and  more  recently  Grimm, 
to  investigate  the  disease.  The  studies  of  the  native  Japanese  physicians, 
particularly  Miura  and  Takagi,  and  of  the  Dutch  physicians  in  the  East, 
have  contributed  much  to  our  knowledge.  An  added  interest  has  been 
given  to  the  subject  by  the  discovery  of  the  disease  among  the  Cape  Cod 
fishermen,  and  by  the  recurring  outbreaks  of  endemic  neuritis  at  the  Eich- 
mond  Asylum  in  Dublin  and  at  the  State  Insane  Hospital  at  Tuscaloosa, 
Ala. 

Distribution. — Beri-beri,  Kakke,  or  endemic  neuritis  prevails  most 
extensively  in  the  Malay  Archipelago;  in  certain  of  the  Dutch  colonies  the 
mortality  among  the  coolies  is  simply  frightful.  It  is  widely  distributed 
in  China,  Japan,  and  the  Philippine  Islands.  In  India  it  has  become  less 
common,  but  is  still  prevalent  in  parts  of  Burma.  Localized  outbreaks 
have  occurred  in  Australia.  It  prevails  extensively  in  parts  of  South 
America  and  in  the  West  Indies,  and  from  the  ports  of  these  countries 
cases  occasionally  reach  the  United  States.  Birge,  of  Provincetown,  and  J. 
J.  Putnam  encountered  beri-beri  among  the  fishermen  on  the  Newfound- 
land Banks.  Birge  writes  (March  10,  1898)  that  he  has  seen  47  cases  of 
both  the  wet  and  the  dry  form.  The  disease  is  not  entirely  confined  to  the 
fishermen  on  the  Grand  Banks,  but  develops  occasionally  among  those  liv- 
ing on  shore  or  making  "  shore  trips."  In  1895-'96  a  remarkable  outbreak 
of  epidemic  neuritis  occurred  at  the  State  Insane  Hospital  at  Tuscaloosa, 
Ala.,  which  has  been  described  fully  by  E.  D.  Bondurant.*  Between  Feb- 
ruary, 1895,  and  October,  1896,  in  a  population  of  1,200  there  were  71  cases 
with  21  deaths.  None  occurred  among  the  200  employees  of  the  hospital. 
The  negroes  were  relatively  less  affected  than  the  whites.  The  chief  symp- 
toms were  "  muscular  weakness,  tenderness,  pain,  par^sthesise,  loss  of  deep 
reflexes,  followed  by  atrophy  of  muscles  and  the  electrical  reaction  of  de- 
generation, accompanied  by  rise  of  temperature,  gastro-intestinal  disturb- 
ance, general  anasarca,  and  tachycardia."  At  the  Arkansas  State  Insane 
Asylum  at  Little  Rock,  in  1895,  there  was  an  outbreak  of  between  20  and 
30  cases  possibly  of  beri-beri. 

In  Great  Britain  the  disease  is  not  infrequent  at  the  seaports. 

At  the  Richmond  Asylum,  Dublin,  there  have  been  extensive  outbreaks 
in  the  years  1894,  1896,  1897,  under  conditions  of  shameful  overcrowding. 

Etiology. — Two  main  views  prevail  as  to  the  nature  of  the  disease — 
that  it  is  an  infection,  and  that  it  is  a  toxaemia  caused  by  food. 

1.  Beri-beri  as  an  Acute  Infection. — Baelz  and  Scheube,  with  many  of 
the  Dutch  physicians,  hold  that  the  disease  is  due  to  a  living  germ.  In 
favor  of  this  view,  Scheube  refers  to  the  fact  that  strong,  well-nourished 
young  people  are  attacked,  that  the  disease  has  definite  foci  in  whieh  it 
prevails,  definite  seasonal  relations,  and  has  of  late  years  spread  in  some 
countries  as  an  epidemic  without  any  special  change  in  the  diet  of  the 

*  New  York  Medical  Journal,  1897,  ii. 


222  SPECIFIC  INFECTIOUS  DISEASES. 

inhabitants.  So  far  as  seasonal  and  telluric  influences  are  concerned,  it  is 
a  disease  which  resembles  malaria,  with  which,  in  fact,  some  authors 
have  confounded  it.  It  is  probably  not  directly  contagious.  On  the  other 
hand,  Scheube,  Manson  and  others  bring  forward  evidence  to  show  that 
beri-beri  may  probably  be  conveyed  from  one  district  to  another. 
Many  bacteriological  studies  have  been  made  in  the  disease,  particu- 
larly by  Dutch  physicians,  but  there  is  no  unanimity  as  to  the  results, 
and  we  may  say  that  no  specific  organism  has  as  yet  been  determined 
upon. 

2.  The  food  theory  of  beri-beri  is  widely  held  in  Japan,  some  believing 
that  it  is  due  to  the  eating  of  bad  rice,  and  others  that  it  is  associated  with 
the  use  of  certain  fish.  In  favor  of  the  dietetic  view  of  its  origin  is  ad- 
duced the  extraordinary  change  which  has  taken  place  in  the  Japanese 
navy  since  the  introduction  by  Takagi  of  an  improved  diet,  allowing  a 
larger  portion  of  nitrogenous  food,  and  forbidding  the  use  of  fresh  fish 
altogether.  Subsequent  to  this  there  has  certainly  been  the  most  remark- 
able diminution  in  the  number  of  cases — a  reduction  from  about  a  fourth 
of  the  entire  strength  attacked  annually  to  a  practical  abolition  of  the 
disease. 

A  recent  number  of  Janus  gives  the  experience  of  the  Dutch  physicians 
in  Java,  many  of  whom  regard  rice  as  the  important  cause  of  the  disease. 
It  is  stated  that  in  the  prisons  of  Java  the  proportion  of  cases  is  1  to  39 
when  th«  rice  is  eaten  completely  shelled,  1  to  10,000  when  the  grain  is 
eaten  with  its  pericarp;  in  some  places  the  disease  has  disappeared  when 
the  unshelled  rice  has  been  substituted  for  the  shelled.  Miura,  with  whose 
studies  of  the  disease  all  readers  of  Virchow's  Archiv  are  familiar,  regards 
beri-beri  as  a  form  of  chronic  poisoning  due  to  the  use  of  the  flesh  of  cer- 
tain fish  eaten  raw  or  improperly  prepared.  Grimm,  in  his  recent  mono- 
graph, regards  the  immunity  of  Europeans  as  in  great  part  owing  to  the 
fact  that  they  do  not  follow  the  Japanese  custom  of  eating  various  kinds  of 
raw  fish. 

Among  the  most  important  faotors  are  the  following:  Overcrowding, 
as  in  ships,  jails,  and  asylums,  hot  and  moist  seasons,  and  exposure  to  wet. 
Europeans  under  good  hygienic  conditions  rarely  contract  the  disease  in 
beri-beri  regions.  The  natives  and  the  imported  coolies  are  the  most  often 
attacked.  Males  are  more  subject  to  the  disease  than  females.  Young  men 
from  sixteen  to  twenty-five  are  most  often  affected. 

Symptoms. — The  incubation  period  is  unknown,  but  it  probably 
extends  over  several  months.  The  following  forms  of  the  disease  are  recog- 
nized by  Scheube: 

1.  The  incomplete  or  rudimentary  form  which  often  sets  in  with  ca- 
tarrhal symptoms,  followed  by  pains  and  weakness  in  the  limbs  and  a  lower- 
ing of  the  sensibility  in  the  legs,  with  the  development  of  parasthesiae. 
Slight  oedema  sometimes  appears.  After  a  time  pargesthesiae  may  develop 
in  other  parts  of  the  body,  and  the  patient  may  complain  of  palpitation  of 
the  heart,  uneasy  sensations  in  the  abdomen,  and  SQmetimes  shortness  of 
breath.  There  may  be  weakness  and  tenderness  of  the  muscles.  After 
lasting  from  a  few  days  to  many  months,  these  symptoms  all  disappear,  but 


BERI-BERI.  223 

with  the  return  of  the  warm  weather  there  may  be  a  recurrence.     One  of 
Scheube's  patients  suffered  in  this  way  for  twenty  years. 

2.  The  atropMo  form  sets  in  with  mucli  the  same  symptoms,  but  the 
loss  of  power  in  the  limbs  progresses  more  rapidly,  and  very  soon  the 
patient  is  no  longer  able  to  walk  or  to  move  the  arms.  The  atrophy, 
which  is  associated  with  a  good  deal  of  pain,  may  extend  to  the  mus- 
cles of  the  face.  The  oedematous  symptoms  and  heart  troubles  play 
a  minor  role  in  this  form,  which  is  known  as  the  dry  or  paralytic  va- 
riety. 

3.  The  Wet  or  Dropsical  Form. — Setting  in  as  in  the  rudimentary  vari- 
ety, the  oedema  soon  becomes  the  most  marked  feature,  extending  over 
the  whole  subcutaneous  tissue,  and  associated  with  effusions  into  the  serous 
sacs.  The  atrophy  of  the  muscles  and  disturbance  of  sensation  are  not  such 
prominent  symptoms.  On  the  other  hand,  palpitation  and  rapid  action  of 
the  heart  and  dyspnoea  are  common.  The  wasting  may  not  be  apparent 
until  the  dropsy  disappears. 

4.  The  acute,  pernicious,  or  cardiac  form  is  characterized  by  threat- 
enings  of  an  acute  cardiac  failure,  developing  rapidly  after  the  existence 
of  slight  symptoms,  such  as  occur  in  the  rudimentary  form.  In  the  most 
acute  type  death  may  follow  within  twenty-four  hours;  more  commonly 
the  symptoms  extend  over  several  weeks. 

The  mortality  of  the  disease  varies  greatly,  from  3  or  3  per  cent  to  40 
or  50  per  cent  among  the  coolies  in  certain  of  the  settlements  of  the  Malay 
Archipelago. 

Morbid  Anatomy.  — The  most  constant  and  striking  features  are 
changes  in  the  peripheral  nerves  and  degenerative  inflammation  involving 
the  axis  cylinder  and  medullary  sheaths.  In  the  acute  cases  this  is  found 
not  only  in  the  peripheral  nerves,  but  also  in  the  pneumogastric  and  in 
the  phrenic.  The  fibres  of  the  voluntary  muscles,  as  well  as  of  the  myo- 
cardium, are  also  much  degenerated. 

Diagnosis. — In  tropical  countries  there  is  rarely  any  diihculty  in  the 
diagnosis.  In  cases  of  peripheral  neuritis,  associated  with  oedema,  coming 
from  tropical  ports,  the  possibility  of  this  disease  should  be  remembered. 
Scheube  states  that  rarely  any  difficulty  offers  in  the  diagnosis  of  the  dif- 
ferent forms.  An  interesting  question  arises  as  to  the  true  nature  of  the 
endemic  neuritis  in  the  Eichmond  Asylum  and  at  Tuscaloosa.  Bondurant's 
report  certainly  shows  a  disease  conforming  with  beri-beri  in  a  majority 
of  its  features.  The  statement  is  made  that  the  Dutch  committee  which 
studied  the  epidemic  at  the  Eichmond  Asylum  did  not  regard  the  disease 
as  quite  identical  with  the  tropical  beri-beri. 

Treatment. — Much  has  been  done  to  prevent  the  disease,  particularly 
in  Japan.  There  is  no  more  remarkable  triumph  of  modern  hygiene  than 
that  which  followed  Takagi's  dietetic  reforms  in  the  Japanese  navy.  In 
beri-beri  districts  Europeans  should  use  a  diet  rich  in  nitrogenous  ingredi- 
ents. In  the  dietary  of  prisons  and  asylums  the  experience  of  the  Javanese 
physicians  with  reference  to  the  remarkable  diminution  of  the  disease  with 
the  use  of  unshelled  rice  should  be  borne  in  mind.  In  ships,  prisons,  and 
asylums  the  disease  has  rarely  occurred  except  in  connection  with  over- 


224  SPECIFIC  INFECTIOUS  DISEASES. 

crowding,  an  element  which  prevailed  both  at  the  Eichmond  Asylum  and 
at  the  State  Hospital  for  the  Insane  at  Tuscaloosa. 

Baelz  recommends  in  early  cases  a  free  use  of  the  salicylates,  15  or  30 
grains  four  or  five  times  a  day.  Others  favor  early  free  purgation.  In 
very  severe  acute  cases,  both  Anderson  and  Baelz  advise  blood-letting. 
The  more  chronic  cases  demand,  in  addition  to  dietetic  measures,  drugs  to 
support  the  heart  and  treatment  of  the  atrophied  muscles  with  electricity 
and  massage. 

XXVII.  ANTHRAX. 

{Splenic  Fever;  Charhon ;  Wool-sorter^ s  Disease.) 

Definition. — An  acute  infectious  disease  caused  by  Bacillus  anthracis. 
It  is  a  widespread  affection  in  animals,  particularly  in  sheep  and  cattle. 
In  man  it  occurs  sporadically  or  as  a  result  of  accidental  inoculations  with 
the  virus. 

Etiology. — The  infectious  agent  is  a  non-motile,  rod-shaped  organ- 
ism, Bacillus  antlwacis,  which  has,  by  the  researches  of  Pollender,  Da- 
vaine,  Koch,  and  Pasteur,  become  the  best  known  perhaps  of  all  patho- 
genic microbes.  The  bacillus  has  a  length  of  from  2  to  25  /a;  the  rods  are 
often  united.  They  multiply  by  fission  with  great  rapidity  and  are  easily 
grown  on  various  culture  media,  extending  into  long  filaments  which  in- 
terlace and  produce  a  dense  network.  The  spore  formation  is  seen  with 
great  readiness  in  these  filaments;  but  ah  asporogenous  variety  is  known, 
and  can  be  produced  artificially  in  cultures.  The  bacilli  themselves  are 
readily  destroyed,  but  the  spores  are  very  resistant,  and  survive  after  pro- 
longed immersion  in  a  5-per-cent  solution  of  carbolic  acid,  or  withstand 
for  some  minutes  a  temperature  of  212°  Fahr.  They  are  capable  also  of  re- 
sisting gastric  digestion.  Outside  the  body  the  spores  are  in  all  probability 
very  durable. 

Geographically  and  zoologically  the  disease  is  the  most  widespread  of 
all  infectious  disorders.  It  is  much  more  prevalent  in  Europe  and  in  Asia 
than  in  America.  Its  ravages  among  the  herds  of  cattle  in  Russia  and 
Siberia,  and  among  sheep  in  certain  parts  of  Europe,  are  not  equalled  by 
any  other  animal  plague.  In  this  country  the  disease  is  rare.  A  few  pas- 
tures in  Delaware  and  Pennsylvania  have  recently  become  infected,  prob- 
ably from  imported  hides.  Human  infections  are  chiefly  in  tanners,  of 
whom  12  died  in  the  State  of  Pennsylvania  of  anthrax  in  1897  (Ravenel). 
So  far  as  I  know,  it  has  never  prevailed  on  the  ranches  in  the  Northwest, 
but  cases  were  not  infrequent  about  Montreal. 

A  protective  inoculation  with  a  mitigated  virus  was  introduced  by 
Pasteur,  and  has  been  adopted  in  certain  anthrax  regions. 

In  animals  the  disease  is  conveyed  sometimes  by  direct  inoculation,  as 
by  the  bites  and  stings  of  insects,  by  feeding  on  carcasses  of  animals  which 
have  died  of  the  disease,  but  more  commonly  by  grazing  in  pastures  in 
which  the  germs  have  been  preserved.  Pasteur  believes  that  the  earth- 
worm plays  an  important  part  in  bringing  to  the  surface  and  distributing 
the  bacilli  which  have  been  propagated  in  the  buried  carcass  of  an  in- 
fected animal.     Certain  fields,  or  even  farms,  may  thus  be  infected  for  an 


ANTHRAX.  225 

indefinite  period  of  time.  It  seems  probable,  however,  that  if  the  carcass 
is  not  opened  or  the  blood  spilt,  spores  are  not  formed  in  the  buried  ani- 
mal and  the  bacilli  quickly  die. 

Animals  vary  in  susceptibility:  the  herbivora  come  first,  then  the  om- 
nivora,  and  lastly  the  carnivora.  The  disease  does  not  occur  spontane- 
ously in  man,  but  always  results  from  infection,  either  through  the  skin, 
the  intestines,  or  in  rare  instances  through  the  lungs.  It  is  found  in  per- 
sons whose  occupations  bring  them  into  contact  with  animals  or  animal 
products,  as  stablemen,  shepherds,  tanners,  butchers,  and  those  who  work 
in  wool  and,  hair. 

Various  forms  of  the  disease  have  been  described,  and  two  chief  groups 
may  be  recognized:  the  external  anthrax  and  the  internal  anthrax,  of  which 
there  are  pulmonary  and  intestinal  forms. 

Symptoms.— (1)  External  Anthrax. 

(a)  Malignant  Pustule. — The  inoculation  is  usually  on  an  exposed  sur- 
face— the  hands,  arms,  or  face.  At  the  site  of  inoculation  there  are,  within 
a  few  hours,  itching  and  uneasiness.  Gradually  a  small  papule  develops, 
which  becomes  vesicular.  Inflammatory  induration  extends  around  this, 
and  within  thirty-six  hours,  at  the  site  of  inoculation  there  is  a  dark  brown- 
ish eschar,  at  a  little  distance  from  which  there  may  be  a  series  of  small 
vesicles.  The  brawny  induration  may  be  extreme.  The  oedema  produces 
very  great  swelling  of  the  parts.  The  inflammation  extends  along  the  lym- 
phatics, and  the  neighboring  lymph-glands  are  swollen  and  sore.  The 
fever  at  first  rises  rapidly,  and  the  concomitant  phenomena  are  marked. 
Subsequently  the  temperature  falls,  and  in  many  cases  becomes  subnormal. 
Death  may  take  place  in  from  three  to  five  days.  In  cases  which  recover 
the  constitutional  symptoms  are  slighter,  the  eschar  gradually  sloughs  out, 
and  the  wound  heals.  The  cases  vary  much  in  severity.  In  the  mildest 
form  there  may  be  only  slight  swelling.  At  the  site  of  inoculation  a  papule 
is  formed,  which  rapidly  becomes  vesicular  and  dries  into  a  scab,  which 
separates  in  the  course  of  a  few  days. 

(b)  Malignant  Anthrax  (Edema. — This  form  occurs  in  the  eyelid,  and 
also  in  the  head,  hand,  and  arm,  and  is  characterized  by  the  absence  of  the 
papule  and  vesicle  forms,  and  by  the  most  extensive  oedema,  which  may 
follow  rather  than  precede  the  constitutional  symptoms.  The  oedema 
reaches  such  a  grade  of  intensity  that  gangrene  results,  and  may  involve  a 
considerable  surface.  The  constitutional  symptoms  then  become  extremely 
grave,  and  the  cases  invariably  prove  fatal. 

The  greatest  fatality  is  seen  in  cases  of  inoculation  about  the  head  and 
face,  where  the  mortality,  according  to  Nasarow,  is  26  per  cent;  the  least 
in  infection  of  the  lower  extremities,  where  it  is  5  per  cent. 

In  a  recent  case,  in  a  hair-picker,  there  was  most  extensive  enteritis, 
peritonitis,  and  endocarditis,  which  last  lesion  has  been  described  by 
Eppinger. 

A  feature  in  both  these  forms  of  malignant  pustule,  to  which  many 
writers  refer,  is  the  absence  of  feeling  of  distress  or  anxiety  on  the  part  of 
the  patient,  whose  mental  condition  may  be  perfectly  clear.  He  may  be 
without  any  apprehension,  even  though  his  condition  is  very  critical. 


226  SPECIFIC  INFECTIOUS  DISEASES. 

The  diagnosis  in  most  instances  is  readily  made  from  the  character  of 
the  lesion  and  the  occupation  of  the  patient.  When  in  doubt,  the  exami- 
nation of  the  fluid  from  the  pustule  may  show  the  presence  of  the  anthrax 
bacilli.  Cultures  should  be  made,  or  a  mouse  or  guinea-pig  inoculated 
from  the  local  lesion.  It  is  to  be  remembered  that  the  blood  may  not  show 
the  bacilli  in  numbers  until  shortly  before  death. 

(2)  Internal  Anthrax. 

(a)  Intestinal  Form,  Mycosis  intestinalis. — In  these  cases  the  infection 
usually  is  through  the  stomach  and  intestines,  and  results  from  eating  the 
flesh  or  drinking  the  milk  of  diseased  animals;  it  may,  however,  follow  an 
external  infection  if  the  germs  are  carried  to  the  mouth.  The  symptoms 
are  those  of  intense  poisoning.  The  disease  may  set  in  with  a  chill,  fol- 
lowed by  vomiting,  diarrhoea,  moderate  fever,  and  pains  in  the  legs  and 
back.  In  acute  cases  there  are  dyspnoea,  cyanosis,  great  anxiety  and  rest- 
lessness, and  toward  the  end  convulsions  or  spasms  of  the  muscles.  Haem- 
orrhage may  occur  from  the  mucous  membranes.  Occasionally  there  are 
small  phlegmonous  areas  on  the  skin,  or  petechise  develop.  The  spleen  is 
enlarged.  The  blood  is  dark  and  remains  fluid  for  a  long  time  after  death. 
Late  in  the  disease  the  bacilli  may  be  found  in  the  blood. 

This  is  one  of  the  forms  of  acute  poisoning  which  may  affect  many  in- 
dividuals together.  Thus  Butler  and  Karl  Huber  describe  an  epidemic 
in  which  twenty-five  persons  were  attacked  after  eating  the  flesh  of  an 
animal  which  had  had  anthrax.  Six  died  in  from  forty-eight  hours  to 
seven  days. 

(h)  Wool-sorter's  Disease. — This  important  form  of  anthrax  is  found 
in  the  large  establishments  in  which  wool  or  hair  is  sorted  and  cleansed. 
The  hair  and  wool  imported  into  Europe  from  Eussia  and  South  America 
appear  to  have  induced  the  largest  number  of  cases.  Many  of  these  show 
no  external  lesion.  The  infective  material  has  been  swallowed  or  inhaled 
with  the  dust.  There  are  rarely  premonitory  symptoms.  The  patient  is 
seized  with  a  chill,  becomes  faint  and  prostrated,  has  pains  in  the  back 
and  legs,  and  the  temperature  rises  to  102°  or  103°.  The  breathing  is 
rapid,  and  he  complains  of  much  pain  in  the  chest.  There  may  be  a  cough 
and  signs  of  bronchitis.  So  prominent  in  some  instances  are  these  bron- 
chial symptoms  that  a  pulmonary  form  of  the  disease  has  been  described. 
The  pulse  is  feeble  and  very  rapid.  There  may  be  vomiting,  and  death 
may  occur  within  twenty-four  hours  with  symptoms  of  profound  collapse 
and  prostration.  Other  cases  are  more  protracted,  and  there  may  be  diar- 
rhoea, delirium,  and  unconsciousness.  The  cerebral  symptoms  may  be 
most  intense;  in  at  least  four  cases  the  brain  seems  to  have  been  chiefly 
affected,  and  its  capillaries  stuffed  with  bacilli  (Merkel).  The  recognition 
of  wool-sorter's  disease  as  a  form  of  anthrax  is-  due  to  J.  H.  Bell,  of  Brad- 
ford, England. 

In  certain  instances  these  profound  constitutional  symptoms  of  internal 
anthrax  are  associated  with  the  external  lesions  of  malignant  pustule. 

The  rag-picJcer's  disease  has  been  made  the  subject  of  an  exhaustive 
study  by  Eppinger  (Die  Hadernkrankheit,  Jena,  1894),  who  has  shown  that 
it  is  a  local  anthrax  of  the  lungs  and  pleura,  with  general  infection. 


HYDROPHOBIA.  227 

The  diagnosis  of  internal  anthrax  is  by  no  means  easy,  unless  the  his- 
tory points  definitely  to  infection  in  the  occupation  of  the  individual. 

Treatment. — In  malignant  pustule  the  site  of  inoculation  should  be 
destroyed  by  the  caustic  or  hot  iron,  and  powdered  bichloride  of  mercury 
may  be  sprinkled  over  the  exposed  surface.  The  local  development  of  the 
bacilli  about  the  site  of  inoculation  may  be  prevented  by  the  subcutaneous 
injections  of  solutions  of  carbolic  acid  or  bichloride  of  mercury.  The 
injections  should  be  made  at  various  points  around  the  pustule,  and  may 
be  repeated  two  or  three  times  a  day.  The  internal  treatment  should  be 
confined  to  the  administration  of  stimulants  and  plenty  of  nutritious  food. 
Davies-Colley  advises  ipecacuanha  powder  in  doses  of  from  5  to  10  grains 
every  three  or  four  hours. 

In  malignant  forms,  particularly  the  intestinal  cases,  little  can  be  done. 
Active  purgatives  may  be  given  at  the  outset,  so  as  to  remove  the  infect- 
ing material.     Quinine  in  large  doses  has  been  recommended. 


XXVIII.    HYDROPHOBIA. 

(Lyssa;  Babies.) 

Definition. — An  acute  disease  of  warm-blooded  animals,  dependent 
upon  a  specific  virus,  and  communicated  by  inoculation  to  man. 

Etiology. — Eabies  is  very  variously  distributed.  In  Eussia  it  is  com- 
mon. In  North  Germany  it  is  relatively  rare,  owing  to  the  wise  provision 
that  all  dogs  shall  be  muzzled;  in  England  and  France  it  is  much  more  com- 
mon. In  this  country  the  disease  occurs  more  often  than  is  generally  sup- 
posed, as  is  shown  by  the  number  of  authentic  cases  collected  by  Salmon 
[Yearbook  of  the  United  States  Department  of  Agriculture,  p.  210,  1901]. 

Canines  are  specially  liable  to  the  disease.  It  is  found  most  frequently 
in  the  dog,  the  wolf,  the  cat,  and  the  cow.  Most  animals  are,  however,  sus- 
ceptible; and  it  is  communicable  by  inoculation  to  the  rabbit,  horse,  or  pig. 
The  disease  is  propagated  chiefly  by  the  dog,  which  seems  specially  suscep- 
tible. In  the  Western  States  the  skunk  is  said  to  be  very  liable  to  the  dis- 
ease. The  nature  of  the  poison  is  as  yet  unknown.  It  is  contained  chiefly 
in  the  nervous  system  and  is  met  with  in  some  of  the  secretions,  particularly 
in  the  saliva. 

A  variable  time  elapses  between  the  introduction  of  the  virus  and  the 
appearance  of  the  symptoms.  Horsley  states  that  this  depends  upon  the 
following  factors:  "  (a)  Age.  The  incubation  is  shorter  in  children  than 
in  adults.  For  obvious  reasons  the  former  are  more  frequently  attacked. 
(h)  Part  infected.  The  rapidity  of  onset  of  the  sjrmptoms  is  greatly  de- 
termined by  the  part  of  the  body  which  may  happen  to  have  been  bitten. 
Wounds  about  the  face  and  head  are  especially  dangerous;  next  in  order 
in  degrees  of  mortality  come  bites  on  the  hands,  then  injuries  on  the  other 
parts  of  the  body.  This  relative  order  is,  no  doubt,  greatly  dependent 
upon  the  fact  that  the  face,  head,  and  hands  are  usually  naked,  while  the 
other  parts  are  clothed;  it  would  also  appear  to  depend  somewhat  upon 
the  richness  in  nerves  of  the  part,     (c)  The  extent  and  severity  of  the 


228  SPECIFIC  INFECTIOUS  DISEASES. 

wound.  Puncture  wounds  are  the  most  dangerous;  the  lacerations  are 
fatal  in  proportion  to  the  extent  of  the  surface  afforded  for  absorption  of 
the  virus,  (d)  The  animal  conveying  the  infection.  In  order  of  decreas- 
ing severity  come:  first,  the  wolf;  second,  the  cat;  third,  the  dog;  and 
fourth,  other  animals."  Only  a  limited  number  of  those  bitten  by  rabid 
dogs  become  affected  by  the  disease;  according  to  Horsley,  not  more  than 
15  per  cent.  On  the  other  hand,  the  death-rate  of  those  persons  bitten  by 
wolves  is  higher,  not  less  than  40  per  cent.  Babes  gives  the  mortality  as 
from  60  to  80  per  cent. 

The  incubation  period  in  man  is  extremely  variable.  The  average  is 
from  six  weeks  to  two  months.  In  a  few  cases  it  has  been  under  two  weeks. 
It  may  be  prolonged  to  three  months.  It  is  stated  that  the  incubation 
may  be  prolonged  for  a  year  or  even  two  years,  but  this  has  not  been  defi- 
nitely settled. 

Symptoms. — Three  stages  of  the  disease  are  recognized: 

(1)  Premonitorij  stage,  in  which  there  may  be  irritation  about  the  bite, 
pain,  or  numbness.  The  patient  is  depressed  and  melancholy;  and  com- 
plains of  headache  and  loss  of  appetite.^  He  is  very  irritable  and  sleepless, 
and  has  a  constant  sense  of  impending  danger.  There  is  often  greatly 
increased  sensibility.  A  bright  light  or  a  loud  voice  is  distressing.  The 
larynx  may  be  injected  and  the  first  symptoms  of  difficulty  in  swallowing 
are  experienced.  The  voice  also  becomes  husky.  There  is  a  slight  rise  in 
the  temperature  and  the  pulse. 

(2)  Stage  of  Excitement. — This  is  characterized  by  great  excitability 
and  restlessness,  and  an  extreme  degree  of  hyper^esthesia.  "  Any  afferent 
stimulant — i.  e.,  a  sound  or  a  draught  of  air,  or  the  mere  association  of 
a  verbal  suggestion — will  cause  a  violent  reflex  spasm.  In  man  this  symp- 
tom constitutes  the  most  distressing  feature  of  the  malady.  The  spasms, 
which  affect  particularly  the  muscles  of  the  larynx  and  mouth,  are  exceed- 
ingly painful  and  are  accompanied  by  an  intense  sense  of  dyspnoea,  even 
when  the  glottis  is  widely  opened  or  tracheotomy  has  been  performed " 
(Horsley).  Any  attempt  to  take  water  is  followed  by  an  intensely  painful 
spasm  of  the  muscles  of  the  larynx  and  of  the  elevators  of  the  hyoid  bone. 
It  is  this  which  makes  the  patient  dread  the  very  sight  of  water  and  gives 
the  name  hydrophobia  to  the  disease.  These  spasmodic  attacks  may  be 
associated  with  maniacal  symptoms.  In  the  intervals  between  them  the 
patient  is  quiet  and  the  mind  unclouded.  The  temperature  in  this  stage 
is  usually  elevated  and  may  reach  from  lOO**  to  103°.  In  some  instances  the 
disease  is  afebrile.  The  patient  rarely  attempts  to  injure  his  attendants, 
and  in  the  intense  spasms  may  be  particularly  anxious  to  avoid  hurting 
any  one.  There  are,  however,  occasional  fits  of  furious  mania,  and  the 
patient  may,  in  the  c&ntractions  of  the  muscles  of  the  larynx  and  pharynx, 
give  utterance  to  odd  sounds.  This  stage  lasts  from  a  day  and  a  half  to 
three  days  and  gradually  passes  into  the — 

(3)  Paralytic  Stage. — In  rodents  the  preliminary  and  furious  stages 
are  absent,  as  a  rule,  and  the  paralytic  stage  may  be  marked  from  the  out- 
set— the  so-called  dumb  rabies.  This  stage  rarely  lasts  longer  than  from 
six  to  eighteen  hours.     The  patient  then  becomes  quiet;  the  spasms  no 


HYDROPHOBIA.  229 

longer  occur;  unconsciousness  gradually  supervenes;  the  heart's  action  he- 
comes  more  and  more  enfeebled,  and  death  occurs  by  syncope. 

Morbid  Anatomy. — The  important  lesions  consist  in  the  accumula- 
tion of  leucocytes  around  the  blood-vessels  and  the  nerve-cells,  particularly 
the  motor  ganglion  cells,  of  the  central  nervous  system  (rabic  tubercles  of 
Babes).  Especial  importance  in  the  rapid  diagnosis  of  rabies  is  attached 
by  van  Gehuchten  and  Nelis  to  the  accumulation  of  lymphoid  and  endothe- 
lioid  cells  around  nerve-cells  of  the  sympathetic  and  cerebro-spinal  ganglia. 
Various  degenerations  of  nerve-cells  occur.  The  inoculation  experiments 
show  that  the  virus  is  not  present  in  the  liver,  spleen,  or  kidneys,  but  is 
abundant  in  the  spinal  cord,  brain,  and  peripheral  nerves. 

Treatment. — Prophylaxis  is  of  the  greatest  importance,  and  by  a 
systematic  muzzling  of  dogs  the  disease  can  be,  as  in  parts  of  Germany, 
practically  eradicated. 

The  bites  should  be  carefully  washed  and  thoroughly  cauterized  with 
caustic  potash  or  concentrated  carbolic  acid.  It  is  best  to  keep  the  wound 
constantly  open  for  at  least  five  or  six  weeks.  When  once  established  the 
disease  is  hopelessly  incurable.  No  measures  have  been  found  of  the  slight- 
est avail,  consequently  the  treatment  must  be  palliative.  The  patient 
should  be  kept  in  a  darkened  room,  in  charge  of  not  more  than  two  care- 
ful attendants.  To  allay  the  spasm,  chloroform  may  be  administered  and 
morphia  given  hypodermically.  It  is  best  to  use  these  powerful  remedies 
from  the  outset,  and  not  to  temporize  with  chloral,  bromide  of  potassium, 
and  other  less  potent  drugs.  By  the  local  application  of  cocaine,  the  sensi- 
tiveness of  the  throat  may  be  diminished  sufficiently  to  enable  the  patient 
to  take  liquid  nourishment.  Sometimes  he  can  swallow  readily.  Nutrient 
enemata  should  be  administered. 

Preventive  Inoculation. — Pasteur  has  found  that  the  virus,  when  propa- 
gated through  a  series  of  rabbits,  increases  in  its  virulence;  so  that  whereas 
subdural  inoculation  from  the  brain  of  a  mad  dog  takes  from  fifteen  to 
twenty  days  to  produce  the  disease,  in  successive  inoculation  in  a  series  of 
rabbits  the  incubation  period  is  gradually  reduced  to  seven  days  (virus  fixe). 
The  spinal  cords  of  these  rabbits  contain  the  virus  in  great  intensity,  but 
when  they  are  preserved  in  dry  air  this  gradually  diminishes.  If  now  dogs 
are  inoculated  from  cords  preserved  for  from  twelve  to  fifteen  days,  and 
then  from  cords  preserved  for  a  shorter  period,  i.  e.,  with  a  progressively 
stronger  virus,  they  gradually  acquire  immunity  against  the  disease.  A 
dog  treated  in  this  way  will  resist  inoculation  with  the  virus  fixe,  which 
otherwise  would  inevitably  have  proved  fatal.  Eelying  upon  these  experi- 
ments, Pasteur  began  inoculations  in  the  human  subject,  using,  on  succes- 
sive days,  material  from  cords  in  which  the  virus  was  of  varying  degrees 
of  intensity. 

The  statistics  published  annually  from  the  Pasteur  Institute  and  else- 
where prove  exclusively  the  importance  of  this  method  as  a  protective 
measure  in  man.  The  figures  given  by  Pottevin,  being  the  cases  treated 
in  Paris  from  1886  to  1894  inclusive,  show  that  of  13,817  persons  bitten 
the  mortality  was  0.5  per  cent     Of  these,  1,347  were  bitten  on  the  head. 


230  SPECIFIC  INFECTIOUS  DISEASES, 

the  mortality  being  1.26  per  cent;  8,722  on  the  hands,  with  0.76  per  cent  of. 
deaths;  and  5,746  on  other  parts  of  the  body,  with  a  mortality  of  0.28  per 
cent. 

Diagnosis. — After  the  symptoms  of  the  disease  have  developed  in 
man  the  diagnosis  should  offer  no  especial  difficulties.  It  is  advisable,  in 
cases  attended  with  any  doubts,  as  soon  as  possible  after  the  injury  has  been 
inflicted,  to  secure  the  medulla  oblongata  of  the  supposed  rabid  animal  for 
the  purpose  of  inoculating  rabbits.  The  subdural  inoculation  of  rabbits 
with  a  small  quantity  of  the  central  nervous  system  of  a  rabid  animal  will 
be  followed  by  the  development  of  the  paralytic  form  of  the  disease  in  from 
fifteen  to  twenty  days. 

Pseudo-liydropliobia  (Lyssophobia). — This  is  a  very  interesting 
affection,  which  may  closely  resemble  hydrophobia,  but  is  really  nothing 
more  than  a  neurotic  or  hysterical  manifestation.  A  nervous  person  bitten 
by  a  dog,  either  rabid  or  supposed  to  be  rabid,  develops  within  a  few  months, 
or  even  later,  symptoms  somewhat  resembling  the  true  disease.  He  is  irri- 
table and  depressed.  He  constantly  declares  his  condition  to  be  serious 
and  that  he  will  inevitably  become  mad.  He  may  have  paroxysms  in  which 
he  says  he  is  unable  to  drink,  grasps  at  his  throat,  and  becomes  emotional. 
The  temperature  is  not  elevated  and  the  disease  does  not  progress.  It  lasts 
much  longer  than  the  true  rabies,  and  is  amenable  to  treatment.  It  is  not 
improbable  that  a  majority  of  the  cases  of  alleged  recovery  in  this  disease 
have  been  of  this  hysterical  form.  In  a  ease  which  Burr  reported  from 
my  clinic  a  few  years  ago  the  patient  had  paroxysmal  attacks  in  which  he 
could  not  swallow.  He  was  greatly  excited  and  alarmed  at  the  sight  of 
water  and  was  extremely  emotional.  The  sj^mptoms  lasted  for  a  couple  of 
weeks  and  yielded  to  treatment  with  powerful  electrical  currents. 


XXIX.    TETANUS. 

{Lochjaw.) 

Definition. — An  infectious  malady  characterized  by  tonic  spasms  of 
the  muscles  with  marked  exacerbations.  The  virus  is  produced  by  a 
bacillus  which  occurs  in  earth  and  sometimes  in  putrefying  fluids  and 
manure. 

Etiology. — It  occurs  as  an  idiopathic  affection  or  follows  trauma.  It 
is  frequent  in  some  localities  and  has  prevailed  extensively  in  epidemic 
form  among  new-born  children,  when  it  is  known  as  tetanus  or  trismus 
neonatorum.  It  is  more  common  in  hot  than  in  temperate  climates,  and 
in  the  colored  than  in  the  Caucasian  race.  This  is  particularly  the  case 
with  tetanus  following  confinement  and  in  tetanus  neonatorum.  In  cer- 
tain of  the  West  Indian  Islands  more  than  one  half  of  the  mortality  among 
the  negro  children  has  been  due  to  this  cause.  St.  Kilda,  one  of  the  west- 
ern Hebrides,  had  been  scourged  for  years  by  the  "  eight  days'  sickness  " 
among  the  new-born.  Of  125  children,  84  died  within  fourteen  days  of 
birth.  Since  the  discovery  of  the  tetanus  bacillus,  some  philanthropic  peo- 
ple in  Glasgow  sent  a  nurse  to  the  island,  who  taught  the  midwives  to  use 


TETANUS.  231 

iodoform  on  the  navel.  The  disease  has  now  practically  disappeared 
(Turner).  In  a  majority  of  the  cases  there  is  an  injury  which  may  be  of 
the  most  trifling  character.  It  is  more  common  after  punctured  and  con- 
tused than  after  incised  wounds,  and  frequently  follows  those  of  the  hands 
and  feet.  The  symptoms  usually  appear  within  two  weeks  of  the  injury.  In 
some  military  campaigns  tetanus  has  prevailed  extensively,  but  in  others, 
as  in  the  late  civil  war,  the  cases  have  been  comparatively  few.  It  was 
formerly  thought  to  occur  after  exposure  or  after  .sleeping  on  the  damp 
ground,  so-called  idiopathic  tetanus.  The  disease  has  occurred  after  pro- 
longed use  of  the  hypodermic  needle  to  inject  morphia  and  quinine. 

The  infectious  nature  of  tetanus  was  suggested  by  its  endemic  occur- 
rence and  from  the  manner  of  its  behavior  in  certain  institutions.  Vet- 
erinarians have  long  been  of  this  belief,  as  cases  are  apt  to  occur  together 
in  horses  in  one  stable.  On  the  eastern  end  of  Long  Island,  where  formerly 
the  disease  was  very  prevalent,  it  is  now  rarely  seen. 

The  Tetanus  Bacillus. — The  observations  of  Rosenbach,  Nicolaier,  and 
Kitasato  have  demonstrated  that  there  is  in  connection  with  the  disease  a 
specific  organism  which  can  be  isolated  and  cultivated.  Bacillus  tetani  is 
a  slender  rod,  which  may  grow  into  long  threads.  One  end  is  often  swollen 
and  occupied  by  a  spore.  It  is  motile,  grows  at  ordinary  temperatures,  and 
is  anaerobic.  The  bacilli  develop  at  the  site  of  the  wound  (and  do  not  in- 
vade the  blood  and  organs),  where  alone  the  toxine  is  manufactured.  With 
small  quantities  of  the  culture  the  disease  may  be  transmitted  to  animals, 
which  die  with  symptoms  of  tetanus.  The  poison  is  a  tox-albumin  of 
extraordinary  potency,  which  has  been  separated  by  Brieger  and  Cohn 
in  a  state  of  tolerable  purity.  It  is  perhaps  the  most  virulent  poison  known. 
Whereas  the  fatal  dose  of  strychnine  for  a  man  weighing  70  kilos  is  from 
30  to  100  milligrammes,  that  of  the  tetanus  toxine  is  estimated  at  0.23 
milligramme.  Every  feature  of  the  disease  can  be  produced  by  it  experi- 
mentally without  the  presence  of  the  bacilli.  The  symptoms  do  not  develop 
immediately,  as  in  the  case  of  ordinary  poisons,  but  slowly,  and  it  has  been 
suggested  that  it  acts  only  after  undergoing  some  further  change  in  the 
body.  The  natural  home  of  the  tetanus  bacillus  is  the  soil  and  the  in- 
testinal canal  of  herbivorous  animals.  The  disease  can  be  produced  by 
inoculating  animals  with  garden  earth.  A  high  degree  of  antitoxic  im- 
munity can  be  conferred  on  animals,  which  then  yield  a  protective  serum. 
It  is,  however,  difficult  to  cure  animals  with  this  serum  on  account  of 
the  combination  of  the  toxine  with  nerve-cells  by  the  time  symptoms 
appear. 

Morbid  Anatomy. — No  characteristic  lesions  have  been  found  in 
the  cord  or  in  the  brain.  Congestions  occur  in  different  parts,  and  peri- 
vascular exudations  and  granular  changes  in  the  nerve-cells  have  been 
found.  The  condition  of  the  wound  is  variable.  The  nerves  are  often 
found  injured,  reddened,  and  swollen.  In  the  tetanus  neonatorum  the  um- 
bilicus may  be  inflamed. 

Symptoms. — After  an  injury  the  disease  sets  in  usually  within  ten 
days.     In  Yandell's  statistics  in  at  least  two  fifths,  and  in  Joseph  Jones's 


232  SPECIFIC  INFECTIOUS  DISEASES. 

in  four  fifths,  the  symptoms  occurred  before  the  fifteenth  day.  The  pa- 
tient complains  at  first  of  slight  stiffness  in  the  neck,  or  a  feeling  of  tight- 
ness in  the  jaws,  or  difficulty  in  mastication.  Occasionally  chilly  feelings 
or  actual  rigors  may  precede  these  symptoms.  Gradually  a  tonic  spasm 
of  the  muscles  of  these  parts  develops,  producing  the  condition  of  trismus 
or  lockjaw.  The  eyebrows  may  be  raised  and  the  angles  of  the  mouth 
drawn  out,  causing  the  so-called  sardonic  grin — risus  sardonicus.  In  chil- 
dren the  spasm  may  be  confined  to  these  parts.  Sometimes  the  attack 
is  associated  with  paralysis  of  the  facial  muscles  and  difficulty  in  swallow- 
ing— the  head-tetanus  of  Eose,  which  has  most  commonly  followed  injuries 
in  the  neighborhood  of  the  fifth  nerve.  Gradually  the  process  extends 
and  involves  the  muscles  of  the  body.  Those  of  the  back  are  most  affected, 
so  that  during  the  spasm  the  unfortunate  victim  may  rest  upon  the  head 
and  heels — a  position  known  as  opisthotonos.  The  rectus  abdominalis  mus- 
cle has  been  torn  across  in  the  spasm.  The  entire  trunk  and  limbs  may 
be  perfectly  rigid — orthotonos.  Flexion  to  one  side  is  less  common — pleuro- 
tliotonos;  while  spasm  of  the  muscles  of  the  abdomen  may  cause  the  body 
to  be  bent  iorwaxdi—em'prostliotonos.  In  very  violent  attacks  the  thorax  is 
compressed,  the  respirations  are  rapid,  and  spasm  of  the  glottis  may  occur, 
causing  asphyxia.  The  paroxysms  last  for  a  variable  period,  but  even  in 
the  intervals  the  relaxation  is  not  complete.  The  slightest  irritation  is 
sufficient  to  cause  a  spasm.  The  paroxysms  are  associated  with  agonizing 
pain,  and  the  patient  may  be  held  as  in  a  vice,  unable  to  utter  a  word. 
Usually  he  is  bathed  in  a  profuse  sweat.  The  temperature  may  remain 
normal  throughout,  or  show  only  a  slight  elevation  toward  the  close.  In 
other  cases  the  pyrexia  is  marked  from  the  outset;  the  temperature  reaches 
105°  or  106°,  and  before  death  109°  or  110°.  In  rare  instances  it  may  go 
still  higher.  Death  either  occurs  during  the  paroxysm  from  heart-failure 
or  asphyxia,  or  is  due  to  exhaustion. 

The  cephalic  tetanus  (Eopftetanus  of  Eose)  originates  usually  from  a 
wound  on  one  side  of  the  head,  and  is  characterized  by  stiffness  of  the 
muscles  of  the  Jaw  and  paralysis  of  the  facial  muscles  on  the  same  side  as 
the  wound,  with  difficulty  in  swallowing. 

The  prognosis  is  good  in  the  chronic  cases;  of  these,  in  Willard's  table 
only  8  of  32  died;  but  in  the  acute  form,  of  45  cases,  only  4  recovered. 

Diagnosis. — Well-developed  cases  following  a  trauma  could  not  be 
mistaken  for  any  other  disease.  The  spasms  are  not  unlike  those  of 
strychnia-poisoning,  and  in  the  celebrated  Palmer  murder  trial  this  was 
the  plea  for  the  defence.  The  Jaw-muscles,  however,  are  never  involved 
early,  if  at  all,  and  between  the  paroxysms  in  strychnia-poisoning  there 
is  no  rigidity.  In  tetany  the  distribution  of  the  spasm  at  the  extremities, 
the  peculiar  position,  the  greater  involvement  of  the  hands,  and  the  con- 
dition under  which  it  occurs,  are  sufficient  to  make  J;he  diagnosis  clear.  In 
doubtful  eases  cialtures  should  be  made  from  the  pus  of  the  wound. 

Prognosis. — Two  of  the  Hippocratic  aphorisms  express  tersely  the 
general  prognosis  even  at  the  present  day:  "  The  spasm  supervening  on  a 
wound  is  fatal,"  and  "  such  persons  as  are  seized  with  tetanus  die  within 
four  days,  or  if  they  pass  these  they  recover." 


GLANDERS.  233 

The  mortality  in  the  traumatic  cases  is  not  less  than  80  per  cent  (Con- 
ner); in  the  idiopathic  cases  it  is  under  50  per  cent.  According  to  Yandell, 
the  mortality  is  greatest  in  children.  Favorable  indications  are:  late  onset 
of  the  attack,  localization  of  the  spasms  to  the  muscles  of  the  neck  and  jaw, 
and  an  absence  of  fever. 

Treatment. — Local  treatment  of  the  wound  is  essential,  as  the  poison 
is  manufactured  here.  Tizzoni  advises  nitrate  of  silver  as  the  best  germi- 
cide for  the  tetanus  bacillus.  Thorough  excision  and  antiseptic  treatment 
should  be  carried  out.  The  patient  should  be  kept  in  a  darkened  room, 
absolutely  quiet,  and  attended  by  only  one  person.  All  possible  sources 
of  irritation  should  be  avoided.  Veterinarians  appreciate  the  importance 
of  this  complete  seclusion,  and  in  well-equipped  infirmaries  there  may  be 
seen  a  brick  padded  chamber  in  which  the  horses  are  treated. 

When  the  lockjaw  is  extreme  the  patient  may  not  be  able  to  take  food 
by  the  mouth,  under  which  circumstances  it  is  best  to  use  rectal  injections, 
or  to  feed  by  a  catheter  passed  through  the  nose.  The  spasm  should  be 
controlled  by  chloroform,  which  may  be  repeatedly  exhibited  at  intervals. 
It  is  more  satisfactory  to  keep  the  patient  thoroughly  under  the  influence 
of  morphia  given  hypodermically.  Chloral  hydrate,  bromide  of  potassium. 
Calabar  bean,  curara,  Indian  hemp,  belladonna,  and  other  drugs  have  been 
recommended,  and  recovery  occasionally  follows  their  use.  It  is  very  diffi- 
cult to  estimate  the  value  of  the  blood-serum  therapy  in  this  disease.  Al- 
though tetanus  antitoxine  of  great  strength  can  be  obtained,  its  use  in  the 
treatment  of  human  tetanus  has  been  disappointing.  The  best  results  are 
obtained  in  the  subacute  cases,  but  here  the  prognosis  is  relatively  favor- 
able even  with  other  methods  of  treatment.  There  may  be  occasion  for  the 
prophylactic  use  of  the  antitoxine  in  man,  as  already  successfully  practised 
in  arresting  the  spread  of  the  disease  in  horses  occupying  infected  stables. 
Of  the  antitoxic  serum  30  to  30  cc.  may  be  used  for  the  first  dose  and  15 
to  20  cc.  every  five  or  ten  hours  after.  Tizzoni  advises  2.25  grammes  of 
his  antitoxine  for  the  first  dose  and  0.6  grammes  for  subsequent  doses. 


XXX.     GLANDERS     {Farcy). 

Definition. — An  infectious  disease  of  the  horse,  communicated  occa- 
sionally to  man.  In  the  horse  it  is  characterized  by  the  formation  of 
nodules,  chiefly  in  the  nares  (glanders)  and  beneath  the  skin  (farcy). 

Etiology. — The  disease  belongs  to  the  infective  granulomata.  The 
local  manifestations  in  the  nostrils  and  the  skin  of  the  horse  are  due  to 
one  and  the  same  cause.  The  specific  germ.  Bacillus  mallei,  was  discovered 
b)'  Loeffler  and  Schutz.  It  is  a  short,  non-motile  bacillus,  not  unlike  that 
of  tubercle,  but  exhibits  different  staining  reactions.  It  grows  readily  on 
the  ordinary  culture  media.  For  the  full  recognition  of  glanders  in  man 
we  are  indebted  to  the  labors  of  Eayer,  whose  monograph  remains  one  of 
the  best  descriptions  ever  given  of  the  disease.  Man  becomes  infected  by 
contact  with  diseased  animals,  and  usually  by  inoculation  on  an  abraded 


234  SPECIFIC  INFECTIOUS  DISEASES. 

surface  of  the  skin.  The  contagion  may  also  be  received  on  the  mncous 
membrane.  In  one  of  the  Montreal  cases  a  gentleman  was  probably  in- 
fected by  the  material  expelled  from  the  nostril  of  his  horse,  which  was 
not  suspected  of  having  the  disease. 

Morbid  Anatomy.  — As  in  the  horse,  the  disease  may  be  localized 
in  the  nose  (glanders)  or  beneath  the  skin  (farcy).  The  essential  lesion 
is  the  granulomatous  tumor,  characterized  by  the  presence  of  numerous 
lymphoid  and  epithelioid  cells,  among  and  in  which  are  seen  the  glanders 
bacilli.  These  nodular  masses  tend  to  break  down  rapidly,  and  on  the 
mucous  membrane  result  in  ulcers,  while  beneath  the  skin  they  form  ab- 
scesses.   The  glanders  nodules  may  also  occur  in  the  internal  organs. 

Symptoms. — An  acute  and  a  chronic  form  of  glanders  may  be  recog- 
nized in  man,  and  an  acute  and  a  chronic  form  of  farcy. 

Acute  Glanders. — The  period  of  incubation  is  rarely  more  than  three 
or  four  days.  There  are  signs  of  general  febrile  disturbance.  At  the  site 
of  infection  there  are  swelling,  redness,  and  lymphangitis.  Within  two  or 
three  days  there  is  involvement  of  the  mucous  membrane  of  the  nose,  the 
nodules  break  down  rapidly  to  ulcers,  and  there  is  a  muco-purulent  dis- 
charge. An  eruption  of  papules,  which  rapidly  become  pustules,  breaks 
out  over  the  face  and  about  the  joints.  It  has  been  mistaken  for  variola. 
This  was  carefully  studied  by  Eayer  and  is  figured  in  his  monograph.  In 
a  Montreal  case  this  copious  eruption  led  the  attending  physician  to  sus- 
pect small-pox,  and  the  patient  was  isolated.  There  is  great  swelling  of 
the  nose.  The  ulceration  may  go  on  to  necrosis,  in  which  case  the  discharge 
is  very  offensive.  The  lymph-glands  of  the  neck  are  usually  much  en- 
larged. Subacute  pneumonia  is  very  apt  to  develop.  This  form  runs  its 
course  in  about  eight  or  ten  days,  and  is  invariably  fatal. 

Chronic  glanders  is  rare  and  difficult  to  diagnose,  as  it  is  usually  mis- 
taken for  a  chronic  coryza.  There  are  ulcers  in  the  nose,  and  often  laryn- 
geal symptoms.  It  may  last  for  months,  or  even  longer,  and  recovery  some- 
times takes  place.  Tedeschi  has  described  a  case  of  chronic  osteomyelitis, 
due  to  the  bacillus  mallei,  which  was  followed  by  a  fatal  glanders  menin- 
gitis. The  diagnosis  may  be  extremely  difficult.  In  such  cases  a  suspen- 
sion of  the  secretion,  or  of  cultures  upon  agar-agar  made  from  the  secre- 
tion, should  be  injected  into  the  peritoneal  cavity  of  a  male  guinea-pig. 
At  the  end  of  two  days,  in  positive  cases,  the  testicles  are  found  to  be 
swollen  and  the  skin  of  the  scrotum  reddened.  The  testicles  continue  to 
increase  in  size,  and  finally  suppurate.  Death  takes  place  after  the  lapse 
of  two  or  three  weeks,  and  generalized  glanders  nodules  are  found  in  the 
viscera.  The  use  of  mallein  for  diagnostic  purposes  is  highly  recommended. 
The  principles  and  methods  of  application  are  the  same  as  for  tuberculin. 

Acute  farcy  in  man  results  usually  from  the  inoculation  of  the  virus 
into  the  skin.  There  is  an  intense  local  reaction  with  a  phlegmonous  in- 
flammation. The  lymphatics  are  early  affected,  and  along  their  course 
there  are  nodular  subcutaneous  enlargements,  the  so-called  farcy  buds, 
which  may  rapidly  go  on  to  suppuration.  There  are  pains  and  swelling 
in  the  joints  and  abscesses  may  form  in  the  muscles.  The  symptoms  are 
those  of  an  acute  infection,  almost  like  an  acute  septicaemia.    The  nose  is 


ACTINOMYCOSIS.  235 

not  involved  and  the  superficial  skin  eruption  is  not  common.  The  bacilli 
have  been  found  in  the  urine  in  acute  cases  in  man  and  animals. 

The  disease  is  fatal  in  a  large  proportion  of  the  cases,  usually  in  from 
twelve  to  fifteen  days. 

Ckronic  farcy  is  characterized  by  the  presence  of  localized  tumors,  usu- 
ally in  the  extremities.  These  tumors  break  down  into  abscesses,  and  some- 
times form  deep  ulcers,  without  much  inflammatory  reaction  and  without 
special  involvement  of  the  lymphatics.  The  disease  may  last  for  months 
or  even  years.  Death  may  result  from  pyaemia,  or  occasionally  acute  glan- 
ders develops.  The  celebrated  French  veterinarian  Bouley  had  it  and  re- 
covered. 

The  disease  is  transmissible  also  from  man  to  man.  Washerwomen 
have  been  infected  from  the  clothes  of  a  patient.  In  the  diagnosis  of  this 
affection  the  occupation  is  very  important.  Nowadays,  in  cases  of  doubt, 
the  inoculation  should  be  made  in  animals,  as  in  this  way  the  disease  can 
be  readily  determined.  Mallein,  a  product  of  the  growth  of  the  bacilli,  is 
now  used  for  the  purpose  of  diagnosing  glanders  in  animals.  Several  in- 
stances of  cured  glanders  have  been  reported  in  animals  treated  with  small 
and  repeated  doses  of  mallein  (Pilavios,  Babes). 

Treatment. — If  seen  early,  the  wound  should  be  either  cut  out  or 
thoroughly  destroyed  by  caustics  and  an  antiseptic  dressing  applied.  The 
farcy  buds  should  be  early  opened.  In  the  acute  cases  there  is  very  little 
hope.    In  the  chronic  cases  recovery  is  possible,  though  often  tedious. 


XXXI.   ACTINOMYCOSIS. 

Definition. — A  chronic  infective  disorder  produced  by  the  actino- 
myces  or  ray-fungus,  Streptothrix  adinomyces. 

Etiology. — The  disease  is  widespread  among  cattle,  and  occurs  also 
in  the  pig.  It  was  first  described  by  Bollinger  in  the  ox,  in  which  it  forms 
the  affection  known  in  this  country  as  "big-jaw."  Examples  of  the  dis- 
ease were  common  in  the  cattle  killed  at  the  abattoir  in  Montreal.  In  man 
it  was  mentioned  by  von  Langenbeck,  who  observed  the  "  sulphur  grains  " 
in  the  characteristic  purulent  material.  The  first  accurate  description  of 
the  disease  was  given  by  James  Israel,  and  subsequently  Ponfick  insisted 
upon  the  identity  of  the  disease  in  man  and  cattle. 

In  this  country  to  May  1,  1898,  about  41  cases  have  been  recognized 
(Ruhrah);  in  England  the  disease  is  rare.  It  is  not  uncommon  in  Ger- 
many and  Russia.  To  the  end  of  1893  about  450  cases  had  been  described 
(Leith,  Edinburgh  Hospital  Reports,  vol.  ii).  It  is  nearly  three  times  as 
common  in  men  as  in  women. 

The  parasite  belongs  probably  to  the  Streptothrix  group  of  bacteria. 
In  both  man  and  cattle  it  can  be  seen  in  the  pus  from  the  affected  region 
as  yellowish  or  opaque  granules  from  one  half  to  two  millimetres  in  diam- 
eter, which  are  made  up  of  cocci  and  radiating  threads,  which  present 
bulbous,  club-like  terminations.  The  youngest  granules  are  gray  in  color 
and  semi-translucent;  in  these  the  bulbous  extremities  are  wanting.  It 
15 


236  .        SPECIFIC  INFECTIOUS  DISEASES. 

was  shown  by  Bostrom  that  the  clubbed  ends  are  the  result  of  a  hyaline, 
degenerative  change  taking  place  in  the  sheaths  of  the  filaments.  The 
organism  is  strikingly  pleomorphic. 

The  parasite  has  been  successfully  cultivated,  and  the  disease  has  been 
inoculated  both  with  the  natural  and  artificially  grown  organism. 

The  Mode  of  Infection. — There  is  no  evidence  of  direct  infection  with  the 
flesh  or  milk  of  diseased  animals.  The  streptothrix  has  not  been  detected 
outside  the  body.  It  seems  highly  probable  that  it  is  taken  in  with  the 
food.  The  site  of  infection  in  a  majority  of  cases  in  man  and  animals  is 
in  the  mouth  or  neighboring  passages.  In  the  cow,  possibly  also  in  man, 
barley,  oats,  and  rye  have  been  carriers  of  the  germ. 

Morbid  Anatomy. — In  the  earliest  stages  of  its  growth  the  para- 
site gives  rise  to  a  small  granulation  tumor  not  unlike  that  produced  by 
Bacillus  tuberculosis,  which  contains,  in  addition  to  small  round  cells, 
epithelioid  elements  and  giant  cells.  After  it  reaches  a  certain  size  there 
is  great  proliferation  of  the  surrounding  connective  tissue,  and  the  growth 
may,  particularly  in  the  jaw,  look  like,  and  was  long  mistaken  for,  osteo- 
sarcoma. Finally  suppuration  occurs,  which  in  man,  according  to  Israel, 
may  be  produced  directly  by  the  streptothrix  itself. 

"'-  Clinical  Forms. — (a)  Alimentary  Canal. — Israel  is  said  to  have 
found  the  fungus  in  the  cavities  of  carious  teeth.  The  jaw  has  been  af- 
fected in  a  number  of  cases  in  man.  The  patient  comes  under  observation 
with  swelling  of  one  side  of  the  face,  or  with  a  chronic  enlargement  of  the 
jaw  which  may  simulate  sarcoma. 

The  tongue  iias  been  involved  in  several  cases,  showing  small  growths, 
either  primary  or  following  disease  of  the  jaw.  In  the  intestines  the  disease 
may  occur  either  as  a  primary  or  secondary  afEection.  Cases  have  been 
reported  of  pericsecal  abscess  due  to  the  germ.  An  actinomycotic  appen- 
dicitis has  been  described;  primary  actinomycosis  of  the  large  intestine 
with  metastases  has  also  been  described.  Eansom  has  found  the  actinomyces 
in  the  stools.  The  liver  may  be  affected  primarily,  as  in  the  case  reported 
by  Sharkey  and  Acland.  The  actinomycotic  abscesses  present  a  reticular 
or  honeycomb-like  arrangement  (Leith). 

{b)  Pulmonary  Actinomycosis. — In  September,  1878,  James  Israel  de- 
scribed a  remarkable  mycotic  disease  of  the  lungs,  which  subsequent  ob- 
servation showed  to  be  the  affection  described  the  year  before  by  Bollinger 
in  cattle.  Since  that  date  many  instances  have  been  reported  in  which 
the  lungs  were  affected.  It  is  a  chronic  infectious  pulmonary  disorder, 
characterized  by  cough,  fever,  wasting,  and  a  muco-purulent,  sometimes 
foetid,  expectoration.  The  lesions  are  unilateral  in  a  majority  of  the  cases. 
Hodenpyl  classifies  them  in  three  groups:  (1)  Lesions  of  chronic  bron- 
chitis; the  diagnosis  has  been  made  by  the  presence  of  the  actinomyces 
in  the  sputum.  (2)  Miliary  actinomycosis,  closely  resembling  miliary  tuber- 
cle, but  the  nodules  are  seen  to  be  made  up  of  groups  of  fungi,  surrounded 
by  granulation  tissue.  This  form  of  pulmonary  actinomycosis  is  not  in- 
frequent in  oxen  with  advanced  disease  of  the  jaw  or  adjacent  structures. 
(3)  The  cases  in  which  there  is  more  extensive  destructive  disease  of  the 
lungs,  broncho-pneumonia,  interstitial  changes,  and  abscesses,  the  latter 


ACTINOMYCOSIS.  237 

forming  cavities  large  enough  to  be  diagnosed  during  life.  Actinomycotic 
lesions  of  other  organs  are  often  present  in  connection  with  the  pulmonary 
disease;  erosion  of  the  vertebrae,  necrosis  of  the  ribs  and  sternum,  with 
node-like  formations,  subcutaneous  abscesses,  and  occasionally  metastases  in 
all  parts  of  the  body. 

Symptoms. — The  fever  is  of  an  irregular  type  and  depends  largely  on 
the  existence  of  suppuration.  The  cough  is  an  important  symptom,  and 
the  diagnosis  in  18  of  the  cases  was  made  during  life  by  the  discovery  of 
the  actinomyces.  Death  results  usually  with  septic  symptoms.  Occasion- 
ally there  is  a  condition  simulating  typhoid  fever.  The  average  duration 
of  the  disease  was  ten  months.  Recovery  is  very  rare.  Clinically  the  dis- 
ease closely  resembles  certain  forms  of  pulmonary  tuberculosis  and  of  foetid 
bronchitis.  It  is  not  to  be  forgotten  in  the  examination  of  the  sputum 
that,  as  Bizzozero  mentions,  certain  degenerated  epithelial  cells  may  be 
mistaken  for  the  organism.  The  radiating  leptothrix  threads  about  the 
epithelium  of  the  mouth  sometimes  present  a  striking  resemblance. 

(c)  Cutaneous  Actinomycosis. — In  several  instances  in  connection  with 
chronic  ulcerative  diseases  of  the  skin  the  ray-fungus  has  been  found.  It 
is  a  very  chronic  affection  resembling  tuberculosis  of  the  skin,  associated 
with  the  development  of  tumors  which  suppurate  and  leave  open  sores, 
which  may  remain  for  years. 

{d)  Cerebral  Actinomycosis. — Bollinger  has  reported  an  instance  of 
primary  disease  of  the  brain.  The  symptoms  were  those  of  tumor.  A 
second  remarkable  ease  has  been  reported  by  Gamgee  and  Delepine.  The 
patient  was  admitted  to  St.  George's  Hospital  with  left-sided  pleural  effu- 
sion. At  the  post  mortem  three  pints  of  purulent  fluid  were  found  in  the 
left  pleura;  there  was  an  actinomycotic  abscess  of  the  liver,  and  in  the 
brain  there  were  abscesses  in  the  frontal,  parietal,  and  temporo-sphenoidal 
lobes  which  contained  the  mycelium,  but  no  clubs.  A  third  case,  reported 
by  0.  B.  Keller,  had  empyema  necessitatis,  which  was  opened  and  actino- 
mycetes  were  found  in  the  pus.  Subsequently  she  had  Jacksonian  epilepsy, 
for  which  she  was  trephined  twice  and  abscesses  opened,  which  contained 
actinomyces  grains.    Death  occurred  after  the  second  operation. 

Diagnosis. — The  disease  is  in  reality  a  chronic  pyasmia.  The  only 
test  is  the  presence  of  the  actinomyces  in  the  pus.  Metastases  may  occur 
as  in  pyaemia  and  in  tumors.  The  tendency,  however,  is  rather  to  the  pro- 
duction of  a  local  purulent  affection  which  erodes  the  bones  and  is  very 
destructive.  In  cattle  the  disease  may  cause  metastases  without  any  suppura- 
tion; thus  in  a  Montreal  case  the  jaw  and  tongue  were  the  seat  of  the  most 
extensive  disease  with  very  slight  suppuration,  while  the  lungs  presented 
numbers  of  secondary  growths  containing  the  organisms. 

•  Treatment. — This  is  largely  surgical  and  is  practically  that  of  py- 
aemia. Incision  of  the  abscess,  removal  of  the  dead  bone,  and  thorough 
irrigation  are  appropriate  measures.  Thomassen  has  recommended  iodide 
of  potassium,  which,  in  doses  of  from  40  to  60  grains  daily,  has  proved 
curative  in  a  number  of  recent  cases. 


238  SPECIFIC  INFECTIOUS  DISEASES. 


XXXIl.    SYPHILIS. 

Definition. — A  specific  disease  of  slow  evolution,  propagated  by  in- 
oculation (acquired  syphilis),  or  by  hereditary  transmission  (congenital 
syphilis).  In  the  acquired  form  the  site  of  inoculation  becomes  the  seat  of 
a  special  tissue  change — primary  lesion.  Within  two  or  three  months  con- 
stitutional symptoms  develop,  with  affections  of  the  skin  and  mucous  mem- 
branes— secondary  lesions.  After  a  period  of  months  or  years  granulom- 
atous growths  develop  in  the  viscera,  muscles,  bones,  or  skin — tertiary 
lesions.  And,  finally,  there  are  certain  diseases,  as  tabes  and  general  paresis, 
which  are  peculiarly  prone  to  develop  on  the  syphilitic  soil — para-  or  meta- 
sypJiilitic  affections. 

I.  Geneeal  Etiology  and  Moebid  Anatomy. 

The  nature  of  the  virus  is  still  doubtful.  Lustgarten  found  in  the 
hard  chancre  and  in  gummata  a  rod-shaped  bacillus  of  3  or  4  /a  in  length, 
which  he  claims  is  specific  and  peculiar  to  the  disease.  This  organism 
closely  resembles  the  smegma  bacillus,  which  is  found  beneath  the  prepuce, 
but  from  its  occurrence  in  gummatous  growths  it  is  hardly  possible  that 
they  can  be  identical.  Further  observations  are  required  before  the  ques- 
tion can  be  considered  settled. 

Syphilis  is  peculiar  to  man,  and  cannot  be  transmitted  to  the  lower 
animals.    All  are  susceptible  to  the  contagion,  and  it  occurs  at  all  ages. 

Modes  of  Infection. — (1)  In  a  large  majority  of  all  cases  the  disease  is 
transmitted  by  sexual  congress,  but  the  designation  venereal  disease  (lues 
venerea)  is  not  always  correct,  as  there  are  many  other  modes  of  inoculation. 

(2)  Accidental  Infection.— In  surgical  and  in  midwifery  practice  phy- 
sicians are  not  infrequently  inoculated.  It  is  surprising  that  such  acci- 
dents are  not  more  common.  General  infection  may  occur  without  a  local 
sore.  Midwifery  chancres  are  usually  on  the  fingers,  but  I  have  met  with 
one  instance  on  the  back  of  the  hand.  The  lip  chancre  is  the  most  common 
of  these  erratic  or  extra-genital  forms,  and  may  be  acquired  in  many  ways 
apart  from  direct  infection.  Mouth  and  tonsillar  sores  result  as  a  rule 
from  improper  practices.  Wet-nurses  are  sometimes  infected  on  the  nipple, 
and  it  occasionally  happens  that  relatives  of  the  child  are  accidentally  con- 
taminated. One  of  the  most  lamentable  forms  of  accidental  infection  is  the 
transmission  of  the  disease  in  humanized  vaccine  lymph.  This,  however, 
is  extremely  rare.  The  conditions  under  which  it  occurs  have  been  already 
referred  to  (see  Vaccination). 

(3)  Hereditary  Transmission. — This  may  be,  and  is,  most  common 
from  (a)  the  father,  the  mother  being  healthy  (sperm  inheritance).  It  is, 
unfortunately,  an  every-day  experience  to  see  cases  of  congenital  syphilis 
in  which  the  infection  is  clearly  paternal.  A  syphilitic  father  may,  how- 
ever, beget  a  healthy  child,  even  when  the  disease  is  fresh  and  full-blown. 
On  the  other  hand,  in  very  rare  instances,  a  man  may  have  had  syphilis 
when  young,  undergo  treatment,  and  for  years  present  no  signs  of  disease, 
and  yet  his  first-born  may  show  very  characteristic  lesions.    Happily,  in  a 


SYPHILIS.  239 

large  majority  of  instances,  when  the  treatment  has  been  thorough,  the 
offspring  escape.  The  closer  the  begetting  to  the  primary  sore,  the  greater 
the  chance  of  infection.  A  man  with  tertiary  lesions  may  beget  healthy 
children.  As  a  general  rule  it  may  be  said  that  with  judicious  treatment 
the  transmissive  power  rarely  exceeds  three  .or  four  years. 

(h)  Maternal  transmission  (germ  inheritance).  It  is  a  remarkable  and 
interesting  fact  that  a  woman  who  has  borne  a  syphilitic  child  is  herself 
immune,  and  cannot  be  infected,  though  she  may  present  no  signs  of  the 
disease.  This  is  known  as  Colles^  law,  and  was  thus  stated  by  the  distin- 
guished Dublin  surgeon:  "That  a  child  born  of  a  mother  who  is  without 
obvious  venereal  symptoms,  and  which,  without  being  exposed  to  any 
infection  subsequent  to  its  birth,  shows  this  disease  when  a  few  weeks  old, 
this  child  will  infect  the  most  healthy  nurse,  whether  she  suckle  it,  or 
merely  handle  and  dress  it;  and  yet  this  child  is  never  known  to  infect  its 
own  mother,  even  though  she  suckle  it  while  it  has  venereal  ulcers  of  the 
lips  and  tongue."  In  a  majority  of  these  cases  the  mother  has  received  a 
sort  of  protective  inoculation,  without  having  had  actual  manifestations  of 
the  disease. 

A  woman  with  acquired  syphilis  is  liable  to  bear  infected  children. 
The  father  may  not  be  affected.  In  a  large  number  of  instances  both 
parents  are  diseased,  the  one  having  infected  the  other,  in  which  case  the 
chances  of  foetal  infection  are  greatly  increased. 

(c)  Placental  transmission.  The  mother  may  be  infected  after  con- 
ception, in  which  case  the  child  may  be,  but  is  not  necessarily,  born  syph- 
ilitic. 

Morbid  Anatomy. — The  primary  lesion,  or  chancre,  shows:  (a)  A  dif- 
fuse infiltration  of  the  connective  tissue  with  small,  round  cells,  (h) 
Larger  epithelioid  cells,  (c)  Giant  cells,  (d)  The  Lustgarten  bacilli,  in 
small  numbers,  (e)  Changes  in  the  small  arteries  and  veins,  chiefly  thick- 
ening of  the  intima,  and  alterations  in  the  nerve-fibres  going  to  the  part 
(Berkley).  The  sclerosis  is  due  in  part  to  this  acute  obliterative  endart- 
eritis. Associated  Math  the  initial  lesions  are  changes  in  the  adjacent 
lymph-glands,  which  undergo  hyperplasia,  and  finally  become  indurated. 

The  secondary  lesions  of  syphilis  are  too  varied  for  description  here. 
They  consist  of  condylomata,  skin  eruptions,  affections  of  the  eye,  etc. 

The  tertiary  lesions  consist  of  circumscribed  tumors  known  as  gum- 
mata,  and  of  an  arteritis,  which,  however,  is  not  peculiar  to  the  disease. 

Gummata. — Syphilomata  develop  in  the  bones  or  periosteum — ^here 
they  are  called  nodes — in  the  muscles,  skin,  brain,  lung,  liver,  kidneys, 
heart,  testes,  and  adrenals.  They  vary  in  size  from  small,  almost  micro- 
scopic, bodies  to  large,  solid  tumors  from  3  to  5  cm.  in  diameter.  They 
are  usually  firm  and  hard,  but  in  the  skin  and  on  the  mucous  membranes 
they  tend  to  break  down  rapidly  and  ulcerate.  On  cross-section  a  medium- 
sized  gumma  has  a  grayish-white,  homogeneous  appearance,  presenting 
in  the  centre  a  firm,  caseous  substance,  and  at  the  periphery  a  translucent, 
fibrous  tissue.  Often  there  are  groups  of  three  or  more  surrounded  by 
dense  sclerotic  tissue. 

The  arteritis  will  be  considered  in  a  separate  section. 


240  SPECIFIC  INFECTIOUS  DISEASES. 

II.  AcQuiEED  Syphilis. 

Primary  Stage. — This  extends  from  the  appearance  of  the  initial  sore 
until  the  onset  of  the  constitutional  symptoms,  and  has  a  variable  dura- 
tion of  from  six  to  twelve  weeks.  The  initial  sore  appears  within  a  month 
after  inoculation,  and  it  first  shows  itself  as  a  small  red  papule,  which 
gradually  enlarges  and  breaks  in  the  centre,  leaving  a  small  nicer.  The 
tissue  about  this  becomes  indurated  so  that  it  ultimately  has  a  gristly,  car- 
tilaginons  consistence — hence  the  name,  hard  or  indurated  chancre.  The 
size  attained  is  variable,  and  when  small  the  sore  may  be  overlooked,  par- 
ticularly if  it  is  just  within  the  urethra.  The  glands  in  the  lymph-district 
of  the  chancre  enlarge  and  become  hard.  Suppuration  both  in  the  initial 
lesion  and  in  the  glands  may  occur  as  a  secondary  change.  The  general 
condition  of  the  patient  in  this  stage  is  good.  There  may  be  no  fever  and 
no  impairment  of  health. 

Secondary  Stage.  — The  first  constitutional  symptoms  are  usually  mani- 
fested within  three  months  of  the  appearance  of  the  primary  sore.  They 
rarely  develop  earlier  than  the  sixth  or  later  than  the  twelfth  week.  The 
symptoms  are:  (a)  Fever,  slight  or  intense,  and  very  variable  in  charac- 
ter. A  mild  continuoua  pyrexia  is  not  uncommon,  the  temperature  not 
rising  above  101°.  The  fever  may  have  a  distinctly  remittent  character; 
but  the  most  remarkable  and  puzzling  type,  which  is  very  apt  to  lead  to 
error  in  diagnosis,  is  the  intermittent  syphilitic  fever.  It  may  come  on 
within  a  month  after  exposure  and  rise  to  104°  or  105°,  with  oscilla- 
tions of  5°  or  6°  (Yeo).  A  remarkable  case  is  reported  by  .Sidney 
Phillips,  in  which  pyrexia  persisted  for  months,  with  paroxysms  resem- 
bling in  all  respects  tertian  ague,  and  which  resisted  quinine  and  yielded 
promptly  to  mercury  and  potassium  iodide.  Although  usually  a  secondary 
manifestation,  the  fever  of  syphilis  may  occur  late  in  the  disease.  Prac- 
titioners are  scarcely  alive  to  the  frequency  and  importance  of  syphilitic 
fever.  Janeway  has  called  attention  to  cases  in  which  the  diagnosis  of 
pulmonary  tuberculosis  had  been  made. 

(&)  AncBmia. — In  many  cases  the  syphilitic  poison  causes  a  pronounced 
anaemia  vrhich  gives  to  the  face  a  muddy  pallor,  and  there  may  even  be  a 
light-yellow  tingeing  of  the  conjunctivge  or  of  the  skin,  a  hsematogenous 
icterus.  This  syphilitic  cachexia  may  in  some  instances  be  extreme.  The 
red  blood-corpuscles  do  not  show  any  special  alterations.  The  blood-count 
may  fall  to  three  millions  per  cubic  millimetre,  or  even  lower.  The  anaemia 
may  develop  suddenly.  In  a  case  of  syphilitic  arthritis  in  a  young  girl 
following  three  or  four  inunctions  of  mercury  the  blood-count  fell  below 
two  millions  per  cubic  millimetre  in  a  few  days. 

(c)  Cutaneous  Lesions. — The  earliest  and  most  common  is  a  macular 
syphilide  or  syphilitic  roseola,  which  occurs  on  the  trunk,  and  on  the  front  of 
the  arms.  The  face  is  often  exempt.  The  spots,  whix^h  are  reddish-brown 
and  symmetrically  arranged,  persist  lor  a  week  or  two.  There  may  be  mul- 
tiple relapses  of  roseola,  sometimes  at  long  intervals,  even  eleven  years  (Four- 
nier).  The  papular  sypJiilide,  which  forms  acne-like  indurations  about  the 
face  and  trunk,  is  often  arranged  in  groups.    Other  forms  are  the  pustular 


SYPHILIS.  241 

rash,  which  may  so  closely  simulate  variola  that  the  patient  may  be  sent  to 
a  small-pox  hospital.  A  squamous  sypMUde  occurs,  not  unlike  ordinary 
psoriasis,  except  that  the  scales  are  less  abundant.  The  rash  is  more  copper- 
colored  and  not  specially  confined  to  the  extensor  surfaces. 

In  the  moist  regions  of  the  skin,  such  as  the  perinseum  and  groins,  the 
axillae,  between  the  toes,  and  at  the  angles  of  the  mouth,  the  so-called 
mucous  patches  develop,  which  are  flat,  warty  outgrowths,  with  well-defined 
margins  and  surfaces  covered  with  a  grayish  secretion.  They  are  among 
the  most  distinctive  lesions  of  syphilis. 

Frequently  the  hair  falls  out  (alopecia),  either  in  patches  or  by  a  gen- 
eral thinning..    Occasionally  the  nails  become  affected  (syphilitic  onychia). 

(d)  Mucous  Lesions. — With  the  fever  and  the  roseolous  rash  the  throat 
and  mouth  become  sore.  The  pharyngeal  mucosa  is  hyperaemic,  the  ton- 
sils are  swollen  and  often  present  small,  kidney-shaped  ulcers  with  grayish - 
white  borders.  Mucous  patches  are  seen  on  the  inner  surfaces  of  the  cheeks 
and  on  the  tongue  and  lips.  Sometimes  on  the  tongue  there  are  whitish 
spots  (leucomata),  which  are  seen  most  frequently  in  smokers,  and  which 
Hutchinson  regards  as  the  Joint  result  of  syphilitic  glossitis  and  the  irri- 
tation of  hot  tobacco-smoke.  Hypertrophy  of  the  papillae  in  various  por- 
tions of  the  mucous  membrane  produces  the  syphilitic  warts  or  condylo- 
mata which  are  most  frequent  about  the  vulva  and  anus. 

(e)  Other  Lesions. — Iritis  is  common,  and  usually  affects  one  eye  be- 
fore the  other.  It  develops  in  from  three  to  six  months  after  the  chancre. 
There  may  be  only  slight  ciliary  congestion  in  mild  cases,  but  in  severer 
forms  there  is  great  pain,  and  the  condition  is  serious  and  demands  care- 
ful management.  Choroiditis  and  retinitis  are  rare  secondary  symptoms. 
Ear  affections  are  not  common  in  the  secondary  stage,  but  instances  are 
found  in  which  sudden  deafness  develops,  which  may  be  due  to  labyrinth- 
ine disease;  more  commonly  the  impaired  hearing  is  due  to  the  extension 
of  inflammation  from  the  throat  to  the  middle  ear.  Epididymitis  and 
parotitis  are  rare.    Jaundice  may  occur,  the  icterus  syphiliticus  precox. 

Tertiary  Stage. — No  hard  and  fast  line  can  be  drawn  between  the 
lesions  of  the  secondary  and  those  of  the  tertiary  period;  and,  indeed,  in 
exceptional  cases,  manifestations  which  usually  appear  late  may  set  in  even 
before  the  primary  sore  has  properly  healed.  The  special  affections  of  this 
stage  are  certain  skin  eruptions,  gummatous  growths  in  the  viscera,  and 
amyloid  degenerations. 

(a)  The  late  syphilides  show  a  greater  tendency  to  ulceration  and  de- 
struction of  the  deeper  layers  of  the  skin,  so  that  in  healing  scars  are  left. 
They  are  also  more  scattered  and  seldom  symmetrical.  One  of  the  most 
characteristic  of  the  tertiary  syphilides  is  rupia,  the  dry  stratified  crusts 
of  which  cover  an  ulcer  which  involves  the  deeper  layers  of  the  skin  and 
in  healing  leaves  a  scar. 

(&)  Gummata. — These  may  develop  in  the  skin,  subcutaneous  tissue, 
muscles,  or  internal  organs.  The  general  character  has  been  already  de- 
scribed. When  they  develop  in  the  skin  they  tend  to  break  down  and 
ulcerate,  leaving  ugly  sores  which  heal  with  difficulty.  In  the  solid  organs 
they  undergo  fibroid  transformation  and  produce  puckering  and  deformity. 


242  SPECIFIC  INFECTIOUS  DISEASES. 

On  the  mucous  membranes  these  tertiary  lesions  lead  to  ulceration,  in  the 
healing  of  which  cicatrices  are  formed;  thus,  in  the  larynx  great  narrow- 
ing may  result,  and  in  the  rectum  ulceration  with  fibroid  thickening  and 
retraction  may  lead  to  stricture.     Gummatous  ulcers  may  be  infective. 

(c)  Amyloid  Degeneration. — Syphilis  plays  a  most  important  role  in 
the  production  of  this  affection.  Of  244  instances  analyzed  by  Fagge,  76 
had  syphilis,  and  of  these  43  had  no  bone  lesions.  It  follows  the  acquired 
form  and  is  very  common  in  association  with  rectal  syphilis  in  women.  In 
congenital  lues  amyloid  degeneration  is  rare. 

(d)  Para-  or  Metasyphilitic  Affections. — Certain  disorders  not  actually 
syphilitic,  yet  so  closely  connected  that  a  large  proportion  of  the  cases  have 
had  the  disease,  are  termed  by  Fournier  parasyphilitic  (Les  Affections 
Parasyphilitiques,  1894).  These  affections  are  not  exclusively  and  neces- 
sarily caused  by  syphilis,  and  they  are  not  influenced  by  specific  treatment. 
The  chief  of  them  are  locomotor  ataxia,  dementia  paralytica,  certain  types 
of  epilepsy,  and,  we  may  add,  arterio-sclerosis. 

III.  Congenital  Syphilis. 

With  the  exception  of  the  primary  sore,  every  feature  of  the  acquired 
disease  may  be  seen  in  the  congenital  form. 

The  intra-uterine  conditions  leading  to  the  death  of  the  foetus  do  not 
here  concern  us.  The  child  may  be  born  healthy-looking,  or  with  well- 
marked  evidences  of  the  disease.  In  the  majority  of  instances  the  former 
is  the  case,  and  within  the  first  month  or  two  the  signs  of  the  disease 
appear. 

Symptoms. — (a)  At  Birth. — When  the  disease  exists  at  birth  the  child 
is  feebly  developed  and  wasted,  and  a  skin  eruption  is  usually  present, 
commonly  in  the  form  of  bullae  about  the  wrists  and  ankles,  and  on  the 
hands  and  feet  (pemphigus  neonatorum).  The  child  snuffles,  the  lips  are 
ulcerated,  the  angles  of  the  mouth  fissured,  and  there  is  enlargement  of 
the  liver  and  spleen.  The  bone  symptoms  may  be  marked,  and  the  epiphy- 
ses may  even  be  separated.  In  such  cases  the  children  rarely  survive 
long. 

(6)  Early  Manifestations. — When  born  healthy  the  child  thrives,  is  fat 
and  plump,  and  shows  no  abnormity  whatever;  then  from  the  fourth  to 
the  eighth  week,  rarely  later,  a  nasal  catarrh  develops,  syphilitic  rhinitis, 
which  impedes  respiration,  and  produces  the  characteristic  symptom  which 
has  given  the  name  snuffles  to  the  disease.  The  discharge  may  be  sero- 
purulent  or  bloody.  The  child  nurses  with  great  difficulty.  In  severe  cases 
ulceration  takes  place  with  necrosis  of  the  bone,  leading  to  a  depression 
at  the  root  of  the  nose  and  a  deformity  characteristic  of  congenital  syphilis. 
This  coryza  may  be  mistaken  at  first  for  an  ordinary  catarrh,  but  the  co- 
existence of  other  manifestations  usually  makes  the  diagnosis  clear.  The 
disease  may  extend  into  the  Eustachian  tubes  and  middle  ears  and  lead 
to  deafness. 

The  cutaneous  lesions  develop  with  or  shortly  after  the  onset  of  the 
snuffles.    The  skin  often  has  a  sallow,  earthy  hue.    The  eruptions  are  first 


SYPHILIS.  243 

noticed  about  the  nates.  There  may  be  an  erythema  or  an  eczematous 
condition,  but  more  commonly  there  are  irregular  reddish-brown  patches 
with  well-defined  edges.  A  papular  syphilide  in  this  region  is  by  no  means 
uncommon.  Fissures  develop  about  the  lips,  either  at  the  angles  of  the 
mouth  or  in  the  median  line.  These  rhagades,  as  they  are  called,  are  very 
characteristic.  There  may  be  marked  ulceration  of  the  muco-cutaneous 
surfaces.  The  secretions  from  these  mouth  lesions  are  very  virulent,  and 
it  is  from  this  source  that  the  wet-nurse  is  usually  infected.  Not  only  the 
nurse,  but  members  of  the  family,  may  be  contaminated.  There  are  in- 
stances in  which  other  children  have  been  accidentally  inoculated  from 
a  syphilitic  infant.  The  hair  of  the  head  or  of  the  eyebrows  may  fall  out. 
The  syphilitic  onychia  is  not  uncommon.  Enlargement  of  the  glands  is 
not  so  frequent  in  the  congenital  as  in  the  acquired  disease.  When  the 
cutaneous  lesions  are  marked,  the  contiguous  glands  can  usually  be  felt. 
As  pointed  out  by  Gee,  the  spleen  is  enlarged  in  many  cases.  The  condi- 
tion may  persist  for  a  long  time.  Enlargement  of  the  liver,  though  often 
present,  is  less  significant,  since  in  infants  it  may  be  due  to  various  causes. 
These  are  among  the  most  constant  symptoms  of  congenital  syphilis,  and 
usually  develop  between  the  third  and  twelfth  weeks.  Frequently  they 
are  preceded  by  a  period  of  restlessness  and  wakefulness,  particularly  at 
night.  Some  authors  have  described  a  peculiar  syphilitic  cry,  high-pitched 
and  harsh.  Among  rarer  manifestations  are  haemorrhages — the  syphilis 
hcemorrhagica  neonatorum.  The  bleeding  may  be  subcutaneovis,  from  the 
mucous  surfaces,  or,  when  early,  from  the  umbilicus.  All  of  such  cases, 
however,  are  not  syphilitic,  and  the  disease  must  not  be  confounded  with 
the  acute  hsemoglobinuria  of  new-born  infants,  which  Winckel  describes 
as  occurring  in  epidemic  form,  and  which  is  probably  an  acute  infectious 
disorder. 

(c)  Late  Manifestations. — Children  with  congenital  syphilis  rarely 
thrive.  Usually  they  present  a  wizened,  wasted  appearance,  and  a  pre- 
maturely aged  face.  In  the  cases  which  recover,  the  general  nutrition 
may  remain  good  and  the  child  may  show  no  further  manifestations  of 
tke  disease;  commonly,  however,  at  the  period  of  second  dentition  or  at 
puberty  the  disease  reappears.  Although  the  child  may  have  recovered 
from  the  early  lesions,  it  does  not  develop  like  other  children.  Growth  is 
slow,  development  tardy,  and  there  are  facial  and  cranial  characteristics 
which  often  render  the  disease  recognizable  at  a  glance.  A  young  man  of 
nineteen  or  twenty  may  neither  look  older  nor  be  more  developed  than  a 
boy  of  ten  or  twelve.  Fournier  describes  this  condition  as  infantilism. 
The  forehead  is  prominent,  the  frontal  eminences  are  marked,  and  the 
skull  may  be  very  asymmetrical.  The  bridge  of  the  nose  is  depressed,  the 
tip  retrousse.  The  lips  are  often  prominent,  and  there  are  striated  lines 
running  from  the  corners  of  the  mouth.  The  teeth  are  deformed  and  may 
present  appearances  which  Jonathan  Hutchinson  claims  are  specific  and 
peculiar.  The  upper  central  incisors  of  the  permanent  set  are  the  teeth 
which  give  information.  The  specific  alterations  are — the  teeth  are  peg- 
shaped,  stunted  in  length  and  breadth,  and  narrower  at  the  cutting  edge 
than  at  the  root.    On  the  anterior  surface  the  enamel  is  well  formed,  and 


244  SPECIFIC  INFECTIOUS  DISEASES. 

not  eroded  or  honeycombed.  At  the  cutting  edge  there  is  a  single  notch, 
usually  shallow,  sometimes  deep,  in  which  the  dentine  is  exposed. 

Among  late  manifestations,  particularly  apt  to  appear  about  puberty, 
is  the  interstitial  Jceratitis,  which  usually  begins  as  a  slight  steaminess  of 
the  cornese,  which  present  a  ground-glass  appearance.  It  affects  both  eyes, 
though  one  is  attacked  before  the  other.  It  may  persist  for  months,  and 
usually  clears  completely,  though  it  may  leave  opacities,  which  prevent 
clear  vision.  Iritis  may  also  occur.  Of  ear  affections,  apart  from  those 
which  develop  as  a  sequence  of  the  pharyngeal  disease,  a  form  occurs  about 
the  time  of  puberty  or  earlier,  in  which  deafness  comes  on  rapidly  and  per- 
sists in  spite  of  all  treatment.  It  is  unassociated  with  obvious  lesions, 
and  is  probably  labyrinthine  in  character.  Bone  lesions,  occurring  oftenest 
after  the  sixth  year,  are  not  rare  among  the  late  manifestations  of  hereditary 
syphilis.  The  tibiae  are  most  frequently  attacked.  It  is  really  a  chronic 
gummatous  periostitis,  which  gradually  leads  to  great  thickening  of  the 
bone.  The  nodes  of  congenital  syphilis,  which  are  often  mistaken  for 
rickets,  are  more  commonly  diffuse  and  affect  the  bones  of  the  upper  and 
lower  extremities.  They  are  generally  symmetrical  and  rarely  painful. 
They  may  develop  late,  even  after  the  twenty-first  year. 

Joint  lesions  are  rare.  Glutton  has  described  a  sjTiimetrical  synovitis 
of  the  knee  in  hereditary  syphilis.  Enlargement  of  the  spleen,  sometimes 
with  the  lymph-glands,  may  be  one  of  the  late  manifestations,  and  may 
occur  either  alone  or  in  connection  with  disease  of  the  liver. 

Gummata  of  the  liver,  brain,  and  kidneys  have  been  found  in  late 
hereditary  syphilis. 

Is  syphilis  transmitted  to  the  third  generation?  The  general  opinion 
is  that  the  recorded  cases  scarcely  stand  criticism.  Occasionally,  however, 
cases  of  pronounced  congenital  syphilis  are  met  with  in  the  children  of 
parents  who  are  perfectly  healthy,  and  who  have  not,  so  far  as  is  known, 
had  syphilis,  and  yet,  as  remarked  by  Goutts,  who  reported  such  a  group 
of  cases,  they  do  not  bear  careful  scrutiny.  This  is  the  opinion  of  the  lead- 
ing syphilographers.  Personally,  I  have  never  met  with  even  a  suspicious 
instance.  On  the  other  hand,  I  know  now  a  number  of  perfectly  healthy 
children,  one  of  whose  grandfathers  was  syphilitic. 

IV.  VisCekal  Syphilis. 

A.  Syphilis  of  the  Brain  and  Cord. — The  following  lesions  occur: 
(1)  Gummata,  forming  definite  tumors,  ranging  in  size  from  a  pea  to 
a  walnut.  They  are  usually  multiple  and  attached  to  the  pia  mater,  some- 
times to  the  dura.  Very  rarely  they  are  found  unassociated  with  the  me- 
ninges. When  small  they  present  a  uniform,  translucent  appearance,  but 
when  large  the  centre  undergoes  a  fibro-caseous  change,  while  at  the 
periphery  there  is  a  firm,  translucent,  grayish  tissue.  They  may  closely 
resemble  large  tuberculous  tumors.  The  growths  are  most  common  in  the 
cerebrum.  They  may  be  multiple  and  may  even  attain  a  considerable  size 
without  becoming  caseous.  Occasionally  gummata  undergo  cystic  degen- 
eration.    In  the  cord  large  gummatous  growths  are  not  so  common.     Ia 


SYPHILIS.  245 

an  instance  recently  reported  by  me  a  tumor,  from  three  eighths  to  one 
fourth  of  an  inch  in  diameter,  was  completely  within  the  cord  opposite 
the  fourth  cervical  nerve,  and  there  were  numerous  gummata  in  the  cauda 
equina. 

(2)  Gummatous  Meningitis. — This  constantly  occurs  in  the  neighbor- 
hood of  the  larger  growths,  and  there  may  be  local  meningeal  thickening 
several  centimetres  in  extent,  in  which  the  pia  is  infiltrated  and  the  arteries 
greatly  thickened.  This  by  no  means  uncommon  form  may  run  a  subacute 
or  a  chronic  course. 

(3)  Gummatous  Arteritis. — The  lesions  may  be  confined  to  the  arteries 
which  present  the  nodular  tumors  to  be  described  hereafter. 

(4:)  Foci  of  sclerosis,  which  Lancereaux  holds  may  be  distinguished  from 
non-specific  forms  by  a  much  greater  tendency  of  the  neuroglia  elements 
to  undergo  fatty  transformation,  and  by  the  secondary  alterations,  as  areas 
of  softening,  which  occur  in  the  neighborhood.  Neither  the  diffuse  nor 
the  nodular  cerebral  sclerosis,  met  with  particularly  in  children,  appears 
to  have  any  special  relation  to  inherited  syphilis. 

(5)  "Whether  a  localized  encephalitis  or  myelitis  can  result  fi"om  the 
action  of  the  syphilitic  poison  without  involvement  of  the  blood-vessels  is 
doubtful.  In  a  case  of  multiple  arterial  gummata  recently  in  my  ward, 
Thomas  found  in  the  lumbar  region  of  the  cord  foci  of  inflammatory  soft- 
ening. 

Secondary  Changes. — In  the  brain  gummatous  arteritis  is  one  of  the 
common  causes  of  softening,  which  may  be  extensive,  as  when  the  middle 
cerebral  artery  is  involved,  or  when  there  is  a  large  patch  of  syphilitic 
meningitis.  In  such  instances  the  process  is  really  a  meningo-encepha- 
litis,  and  the  symptoms  are  due  to  the  secondary  changes  in  the  brain-sub- 
stance, not  directly  to  the  gumma.  In  the  neighborhood  of  a  gummatous 
growth  intense  encephalitis  or  myelitis  may  develop,  and  within  a  few  days 
change  the  clinical  picture.  Gummatous  arteritis  may  lead  to  weakening 
of  the  wall  of  the  vessel  and  rupture  with  meningeal  haemorrhage. 

Syphilitic  disease  of  the  nerve-centres  may  occur  in  the  inherited  or 
acquired  form,  more  commonly  in  the  latter.  In  the  congenital  cases  the 
tumors  usually  develop  early,  but  may  be  as  late  as  the  twenty-first  year 
(H.  C.  Wood).  In  the  acquired  form  the  nerve  lesions  belong,  as  a  rule, 
to  the  late  manifestations,  and  patients  may  have  quite  forgotten  the  ex- 
istence of  a  primary  infection,  and  in  very  many  instances  the  secondary 
manifestations  have  been  slight.  Heubner,  to  whom  we  owe  so  much  in 
connection  with  this  subject,  has  seen  them  as  late  as  the  thirtieth  year. 
On  the  other  hand,  in  exceptional  instances,  they  may  occur  very  early,  and 
severe  convulsions  with  hemiplegia  have  been  reported  within  three  months 
of  the  primary  sore.  The  great  frequency  of  syphilis  of  the  brain  and  spinal 
cord  suggests  laxity  on  the  part  of  the  general  practitioner  in  the  treatment 
of  the  primary  disease.  For  the  most  complete  account  in  the  literature 
consult  Nonne's  splendid  monograph  (1902). 

Symptoms. — The  chief  features  of  cerebral  syphilis  are  those  of  tumor, 
which  will  be  considered  subsequently  under  that  section.  They  may  be 
classified  here  as  follows: 


246  SPECIFIC  INFECTIOUS  DISEASES. 

(1)  Psychical  features.  A  sudden  and  violent  onset  of  delirium  may 
be  the  first  symptom.  In  other  instances  prior  to  the  occurrence  of  de- 
lirium there  have  been  headache,  alteration  of  character,  and  loss  of  mem- 
ory. The  condition  may  be  accompanied  by  convulsions.  There  may  be  no 
neuritis,  no  palsy,  and  no  localizing  symptoms. 

(2)  More  commonly  following  headache,  giddiness,  or  an  excited  state 
which  may  amount  to  delirium,  the  patient  has  an  epileptic  seizure  or 
develops  hemiplegia,  or  there  is  involvement  of  the  nerves  of  the 
base.  Some  of  these  cases  display  a  prolonged  torpor,  a  special  feature  of 
brain  syphilis  to  which  both  Buzzard  and  Heubner  have  referred,  which 
may  persist  for  as  long  as  a  month.  H.  C.  Wood  describes  with  this 
a  state  of  automatism  occurring  particularly  at  night,  in  which  the 
patient  behaves  like  a  "  restless  nocturnal  automaton  rather  than  a 
man.'^ 

(3)  A  clinical  picture  of  general  paralysis — dementia  paralytica.  The 
question  is  still  in  dispute  whether  this  syphilitic  encephalopathy,  which 
so  closely  resembles  general  paralysis,  is  a  distinct  and  independent  affec- 
tion. Mickle,  who  has  carefully  reviewed  the  subject,  concludes  that 
syphilis  may  directly  produce  the  inflammatory  changes  in  the  brain,  while 
in  other  instances  it  directly  predisposes  to  this  affection.  It  is  a  some- 
what remarkable  feature  that  the  cases  which  present  the  clinical  picture 
of  general  paresis  are  most  frequently  those  which  have  not  had  any  local- 
izing symptoms,  and  they  may  not  have  convulsions  until  the  disease  is 
well  advanced. 

(4)  Many  cases  of  cerebral  syphilis  display  the  symptoms  of  brain 
tumor — headache,  optic  neuritis,  vomiting,  and  convulsions.  Of  these 
symptoms  convulsions  are  the  most  important,  and  both  Fournier  and 
Wood  have  laid  great  stress  on  the  value  of  this  symptom  in  persons  over 
thirty.  The  first  symptoms  may,  however,  rather  resemble  those  of  em- 
bolism or  thrombosis;  thus  there  may  be  sudden  hemiplegia,  with  or  with- 
out loss  of  consciousness. 

The  symptoms  of  spinal  syphilis  are  extremely  varied  and  may  be 
caused  by  large  gummatous  growths  attached  to  the  meninges,  in  which 
case  the  features  are  those  of  tumor;  by  gummatous  arteritis  with  second- 
ary softening;  by  meningitis  with  secondary  cord  changes;  or  by  scleroses 
developing  late  in  the  disease,  the  relation  of  which  to  syphilis  is  still  ob- 
scure. Erb's  syphilitic  myelitis  will  be  considered  under  the  spastic  para- 
plegias. 

Diagnosis. — The  history  is  of  the  first  importance,  but  it  may  be  ex- 
tremely difficult  to  get  a  reliable  account.  Careful  examination  should  be 
made  for  traces  of  the  primary  sore,  for  the  cicatrices  of  bubo,  for  scars  of 
the  skin  eruption  or  throat  ulcers,  and  for  bone  lesions.  The  character 
of  the  symptoms  is  often  of  great  assistance.  They  are  multiform,  vari- 
able, and  often  such  as  could  not  be  explained  by  a  single  lesion;  thus 
there  may  be  anomalous  spinal  symptoms  or  involvement  of  the  nerves  of 
the  brain  on  both  sides.  And  lastly  the  result  of  treatment  has  a  definite 
bearing  on  the  diagnosis,  as  the  symptoms  may  clear  up  and  disappear  with 
the  use  of  antisyphilitic  remedies. 


SYPHILIS.  247 

B.  S3rpliilis  of  the  Lung. 

This  is  a  very  rare  disease.  During  twenty-five  years  I  have  not  seen 
more  than  half  a  dozen  specimens  in  which  there  was  no  question  as  to  the 
nature  of  the  trouble.  Fowler  states  that  he  has  recently  visited  the  muse- 
ums of  the  London  hospitals  and  at  the  Eoyal  College  of  Surgeons,  and  can 
find  only  twelve  specimens  illustrating  syphilitic  lesions  of  the  lungs,  two 
of  which  are  doubtful.  For  the  most  full  and  satisfactory  consideration 
of  pulmonary  syphilis,  the  reader  is  referred  to  chapter  xxxvii  of  Fowler 
and  Godlee's  work  on  Diseases  of  the  Lungs. 

Etiology  and  Morbid  Anatomy. — Syphilis  of  the  lung  occurs  under  the 
following  forms: 

(1)  The  white  pneumonia  of  the  foetus.  This  may  affect  large  areas  or 
an  entire  lung,  which  then  is  firm,  heavy,  and  airless,  even  though  the 
child  may  have  been  born  alive.  On  section  it  has  a  grayish-white  appear- 
ance— the  so-called  white  hepatization  of  Virchow.  The  chief  change  is 
in  the  alveolar  walls,  which  are  greatly  thickened  and  infiltrated,  so  that, 
as  Wagner  expressed  it,  the  condition  resembles  a  diffuse  syphiloma.  In 
the  early  stages,  for  example,  in  a  seven  or  eight  months'  foetus,  there  may 
be  scattered  miliary  foci  of  this  induration  chiefly  about  the  arteries.  The 
air-cells  are  filled  with  desquamated  and  swollen  epithelium. 

(2)  In  the  form  of  definite  gummata,  which  vary  in  size  from  a  pea  to 
a  goose-egg.  They  occur  irregularly  scattered  through  the  lung,  but,  as 
a  rule,  are  more  numerous  toward  the  root.  They  present  a  grayish-yellow 
caseous  appearance,  are  dry  and  usually  imbedded  in  a  translucent,  more 
or  less  firm,  connective  tissue.  In  a  case  from  my  wards  described  by 
Councilman,  there  was  extensive  involvement  of  the  root  of  the  lungs. 
Bands  of  connective  tissue  passed  inward  from  the  thickened  pleura  and 
between  these  strands  and  surrounding  the  gummata  there  was  in  places 
a  mottled  red  pneumonic  consolidation.  In  the  caseous  nodules  there  is 
typical  hyaline  degeneration.  Councilman  describes  as  the  primary  lesion, 
atrophy  of  the  alveolar  walls  with  hyaline  degeneration  of  the  capillaries; 
not  the  syphilitic  endarteritis,  which  is  well  marked,  and  to  which  the 
lesions  are  attributed.  The  bronchi  are  usually  involved,  and  surrounding 
the  gummata  there  may  be  a  diffuse  broncho-pneumonia,  which  does  not 
appear  to  have  any  peculiar  characters. 

(3)  A  majority  of  authors  follow  Virchow  in  recognizing  the  fibrous 
interstitial  pneumonia  at  the  root  of  the  lung  and  passing  along  the  bron- 
chi and  vessels  as  probably  syphilitic.  This  much  may  be  said,  that  in  cer- 
tain cases  gummata  are  associated  with  these  fibroid  changes.  Again,  this 
condition  alone  is  found  in  persons  with  well-marked  syphilitic  history  or 
with  other  visceral  lesions.  It  seems  in  many  instances  to  be  a  purely 
sclerotic  process,  advancing  sometimes  from  the  pleura,  more  commonly 
from  the  root  of  the  lung,  and  invading  the  interlobular  tissue,  gradually 
producing  a  more  or  less  extensive  fibroid  change.  It  rarely  involves  more 
than  a  portion  of  a  lobe  or  portions  of  the  lobes  at  the  root  of  the  limg. 
The  bronchi  are  often  dilated. 

Symptoms. — Is  there  a  syphilitic  phthisis,  an  ulcerative  and  destructive 
disease,  due  to  lues?     Personally  I  have  no  knowledge  of  such  an  affec- 


248  SPECIFIC  INFECTIOUS  DISEASES. 

tion^  either  clinically  or  anatomically,  and  the  cases  which  I  have  seen 
demonstrated  do  not  seem  to  me  to  have  characters  distinctive  enough  to 
separate  them  from  ordinary  tuberculous  phthisis.  Certain  French  writers 
recognize  not  only  a  chronic  syphilitic  phthisis  but  an  acute  syphilitic 
pneumonia  in  adults,  simulating  acute  pneumonic  phthisis.  Clinically, 
pulmonary  syphilis  is  not  of  much  importance,  as  the  cases  can  rarely  be 
diagnosed,  and  the  symptoms  which  arise  are  usually  those  of  bronchi- 
ectasis or  of  chronic  interstitial  pneumonia.  The  white  pneumonia  is  usu- 
ally found  in  the  still-born. 

Diagnosis. — It  is  to  be  borne  in  mind,  in  the  first  place,  that  hospital 
physicians'  and  pathologists  the  world  over  bear  witness  to  the  extreme 
rarity  of  lung  syphilis.  In  the  second  place,  the  therapeutic  test  upon 
which  so  much  reliance  is  placed  is  by  no  means  conclusive.  With  pul- 
monary tuberculosis  there  should  now  be  no  confusion,  owing  to  the  readi- 
ness with  which  the  presence  of  bacilli  is  determined.  Bronchiectasy  in 
the  lower  lobe  of  a  lung,  dependent  upon  an  interstitial  pneumonia  of 
syphilitic  origin,  could  not  be  distinguished  from  any  other  form  of  the 
disease.  In  persons  with  well-marked  syphilitic  lesions  elsewhere,  when 
obscure  pulmonary  symptoms  occur,  or  if  there  are  signs  of  chronic  inter- 
stitial pneumonia  with  dilated  bronchi,  and  no  tubercle  bacilli  are  present,, 
the  condition  may  possibly  be  due  to  syphilis.  So  far  as  my  experience 
goes,  tuberculous  phthisis  occurring  in  a  syphilitic  subject  has  no  special 
peculiarities.  The  lesions  of  syphilis  and  tuberculosis  could  of  course  co- 
exist in  a  lung. 

c.  Syphilis  of  the  Liver. 

This  occurs  in  three  forms:  (a)  Diffuse  SypJiilitic  Hepatitis. — This  is 
most  common  in  cases  of  congenital  syphilis.  The  liver  preserves  its  form, 
is  large,  hard,  and  resistant.  Sometimes  it  has  a  yellow  look,  compared 
by  Trousseau  to  sole-leather,  or  an  appearance  not  unlike  the  amyloid 
liver.  Careful  inspection  shows  grayish  or  whitish  points  and  lines  cor- 
responding to  the  interlobular  new  growth.  Microscopically,  great  increase 
in  the  connective  tissue  is  seen,  and  in  many  places  foci  of  small-celled 
infiltration.  Sometimes  these  nodules  are  visible,  forming  firm  miliary 
gummata  which  in  cicatrizing  produce  more  or  less  deformity.  Larger 
gummata  may  also  be  present. 

(h)  Gummata. — ^As  a  result  of  congenital  syphilis  these  may  occur  in 
childhood  or  in  adult  life.  In  acquired  syphilis  they  rarely  come  on  before 
the  second  year  after  infection.  In  the  early  stage  there  are  pale  grayish 
nodules,  varying  in  size  from  a  pea  to  a  marble.  The  larger  present  yellow- 
ish centres  at  first;  but  later  there  is  a  "  pale  yellowish,  cheese-like  nodule 
of  irregular  outline,  surrounded  by  a  fibrous  zone,  the  outer  edge  of  which 
loses  itself  in  the  lobular  tissue,  the  lobules  dwindling  gradually  in  its  grasp. 
This  fibrous  zone  is  never  very  broad;  the  cheesy  centre  varies  in  consist- 
ence from  a  gristle-like  toughness  to  a  pulpy  softness;  it  is  sometimes 
mortar-like,  from  cretaceous  change  "  ("Wilks).  When  numerous,  the  most 
extensive  deformity  of  the  liver  is  produced  in  the  gradual  healing  of  these 
gummata.  On  the  surface  there  are  deep,  scar-like  depressions,  and  the  en- 
tire organ  may  be  divided  into  a  cluster  of  irregular  masses,  held  together  by 


SYPHILIS.  249 

fibrous  tissue.  To  this  condition  tlie  term  hotyroid  has  been  given,  from 
its  resemblance  to  a  bunch  of  grapes.  As  a  rule,  the  gummata  graduall}' 
undergo  fibroid  transformation.  They  may,  however,  soften  and  liquefy, 
and,  according  to  Wilks,  may  form  a  fluctuating  tumor. 

(c)  Occasionally  the  syphilitic  changes  are  chiefly  manifested  in  Glis- 
son's  sheath,  in  a  thickening  of  the  capsule,  producing  perihepatitis,  and 
increase  in  the  connective  tissue  in  the  portal  canals,  so  that  on  section 
the  organ  presents  a  number  of  branching  fibrous  scars  which  may  cause 
considerable  deformity. 

Symptoms. — The  symptoms  of  syphilitic  hepatitis  are  very  variable. 
In  the  new-born  icterus  is  not  uncommon,  but  the  condition  of  the  liver 
can  scarcely  be  recognized.    In  the  adult  there  are  three  groups  of  cases: 

The  patient  presents  a  picture  of  cirrhosis  of  the  liver;  there  are  di- 
gestive disturbances,  slight  icterus,  loss  of  weight,  and  ascites.  If  signs 
of  syphilis  are  present  in  other  organs,  the  condition  may  be  suspected, 
or  if  after  removal  of*  the  fluid  the  liver  is  felt  to  be  extremely  irregular, 
the  diagnosis  may  be  made  almost  with  certainty.  These  cases  are  com- 
mon, and  with  proper  treatment  get  well;  they  form  an  important  con- 
tingent of  the  reputed  recoveries  in  ordinary  cirrhosis  of  the  liver. 

In  a  second  group  of  cases  the  patient  is  anaemic,  passes  large  quan- 
tities of  pale  urine  containing  albumin  and  tube-casts;  the  liver  is  en- 
larged, perhaps  irregular,  and  the  spleen  also  is  enlarged.  Dropsical  symp- 
toms may  supervene,  or  the  patient  may  be  carried  off  by  some  intercurrent 
disease.  Extensive  amyloid  degeneration  of  the  spleen,  the  intestinal  mu- 
cosa, and  of  the  liver,  with  gummata,  are  found. 

Thirdly,  the  gummata  may  form  an  irregular  tumor  on  the  right  or 
left  lobe,  perhaps  with  very  few  or  very  obscure  symptoms.  The  diagnosis 
may  be  doubtful  until  some  other  evidence  of  syphilis  develops.  I  have 
recorded  several  illustrative  cases  in  my  Lectures  on  Abdominal  Tumors. 

The  diagnosis  of  syphilis  of  the  liver  is  very  important,  since  upon  it 
the  proper  treatment  depends.  If  with  a  history  of  infection  the  liver 
is  enlarged  and  irregular,  and  the  general  health  fairly  good,  the  condi- 
tion is  probably  syphiloma. 

D.  Syphilis  of  the  Digestive  Tract. 

The  oesophagus  is  very  rarely  affected.  Stenosis  is  the  usual  result. 
Syphilis  of  the  stomach  is  excessively  rare.  Flexner  has  reported  a  remark- 
able case  in  association  with  gummata  of  the  liver.  He  has  collected  14 
cases  in  the  literature.  Syphilitic  ulceration  has  been  found  in  "the  small 
intestine  and  in  the  caecum. 

The  most  common  seat  of  syphilitic  disease  in  this  tract  is  the  rectum. 
The  affection  is  found  most  commonly  in  women,  and  results  from  the 
development  of  gummata  in  the  submucosa  above  the  internal  sphincter. 
The  process  is  slow  and  tedious,  and  may  last  for  years  before  it  finally 
induces  stricture.  The  symptoms  are  usually  those  of  narrowing  of  the 
lower  bowel.  The  condition  is  readily  recognized  by  rectal  examination. 
The  history  of  gradual  on-coming  stricture',  the  state  of  the  patient,  and 
the  fact  that  there  is  a  bard,  fibrous  narrowing,  not  an  elevated  crater-like 
ulcer,  usually  render  easy  the  diagnosis  from  malignant  disease.     In  medi- 


250  SPECIFIC  INFECTIOUS  DISEASES. 

cal  practice  these  cases  come  under  observation  for  other  spnptoms,  par- 
ticularly amyloid  degeneration;  and  the  rectal  disease  may  be  entirely  over- 
lookedj  and  only  discovered  post  mortem. 

E.  Circulatory  System. 

Syphilis  of  the  Heart. — A  fresh,  warty  endocarditis  due  to  syphilis  is 
not  recognized,  though  occasionally  in  persons  dead  of  the  disease  this 
form  is  present,  as  is  not  uncommon  in  conditions  of  debility.  Outgrowths 
on  the  valves  in  connection  with  gummata  have  been  reported  by  Janeway 
and  others.  In  a  recent  study  of  the  subject  Loomis  groups  the  lesions 
into:  (1)  Gummata,  recent  or  old;  (2)  fibroid  induration,  localized  or  dif- 
fuse; (3)  amyloid  degeneration;  and  (4)  endarteritis  obliterans.  I.  Adler 
claims  that  changes  in  the  blood-vessels  of  the  walls  of  the  heart  are  com- 
mon both  in  congenital  and  acquired  syphilis,  even  in  cases  without  clin- 
ical symptoms  or  gross  lesions. 

Eupture  may  take  place,  as  in  the  cases  reported  by  Dandridge  and 
Nalty,  or  sudden  death,  as  in  the  cases  of  Cayley  and  Pearce  Gould;  in- 
deed, sudden  death  is  frequent,  occurring  in  21  of  63  cases  (Mracek). 

Syphilis  of  the  Arteries. — Syphilis  is  believed  to  play  an  important  role 
in  arterio-sclerosis  and  aneurism.  Its  connection  with  these  processes  will 
be  considered  later;  here  we  shall  refer  only  to  the  syphilitic  arteritis,  which 
occurs  in  two  forms: 

(a)  An  obliterating  endarteritis,  characterized  by  a  proliferation  of  the 
subendothelial  tissue.  The  new  growth  lies  within  the  elastic  lamina,  and 
may  gradually  fill  the  eiltire  lumen;  hence  the  term  obliterating.  The 
media  and  adventitia  are  also  infiltrated  with  small  cells.  This  form  of 
endarteritis  described  by  Heubner  is  not,  however,  characteristic  of  syphi- 
lis, and  its  presence  alone  in  an  artery  could  not  be  considered  pathog- 
nomonic. If,  however,  there  are  gummata  in  other  parts,  or  if  the  con- 
dition about  to  be  described  exists  in  adjacent  arteries,  the  process  may 
be  regarded  as  syphilitic. 

(h)  Gummatous  Periarteritis. — "With  or  without  involvement  of  the 
intima,  nodular  gummata  may  develop  in  the  adventitia  of  the  artery,  pro- 
ducing globular  or  ovoid  swellings,  which  may  attain  considerable  size. 
They  are  not  infrequently  seen  in  the  cerebral  arteries,  which  seem  to  be 
specially  prone  to  this  affection.  This  form  is  specific  and  distinctive  of 
syphilis.  The  disease  usually  affects  the  smaller  vessels  and  may  be  found 
in  the  coronary  arteries,  and  particularly  in  those  of  the  brain. 

F.  Renal  S3rpllilis. — (a)  Gummata  occasionally  develop  in  the  kidneys, 
particularly  in  cases  in  which  there  is  extensive  gummatous  hepatitis. 
They  are  rarely  numerous,  and  occasionally  lead  to  scattered  cicatrices. 
Clinically  the  affection  is  not  recognizable. 

(h)  Acute  Syphilitic  Nephritis. — This  condition  has  been  carefully 
studied  by  the  French  writers  and  by  Lafleur,  of  Montreal.  It  is  estimated 
to  occur  in  the  secondary  stage  in  about  3.8  per  cent,  and  may  develop  in 
from  three  to  six  months,  sometimes  later,  from  the  initial  lesion.  The 
outlook  is  good,  though  often  the  albuminuria  may  persist  for  months; 
more  rarely  chronic  Bright's  disease  develops.  In  a  few  instances  syph- 
ilitic nephritis  has  proved  rapidly  fatal  in  a  fortnight  or  three  weeks.    The 


SYPHILIS.  251 

lesions  are  not  specific,  but  are  similar  to  those  in  other  acute  infec- 
tions. 

G.  Syphilitic  Orchitis. — This  affection  is  of  special  significance  to  the 
physician,  as  its  detection  frequently  clinches  the  diagnosis  in  obscure 
internal  disorders.     Syphilis  occurs  in  the  testes  in  two  forms: 

(a)  The  gummatous  growth,  forming  an  indurated  mass  or  group  of 
masses  in  the  substance  of  the  organ,  and  sometimes  difficult  to  distin- 
guish from  tuberculous  disease.  The  area  of  induration  is  harder  and  it 
affects  the  body  of  the  testes,  while  tubercle  more  commonly  involves  the 
epididymis.  It  rarely  tends  to  invade  the  skin,  or  to  break  down,  soften, 
and  suppurate,  and  is  usually  painless. 

(i)  There  is  an  interstitial  orchitis  regarded  as  syphilitic,  which  leads 
to  fibroid  induration  of  the  gland  and  gradually  to  atrophy.  It  is  a  slow, 
progressive  change,  coming  on  without  pain,  usually  involving  one  organ 
more  than  another. 

General  Diagnosis  of  Syphilis. — There  is  seldom  any  doubt 
concerning  the  existence  of  syphilitic  lesions.  The  negative  statements 
of  the  patient  must  be  taken  with  extreme  caution,  as  persons  will  lie 
deliberately  with  reference  to  primary  infection,  when  it  is  in  their  best 
interest  to  make  a  straightforward  truthful  statement.  It  is  to  be  remem- 
bered that  syphilis  is  common  in  the  community,  and  there  are  probably 
more  families  with  a  luetic  than  with  a  tuberculous  taint.  It  is  possible 
that  the  primary  sore  may  have  been  of  trifling  extent,  or  urethral  and 
masked  by  a  gonorrhoea,  and  the  patient  may  not  have  had  severe  secondary 
symptoms,  but  such  instances  are  extremely  rare.  Inquiries  should  be 
made  into  the  history  to  ascertain  if  the  patient  has  had  skin  rashes,  sore 
throat,  or  if  the  hair  has  fallen  out.  Careful  inspection  should  be  made 
of  the  throat  and  skin  for  signs  of  old  lesions.  Scars  in  the  groins,  the 
result  of  buboes,  are  uncertain  evidences  of  syphilitic  infection.  The 
cicatrices  on  the  legs  are  often  copper-colored,  though  this  can  not  be 
regarded  as  peculiar  to  syphilis.  The  bones  should  be  examined  for  nodes. 
In  doubtful  cases  the  scar  of  the  primary  sore  may  be  found,  or  there  may 
be  signs  of  atrophy  or  of  hardening  of  the  testes.  In  women,  special  stress 
has  been  laid  upon  the  occurrence  of  frequent  miscarriages,  which,  in  con- 
nection with  other  circumstances,  are  always  suggestive. 

In  the  congenital  disease,  the  occurrence  within  the  first  three  months 
of  snuffles  and  skin  rash  is  conclusive.  Later,  the  characters  of  the  syphi- 
litic facies,  already  referred  to,  often  give  a  clew  to  the  nature  of  some 
obscure  visceral  lesion.  Other  distinctive  features  are  the  symmetrical  de- 
velopment of  nodes  on  the  bones,  and  the  interstitial  keratitis. 

In  doubtful  cases  much  stress  is  laid  by  some  writers  upon  the  thera- 
peutic test,  by  placing  the  patient  upon  antisyphilitic  treatment.  In  the 
case  of  an  obstinate  skin  rash  of  doubtful  character,  which  has  resisted  all 
other  forms  of  medication,  this  has  much  greater  weight  than  in  obscure 
visceral  lesions.  I  have  on  several  occasions  known  such  marked  improve- 
ment to  follow  large  doses  of  iodide  of  potassium  that  the  diagnosis  of 
syphilitic  lesion  was  greatly  strengthened,  but  the  subsequent  course  and 
the  post  mortem  have  shown  that  the  disease  was  not  syphilis. 
16 


252  SPECIFIC  INFECTIOUS  DISEASES. 

Prophylaxis. — Irregular  intercourse  has  existed  from  the  beginning 
of  recorded  history,  and  unless  man's  nature  wholly  changes — and  of  this 
we  can  have  no  hope — will  continue.  Eesisting  all  attempts  at  solution, 
the  social  evil  remains  the  great  blot  upon  our  civilization,  and  inextricably 
blended  with  it  is  the  question  of  the  prevention  of  syphilis.  Two  meas- 
ures are  available — the  one  personal,  the  other  administrative. 
^  Personal  purity  is  the  prophylaxis  which  we,  as  physicians,  are  espe- 
cially bound  to  advocate.  Continence  may  be  a  hard  condition  (to  some 
harder  than  to  others),  but  it  can  be  borne,  and  it  is  our  duty  to  urge  this 
lesson  upon  young  and  old  who  seek  our  advice  in  matters  sexual.  Cer- 
tainly it  is  better,  as  St.  Paul  says,  to  marry  than  to  burn,  but  if  the  former 
is  not  feasible  there  are  other  altars  than  those  of  Venus  upon  which  a 
young  man  may  light  fires.  He  may  practise  at  least  two  of  the  five  means 
by  which,  as  the  physician  Eondibilis  counselled  Panurge,  carnal  concupis- 
cence may  be  cooled  and  quelled — hard  work  of  body  and  hard  work  of 
mind.  Idleness  is  the  mother  of  lechery;  and  a  young  man  will  find  that 
absorption  in  any  pursuit  will  do  much  to  cool  passions  which,  though 
natural  and  proper,  cannot  in  the  exigencies  of  our  civilization  always  ob- 
tain natural  and  proper  gratification. 

The  second  measure  is  a  rigid  and  systematic  regulation  of  prostitu- 
tion. The  state  accepts  the  responsibility  of  guarding  citizens  against 
small-pox  or  cholera,  but  in  dealing  with  syphilis  the  problem  has  been 
too  complex  and  has  hitherto  bafiled  solution.  On  the  one  hand,  inspec- 
tion, segregation,  and  regulation  are  difficult,  if  not  impossible,  to  carry 
out;  on  the  other  hand,  public  sentiment,  in  Anglo-Saxon  communities 
at  least,  is  as  yet  bitterly  opposed  to  this  plan.  While  this  feeling,  though 
unreasonable,  as  I  think,  is  entitled  to  consideration,  the  choice  lies  be- 
tween two  evils — licensing,  even  imperfectly  carried  out,  or  widespread 
disease  and  misery.  If  the  offender  bore  the  cross  alone,  I  would  say, 
forbear;  but  the  physician  behind  the  scenes  knows  that  in  countless  in- 
stances syphilis  has  wrought  havoc  among  innocent  mothers  and  helpless 
infants,  often  entailing  life-long  suffering.  It  is  for  them  he  advocates 
protective  measures. 

Treatment. — We  must  admit  that  various  constitutions  react  very 
differently  to  the  poison  of  syphilis.  There  are  individuals  who,  although 
receiving  brief  and  unsatisfactory  treatment,  display  for  years  no  traces  of 
the  disease.  On  the  other  hand,  there  are  persons  thoroughly  and  sys- 
tematically treated  from  the  outset  who  from  time  to  time  show  well- 
marked  indications  of  syphilis.  Certainly  there  are  grounds  for  the 
opinion  that  persons  who  have  suffered  very  slightly  from  secondary  symp- 
toms are  more  prone  to  have  the  severer  visceral  lesions  of  the  later  stage. 

When  we  consider  that  syphilis  is  one  of  the  most  amenable  of  all  dis- 
eases to  treatment,  it  is  lamentable  that  the  later  stages  which  come  under 
the  charge  of  the  physician  are  so  common.  This  results,  in  great  part, 
from  carelessness  of  the  patient,  who,  wearied  with  treatment,  cannot  un- 
derstand why  he  should  continue  to  take  medicine  after  all  the  symptoms 
have  disappeared;  but,  in  part,  the  profession  also  is  to  blame  for  not 
insisting  more  urgently  in  every  instance  that  acquired  syphilis  is  not  cured  . 


SYPHILIS.  "  253 

in  a  few  months,  but  takes  at  least  two  years,  during  which  time  the  pa- 
tient should  be  under  careful  supervision.  The  treatment  of  the  disease 
is  now  practically  narrowed  to  the  use  of  two  remedies,  justly  termed  spe- 
cifics— namely,  mercury  and  iodide  of  potassium.  The  former  is  of  special 
service  in  the  secondary,  the  latter  in  the  tertiary  manifestations  of  the 
disease;  but  they  are  often  combined  with  advantage. 

Mercury  may  be  given  by  the  mouth  in  the  form  of  gray  powder,  the 
hydrargyrum  cum  creta,  which  Hutchinson  recommends  to  be  given  in 
pills,  one-grain  doses  with  a  grain  of  Dover's  powder.  One  pill  from  four 
to  six  times  a  day  will  usually  suffice.  I  warmly  endorse  the  excellent 
results  which  are  obtained  by  this  method,  under  which  the  patient  often 
gains  rapidly  in  weight,  and  the  general  health  improves  remarkably.  It 
may  be  continued  for  months  without  any  ill  effects.  Other  forms  given 
by  the  mouth  are  the  pilules  of  the  biniodide  (gr.  ■^),  or  of  the  protiodide 
(gr.  \),  three  times  a  day.  "  If  mercury  be  begun  as  soon  as  the  state  of 
the  sore  permits  of  diagnosis,  and  continued  in  small  but  adequate  doses, 
the  patient  will  usually  escape  both  sore  throat  and  eruption  "  (Jonathan 
Hutchinson). 

Inunction  is  a  still  more  effective  means.  A  drachm  of  the  ordinary 
mercurial  ointment  is  thoroughly  rubbed  into  the  skin  every  evening  for 
six  days;  on  the  seventh  a  warm  bath  is  taken,  and  on  the  eighth  the  mer- 
curial course  is  resumed.  At  least  half  an  hour  should  be  given  to  each 
inunction.  It  is  well  to  apply  it  at  different  places  on  successive  days. 
The  sides  of  the  chest  and  abdomen  and  the  inner  surfaces  of  the  arms 
and  thighs  are  the  best  positions. 

The  mercury  may  be  given  by  direct  injection  into  the  muscles.  If 
proper  precautions  are  taken  in  sterilizing  the  syringe,  and  if  the  injec- 
tions are  made  into  the  muscles,  not  into  the  subcutaneous  tissue,  abscesses 
rarely  result.  One  third  of  a  grain  of  the  bichloride  in  twenty  drops  of 
water  may  be  injected  once  a  week,  or  from  one  to  two  grains  of  calomel  in 
glycerin  (20  minims). 

Still  another  method,  greatly  in  vogue  in  certain  parts  of  the  Continent 
and  in  institutions,  is  fumigation.  It  may  be  carried  out  effectively  by 
means  of  Lee's  lamp.  The  patient  sits  on  a  chair  wrapped  in  blankets, 
with  the  head  exposed.  The  calomel  is  volatilized  and  deposited  with  the 
vapor  on  the  patient's  skin.  The  process  lasts  about  twenty  minutes,  and 
the  patient  goes  to  bed  wrapped  in  blankets  without  washing  or  drying  the 
skin.  A  patient  under  mercurial  treatment  should  avoid  stimulants  and 
live  a  regular  life,  not  necessarily  abstaining  from  business.  Green  vege- 
tables and  fruit  should  not  be  taken.  Salivation  is  to  be  avoided.  The 
teeth  should  be  cleansed  twice  a  day,  and  if  the  gums  become  tender,  the 
breath  fetid,  or  the  tongue  swollen  and  indented,  the  drug  should  be  sus- 
pended for  a  week  or  ten  days. 

In  congenital  syphilis  the  treatment  of  cases  born  with  bullae  and  other 
signs  of  the  disease  is  not  satisfactory,  and  the  infants  usually  die  within  a 
few  days  or  weeks.  The  child  should  be  nursed  by  the  mother  alone,  or, 
if  this  is  not  feasible,  should  be  hand-fed,  but  under  no  circumstances 
should  a  wet-nurse  be  employed.     The  child  is  most  rapidly  and  thor- 


254  SPECIFIC  INFECTIOUS  DISEASES. 

oughly  brought  under  the  influence  of  the  drug  by  inunction.  The  mer- 
curial ointment  may  be  smeared  on  the  flannel  roller.  This  is  not  a  very 
cleanly  method,  and  sometimes  rouses  the  suspicion  of  the  mother.  It 
is  preferable  to  give  the  drug  by  the  mouth,  in  the  form  of  gray  powder, 
half  a  grain  three  times  a  day.  In  the  late  manifestations  associated  with 
bone  lesions,  the  combination  of  mercury  and  iodide  of  potassium  is  most 
suitable  and  is  well  given  in  the  form  of  Gilbert's  syrup,  which  consists 
of  the  biniodide  of  mercury  (gr.  j),  of  potassium  iodide  (  §  ss.),  and  water 
(  §  ij).  Of  this  a  dose  for  a  child  under  three  is  from  flve  to  ten  drops  three 
times  a  day,  gradually  increased.  Under  these  measures,  the  cases  of  con- 
genital syphilis  usually  improve  with  great  rapidity.  The  medication 
should  be  continued  at  intervals  for  many  months,  and  it  is  well  to  watch 
these  patients  carefully  during  the  period  of  second  dentition  and  at 
puberty,  and  if  necessary  to  place  them  on  speciflc  treatment. 

In  the  treatment  of  the  visceral  lesions  of  syphilis,  which  come  more 
distinctly  within  the  province  of  the  physician,  iodide  of  potassium  is  of 
equal  or  even  greater  value  than  mercury.  Under  its  use  ulcers  rapidly 
heal,  gummatous  tumors  melt  away,  and  we  have  an  illustration  of  a  spe- 
cific action  only  equalled  by  that  of  mercury  in  the  secondary  stages,  by 
iron  in  certain  forms  of  ansemia,  and  by  quinine  in  malaria.  It  is  as  a 
rule  well  borne  in  an  initial  dose  of  10  grains,  or  10  minims  of  the  saturated 
solution;  given  in  milk  the  patient  does  not  notice  the  taste.  It  should 
be  gradually  increased  to  30  or  more  grains  three  times  a  day.  In  syphilis 
of  the  nervous  system  it  may  be  used  in  still  larger  doses.  Seguin,  who 
specially  insisted  upon  the  advantage  of  this  plan,  urged  that  the  drug 
should  be  pushed,  as  good  effects  were  not  obtained  with  the  moderate  doses. 

When  syphilitic  hepatitis  is  suspected  the  combination  of  mercury  and 
iodide  of  potassium  is  most  satisfactory.  If  there  is  ascites,  Addison's  or 
Niemeyer's  pill  (as  it  is  often  called)  of  calomel,  digitalis,  and  squills  will 
be  found  very  useful.  A  patient  of  mine  with  recurring  ascites,  on  whom 
paracentesis  was  repeatedly  performed  and  who  had  an  enlarged  and  irregu- 
lar liver,  took  this  pill  for  more  than  a  year  with  occasionally  intermissions, 
and  ultimately  there  was-  a  complete  disappearance  of  the  dropsy  and  an 
extraordinary  reduction  in  the,  volume  of  the  liver.  Occasionally  the  iodide 
of  sodium  is  more  satisfactory  than  the  iodide  of  potassium.  It  is  less 
depressing  and  agrees  better  with  the  stomach.  Many  patients  possess  a 
remarkable  idiosyncrasy  to  the  iodide,  but  as  a  rule  it  is  well  borne.  Severe 
coryza  with  salivation,  and  oedema  about  the  eyelids,  are  its  most  common 
disagreeable  effects.  Skin  eruptions  also  are  frequent.  I  have  known  pa- 
tients unable  to  take  more  than  from  20  to  30  grains  without  suffering 
from  an  erythematous  rash;  much  more  common  is  the  acne  eruption. 
Occasionally  an  urticarial  rash  may  develop  with  spots  of  purpura.  Some 
of  these  iodide  eruptions  may  closely  resemble  syphilis.  Hutchinson  has 
reported  instances  in  which  they  have  proved  fatal. 

Upon  the  question  of  syphilis  and  marriage  the  family  physician  is 
often  called  to  decide.  He  should  insist  upon  the  necessity  of  two  full 
years  elapsing  between  the  date  of  infection  and  the  contracting  of  mar- 
riage.   This,  it  should  be  borne  in  mind,  is  the  earliest  possible  limit,  and 


GONORRHGEAL  INFECTION.  255 

there  should  be  at  least  a  yeai^of  complete  immunity  from  all  manifesta- 
tions of  the  disease. 

In  relation  to  life  insurance,  an  individual  with  syphilis  cannot  be  re- 
garded as  a  first-class  risk  unless  he  can  furnish  evidence  of  prolonged  and 
thorough  treatment  and  of  immunity  for  two  or  three  years  from  all  mani- 
festations. Even  then,  when  we  consider  the  extraordinary  frequency  of 
the  cerebral  and  other  complications  in  persons  who  have  had  this  disease 
and  who  may  even  have  undergone  thorough  treatment,  the  risk  to  the 
company  is  certainly  increased. 


XXXIII.    GONORRHCEAL    INFECTION. 

Gonorrhoea,  one  of  the  most  widespread  and  serious  of  infectious  dis- 
eases, presents  many  features  for  consideration.  As  a  cause  of  ill-health 
and  disability  the  gonococcus  occupies  a  position  of  the  very  first  rank 
among  its  fellows.  While  the  local  lesion  is  too  often  thought  to  be  trifling, 
in  its  singular  obstinacy,  in  the  possibilities  of  permanent  sexual  damage 
to  the  individual  himself  and  still  more  in  the  "  grisly  troop  "  which  may 
follow  in  its  train,  gonorrhoeal  infection  does  not  fall  very  far  short  of 
syphilis  in  importance. 

The  immediate  and  remote  effects  of  the  gonococcus  may  be  considered 
under — 

I.  The  primary  infection. 

II.  The  spread  in  the  genito-urinary  organs  by  direct  continuity  of 
surface. 

III.  Systemic  gonorrhoeal  infection. 

I.  The  primary  lesion  we  need  not  here  consider,  but  we  may  call 
attention  to  the  frequency  of  the  complications,  such  as  periurethral  ab- 
scess, gonorrhoeal  prostatitis  in  the  male,  and  vaginitis,  endocervicitis,  and 
inflammation  of  the  glands  of  Bartholin!  in  the  female. 

II.  Perhaps  the  most  serious  of  all  the  sequels  of  gonorrhoea  are  those 
which  result  from  the  spread  by  direct  continuity  of  tissue.  Gonorrhoeal 
salpingitis  has  been  shown  to  be  a  not  infrequent  event.  Metritis  and 
ovaritis  are  also  occasionally  met  with,  and  peritonitis.  Young  and  Gush- 
ing have  found  the  gonococcus  in  pure  culture  in  two  cases  of  acute  general 
peritonitis.  Equally  important  is  the  development  of  cystitis,  which  is 
probably  much  more  frequently  the  result  of  a  mixed  infection  than  due 
to  the  gonococcus  itself.  There  is  some  danger  of  extension  upward  through 
the  ureters  to  the  kidneys.  The  pyelitis,  like  the  cystitis,  is  usually  a  mixed 
infection. 

III.  Systemic  Gonorrhceal  Infection. 

1.  Gonorrhceal  Septiccemia  and  Pyccmia. — The  fever  associated  with  the 
primary  disease  is  not  an  indication  of  a  general  infection,  but  probably 
follows  the  absorption  of  toxines.  The  presence  of  the  gonococcus  has 
been  demonstrated  in  the  blood  in  a  few  cases,  usually  in  connection  with 
some  local  lesion,  as  in  Thayer's  and  Blumer's  case  from  my  wards,  in 


256  SPECIFIC  INFECTIOUS  DISEASES. 

which  the  patient  succumbed  to  an  acute  endocarditis.  Instances  of  se- 
vere, rapidly  fatal  general  infection  in  gonorrhoea  are  probably  always 
associated  with  foci  of  suppuration  in  the  urinary  tract.  I  held  an  autopsy 
in  Montreal  on  a  remarkable  case  of  rapid  gonorrhoeal  sepsis  in  a  young 
man,  who  within  ten  days  of  the  primary  lesion  was  seized  with  severe 
chills  and  high  fever.  He  rapidly  became  unconscious,  the  fever  persisted, 
and  he  fell  into  a  condition  of  profound  toxsemia  and  died  early  on  the 
morning  of  the  fourth  day  from  the  chill.  At  the  autopsy,  which  was  made 
about  twelve  hours  after  death,  there  was  an  acute  urethritis  and  a  small 
prostatic  abscess  not  more  than  3  or  3  cm.  in  diameter.  The  blood  was 
fluid,  tarry  black,  and  unlike  anything  I  have  ever  seen  before  or  since. 

Gonorrheal  Endocarditis. — R.  L.  MacDonnell  found  4  cases  of  endo- 
carditis in  27  instances  of  gonorrhoeal  arthritis.  Two  remarkable  cases 
have  been  reported  from  my  wards  lately  by  Thayer  and  Blumer  and 
Thayer  and  Lazear.  They  are  of  special  interest,  as  in  both  the  gonococci 
were  isolated  from  the  blood  during  life  and  after  death  from  the  affected 
valves.  Thayer  and  Lazear  have  analyzed  30  instances  of  fatal  ulcerative 
endocarditis  in  gonorrhoea.  Of  these,  22  were  in  men,  8  in  women.  As  a 
rule,  the  arthritis  preceded  the  cardiac  affection,  but  in  a  number  of  in- 
stances the  cardiac  complication  occurred  without  or  before  the  develop- 
ment of  joint  symptoms. 

Of  other  cardiac  lesions,  pericarditis  occurred  in  7  of  the  fatal  cases. 
Acute  myocarditis  was  present  in  Councilman's  case. 

2.  Gonorrhoeal  Arthritis. — In  many  respects  this  is  the  most  damaging, 
disabling,  and  serious  of  all  the  complications  of  gonorrhoea.  Clement 
Lucas  has  collected  23  cases  in  children,  of  which  18  followed  ophthalmia 
neonatorum.  It  occurs  more  frequently  in  males  than  in  females.  In  a 
series  of  252  cases  collected  by  ISTorthrup,  230  were  in  males;  130  cases 
were  between  twenty  and  thirty  years  of  age.  It  occurs,  as  a  rule,  during 
an  acute  attack  of  gonorrhoea.  In  208  of  Northrup's  series  there  was  a 
urethral  discharge  while  in  hospital.  It  may  occur  as  the  attack  subsides, 
or  even  when  it  has  become  chronic.  A  gonorrhoeal  arthritis  of  great  inten- 
sity may  develop  in  a  newly  married  woman  infected  by  an  old  gleet  in  her 
husband.  As  a  rule,  many  joints  are  affected.  In  Northrup's  series  three 
or  more  joints  were  affected  in  175  cases,  one  joint  in  56  cases.  It  is  pecul- 
iar in  attacking  certain  joints  which  are  rarely  involved  in  acute  rheuma- 
tism, as  the  sterno-clavicular,  the  intra-vertebral,  the  temporo-maxillary 
and  sacro-iliac. 

The  anatomical  changes  are  variable.  The  inflammation  is  often  peri- 
articular, and  extends  along  the  sheaths  of  the  tendons.  Wlien  effusion 
occurs  in  the  joints  it  rarely  becomes  purulent.  It  has  more  commonly 
the  characters  of  a  synovitis.  About  the  wrist  and  hand  suppuration  some- 
times occurs  in  the  sheaths.  It  has  been  suggested  that  the  simple  arthritis 
or  synovitis  follows  absorption  of  ptomaines  from  the  urethral  discharge, 
while  the  more  severe  suppurating  forms  are  due  to  infection  with  pus  or- 
ganisms. It  has  now  been  definitely  shown  that  the  gonocoeeus  itself  may 
be  present  in  the  inflamed  joint  or  in  the  peri-arthritic  exudate.  Within 
the  past  eighteen  months  Young  has  obtained  the  gonocoeeus  in  pure  cul- 


GONORRHCEAL  INFECTION.  257 

ture  in  7  cases  of  gonorrhoeal  arthritis  in  the  Johns  Hopkins  Hospital. 
Sometimes  the  cultures  are  negative;  in  other  instances  there  is  a  mixed 
infection  with  staphylococci  or  streptococci. 

Clinical  Course. — Variability  and  obstinacy  are  the  two  most  dis- 
tinguishing features.    The  following  are  the  most  important  clinical  forms: 

(a)  Arthralgic,  in  which  there  are  wandering  pains  about  the  Joints, 
without  redness  or  swelling.    These  persist  for  a  long  time. 

(h)  Polyarthritic,  in  which  several  joints  become  affected,  just  as  in 
subacute  articular  rheumatism.  The  fever  is  slight;  the  local  inflamma- 
tion may  fix  itself  in  one  joint,  but  more  commonly  several  become  swollen 
and  tender.    In  this  form  cerebral  and  cardiac  complications  may  occur. 

(c)  Acute  gonorrhoeal  arthritis,  in  which  a  single  articulation  becomes 
suddenly  involved.  The  pain  is  severe,  the  swelling  extensive,  and  due 
chiefly  to  peri-articular  oedema.  The  general  fever  is  not  at  all  proportion- 
ate to  the  intensity  of  the  local  signs.  The  exudate  usually  resolves, 
though  suppuration  occasionally  supervenes. 

(d)  Chronic  Hydrarthrosis. — This  is  usually  mono-articular,  and  is  par- 
ticularly apt  to  involve  the  knee.  It  comes  on  often  without  pain,  redness, 
or  swelling.  Formation  of  pus  is  rare.  It  occurred  only  twice  in  96  cases 
tabulated  by  Nolen. 

(e)  Bursal  and  Synovial  Form. — This  attacks  chiefly  the  tendons  and 
their  sheaths  and  the  bursee  and  the  periosteum.  The  articulations  may 
not  be  affected.  The  burs^  of  the  patella,  the  olecranon,  and  the  tendo 
Achillis  are  most  apt  to  be  involved. 

(/)  Septicemic. — In  which  with  an  acute  arthritis  the  gonococci  invade 
the  blood,  and  the  picture  is  that  of  an  intense  septico-pygemia,  usually 
with  endocarditis. 

The  disease  is  much  more  intractable  than  ordinary  rheumatism,  and 
relapses  are  extremely  common.    It  may  become  chronic  and  last  for  years. 

Complications. — Iritis  is  not  infrequent  and  may  recur  with  suc- 
cessive attacks.  The  visceral  complications  are  rare.  Endocarditis,  peri- 
carditis, and  pleurisy  may  occur. 

Treatment. — The  salicylates  are  of  very  little  service,  nor  do  they 
often  relieve  the  pains  in  this  affection.  Iodide  of  potassium  has  also  proved 
useless  in  my  hands,  even  in  large  doses.  A  general  tonic  treatment  seems 
much  more  suitable — quinine,  iron,  and,  in  the  chronic  cases,  arsenic. 

The  local  treatment  of  the  joints  is  very  important.  The  thermo- 
cautery may  be  used  to  allay  the  pain  and  reduce  the  swelling.  In  acute 
cases,  fixation  of  the  joints  is  very  beneficial,  and  in  the  chronic  forms, 
massage  and  passive  motion.  I  have  seen  very  good  results  follow  in  a  few 
cases  the  use  of  the  dry  hot  air.  The  surgical  treatment  of  this  affection, 
as  carried  out  nowadays,  is  more  satisfactory,  and  I  have  seen  strikingly 
good  effects  from  incision  and  irrigation. 


258  SPECIFIC  INFECTIOUS  DISEASES. 

XXXIV.  TUBERCULOSIS. 

I.  Geneeal  Etiology  and  Moiibid  Anatomy. 

Definition. — An  infective  disease,  caused  by  Bacillus  tuberculosis,  the 
lesions  of  which  are  characterized  by  nodular  bodies  called  tubercles  or 
diffuse  infiltrations  of  tuberculous  tissue  which  undergo  caseation  or  scle- 
rosis and  may  finally  ulcerate,  or  in  some  situations  calcify. 

Etiology. — 1.  Zoological  Distribution. — Tuberculosis  is  one  of  the 
most  widespread  of  maladies. 

In  cold-blooded  animals  it  is  rare,  owing  doubtless  to  temperature  con- 
ditions unfavorable  to  the  development  of  the  bacillus.  Among  reptiles 
in  confinement  it  is,  however,  occasionally  seen  (Sibley).  In  fowls  it  is  an 
extremely  common  disease,  but  there  are  differences  in  avian  tuberculosis 
sufficient  to  warrant  its  separation  from  the  ordinary  form. 

Among  domestic  animals  tuberculosis  is  widely  but  unevenly  distrib- 
uted. Among  ruminants,  bovines  are  chiefly  affected.  The  percentage 
for  oxen  and  cows  at  the  Berlin  abattoir  in  the  year  1892-'93  was  15.1.  In 
this  country  much  has  been  done,  particularly  in  Massachusetts  and  Penn- 
sylvania, to  determine  the  presence  of  the  disease  in  the  dairy  herds,  for 
which  purpose  the  tuberculin  test  has  been  extensively  employed.  The 
results  show  a  widespread  prevalence  of  the  disease. 

Of  5,297  cattle  slaughtered  in  Maryland  only  159  were  tuberculous 
(A.  W.  Clement).  Of  15,506  slaughtered  at  the  Brighton  abattoir,  Boston, 
only  29  were  tuberculous  (A.  Burr).  The  tuberculin  test  has  shown  in 
some  places  a  percentage  of  from  15  to  30. 

In  sheep  the  disease  is  very  rare.  In  pigs  it  is  frequent,  but  not  so 
common  in  this  country  as  in  Europe.  In  the  inspection  of  1,000  hogs, 
which  was  made  by  A.  W.  Clement  and  myself  in  Montreal  in  1880,  tuber- 
culosis was  seen  only  once  or  twice.  At  the  Berlin  abattoir  in  1887-88 
there  were  6,393  pigs  affected  with  the  disease. 

Horses  are  rarely  attacked.  Dogs  and  cats  are  not  prone  to  the  disease, 
but  cases  are  described  in  which  infection  of  pet  animals  has  taken  place 
from  phthisical  masters.  Among  the  semi-domestic  animals,  such  as  the 
rabbit  and  guinea-pig,  the  disease  under  natural  conditions  is  rare,  al- 
though these  animals,  particularly  the  latter,  are  extremely  susceptible  to 
the  disease  when  inoculated.  Among  apes  and  monkeys  in  the  wild  state, 
tuberculosis  is  unknown,  but  in  confinement  it  is  the  most  formidable  dis- 
ease with  which  they  have  to  contend. 

The  important  etiological  fact  in  connection  with  tuberculosis  in  ani- 
mals is  the  widespread  occurrence  of  the  disease  in  bovines,  from  which 
class  we  derive  nearly  all  the  milk  and  a  very  large  proportion  of  the  meat 
used  for  food. 

2.  General  Statistics  of  the  Disease  in  Man. — Tuberculosis  is  the  most 
universal  scourge  of  the  human  race.  It  prevails  more  particularly  in  the 
large  cities  and  wherever  the  population  is  massed  together.  One  seventh 
of  all  deaths  are  due  to  it.  In  the  United  States  Census  Eeport  for  1890, 
102,188  deaths  were  reported  to  be  due  to  consumption.     At  a  low  esti- 


TUBERCULOSIS.  259 

mate  one  can  say  that  at  least  150,000  persons  die  annually  in  the  United 
States  of  some  form  of  tuberculosis.  An  estimation  based  on  the  Census 
Eeport  gives  the  total  number  of  persons  in  this  country  infected  with 
tuberculosis  as  1,050,000,  or  1  in  every  60  of  the  population  (Vaughan). 

Geographical  position  has  very  little  influence.  The  disease  is  perhaps 
more  prevalent  in  the  temperate  regions  than  in  the  tropics,  but  altitude 
is  a  more  potent  factor  than  latitude;  in  the  high  regions  of  the  Alps  and 
Andes  and  in  the  central  plateau  of  Mexico  the  death-rate  from  tubercu- 
losis is  very  low. 

The  influence  of  race,  which  has  been  much  studied,  is  probably  less 
owing  to  any  inherent  differences  than  to  the  conditions  under  which  the 
individuals  live.  The  Indians  of  this  continent  are  very  prone  to  the  dis- 
ease, Matthews  states  that  the  death-rate  in  the  older  reservations  in  the 
East  was  three  times  as  great  as  that  of  the  Indians  still  living  in  the 
Northwest.  In  this  country  the  Irish  and  the  negroes  appear  specially 
prone  to  the  disease;  on  the  other  hand,  the  Hebrews  possess  a  relative 
immunity.  For  the  six  years  ending  May  31,  1890,  the  average  annual 
death-rate  from  consumption  in  New  York  city  per  100,000  of  population 
was:  For  the  Irish,  645.73;  for  the  colored,  531.35;  for  the  Germans, 
328.80;  for  the  American  whites,  205.14;  and  for  the  Kussian-Polish  Jews, 
76.72.  In  this  city  the  disease  prevails  extensively  among  the  Kussian 
Jews. 

The  Decrease  of  Tuberculosis. — E.  F.  Wells,  who  has  tabulated  an  im- 
mense body  of  statistics  on  this  subject,  states  that  the  evidence  is  in  favor 
of  a  very  positive  decline  in  the  prevalence  of  the  disease.  While  the  last 
decennial  census  of  the  United  States  does  not  show  any  decrease,  yet  in 
many  of  the  larger  cities  there  has  been  a  striking  diminution.  The  ques- 
tion has  been  considered  very  carefully  by  James  B.  Russell,  of  Glasgow,  in 
his  Sanitary  History  of  that  city.  One  or  two  of  the  sentences  from  his  re- 
port may  be  quoted  with  advantage:  "  Between  the  five  years  1870-74  and 
the  five  years  1890-'94  there  was  a  decrease  of  41  per  cent  in  the  death-rate. 
If  we  start  from  the  maximum  period  of  fatality  (1860-'64),  the  decrease 
amounts  to  44  per  cent.  The  acceptance  of  the  doctrine  that  every  case 
of  phthisis  is  the  result  of  a  specific  infection — that,  consequently,  no  one 
is  foredoomed  to  have  phthisis  or  any  other  form  of  tuberculous  disease — 
gives  great  precision  to  our  ideas  of  prevention."  He  attributes  a  good 
deal  to  the  diffusion  of  the  knowledge  that  the  existence  and  distribution  of 
the  tubercle  bacillus  are  the  first  conditions  of  infection,  and  also  to  the  suc- 
cessful administrative  efforts  in  securing  "  ventilation,  especially  of  houses 
and  byres;  the  removal  of  dampness  by  subsoil  drainage  and  precautions 
adapted  to  the  foundations  and  walls  of  houses;  the  abolition  of  dark  spaces 
and  inclosures;  the  dissemination  of  direct  sunlight." 

The  diminution  of  pulmonary  tuberculosis  in  Massachusetts  is  remark- 
able, the  death-rate  having  fallen  from  42  per  10,000  inhabitants  in  1853 
to  21.8  per  10,000  in  1895.  A  remarkable  reduction  has  also  taken  place  in 
New  York  and  in  London  (Bcevor). 

3.  Bacillus  Tuberculosis. — Regarded  as  contagious  in  olden  time,  and 
always  in  certain  countries,  Villemin  first  placed  the  infective  nature  of 
tuberculosis  on  a  solid  experimental  basis.     Cohnheim  and  Salamonson 


260  SPECIFIC  INFECTIOUS  DISEASES. 

confirmed  his  results.  Finally,  after  years  of  work,  came  the  isolation  of 
the  tubercle  bacillus  by  Koch,  who  demonstrated  its  invariable  association 
with  the  disease.  The  investigations  which  he  had  previously  made  upon 
anthrax  and  experimental  traumatic  infections,  by  perfecting  the  methods 
of  research,  paved  the  way  for  this  brilliant  discovery.  His  preliminary 
article  *  and  his  more  elaborate  later  work  f  should  be  carefully  studied  by 
any  one  who  wishes  to  appreciate  the  valiie  of  scientific  methods.  It  forms 
one  of  the  most  masterly  demonstrations  of  modern  medicine.  Its  thor- 
oughness appears  in  the  fact  that  in  the  years  which  have  elapsed  since  its 
appearance  the  innumerable  workers  on  the  subject  have  not,  so  far  as 
I  know,  added  a  solitary  essential  fact  to  those  presented  by  Koch. 

Morphological  Characters. — The  tubercle  bacillus  occurs  usually  as  a 
short,  fine  rod,  often  slightly  bent  or  curved,  and  has  an  average  length  of 
nearly  half  the  diameter  of  a  red  blood-corpuscle  (3  to  4  /x);  more  rarely  it 
shows  lateral  outgrowths  or  simple  branches.  When  stained  it  often  presents 
a  beaded  appearance,  which  some  have  attributed  to  the  presence  of  spores. 

With  the  basic  aniline  dyes  it  stains  slowly,  except  at  the  body  tem- 
perature, but  retains  the  dye  after  treatment  with  acids — a  characteristic 
which  separates  it  from  all  other  known  forms  of  bacteria,  with  the  excep- 
tion of  the  bacillus  of  leprosy. 

Modes  of  Growth. — It  grows  on  blood-serum,  glycerin-agar,  bouillon,  or 
on  potato — ^most  readily  on  the  first.  The  cultures  must  be  kept  at  blood- 
heat.  They  grow  slowly,  and  do  not  appear  until  about  the  end  of  the 
second  week.  The  colonies  form  thin,  grayish-white,  dry,  scale-like  masses 
on  the  surface  of  the  culture  medium.  Successive  inoculations  may  be 
made  from  the  cultures,  and  at  the  end  of  an  indefinite  series  material 
from  one  of  them  inoculated  into  a  guinea-pig  will  produce  tuberculosis. 

Variations. — (a)  In  Form. — The  small  branching  forms  are  found  not 
infrequently  in  tuberculous  lesions.  Some  investigators  claim  to  have  pro- 
duced more  complex  structures,  resembling  the  "  Driisen  "  of  the  actino- 
myces. 

(&)  Specific  Varieties. — In  1901  Koch  startled  the  scientific  world  with 
the  statement  that  the  bacillus  of  bovine  tuberculosis  was  a  specific  variety 
which  probably  did  not  cause  human  tuberculosis,  and  that  the  bacillus 
of  human  tuberculosis  did  not  cause  tuberculosis  in  cattle.  Naturally  the 
question  has  been  much  discussed.  The  truth  seems  to  be  that  while  there 
are  differences  in  the  bacilli,  as  pointed  out  by  Theobald  Smith,  the  re- 
searches of  von  Behring,  Eavenel,  and  others  have  shown  that  it  is  possible 
to  cause  tuberculosis  in  cattle  with  the  bacillus  from  man;  and  there  are  un- 
doubted cases  in  man  caused  by  accidental  infection  from  cattle.  Bacillus 
tuberculosis  avium  appears  in  more  irregular  forms  and  produces  only 
local  inflammatory  processes  in  mammals.  Possibly  infection  with  it  may 
sometimes  occur  in  man  (Pausini). 

Composition  and  Products. — Tubercle  bacilli  contain  water,  various  pro- 
teids,  fats  (to  which  the  peculiar  staining  reaction  is  due),  a  carbohydrate 

*  Berliner  klinische  "Wochenschrift,  1882. 

f  Mittheilungen  a.  d.  k.  Gesundheitsamte,  Bd.  2. 


TUBERCULOSIS.  261 

resembling  glycogen,  cellulose,  free  and  combined  nucleic  acid,  and  ash 
(P.  A.  Levene).  Koch's  tuberculin  is  a  proteid  glycerin  extract  from  the 
bacilli. 

Distribution  of  the  Bacilli. — The  bacilli  are  found  in  all  tuberculous 
lesions;  in  some  in  great  abundance,  in  others  sparsely.  They  are  par- 
ticularly numerous  in  actively  developing  tubercles,  but  in  the  chronic 
tuberculous  processes  of  lymph-glands  and  of  the  joints  they  are  scanty. 
When  a  tuberculous  focus  communicates  with  a  vein  or  with  lymph-ves- 
sels, the  bacilli  may  be  spread  widely  throughout  the  body.  In  old  lesions 
they  may  not  be  found  in  the  sections,  and  the  demonstration  of  the  true 
nature  may  be  possible  only  by  culture  or  inoculation. 

The  Bacilli  outside  the  Body. — Patients  with  advanced  pulmonary 
tuberculosis  throw  off  in  the  expectoration  countless  millions  of  the  bacilli 
daily.  Some  idea  of  the  extraordinary  numbers  may  be  gained  from  the 
studies  of  Nuttall.  From  a  patient  with  moderately  advanced  disease, 
the  amount  of  whose  expectoration  was  from  70  to  130  cc.  daily,  he  esti- 
mated by  his  method  that  there  were  in  sixteen  counts,  between  January 
10th  and  March  1st,  from  one  and  a  half  to  four  and  a  third  billions  of 
bacilli  thrown  off  in  the  twenty-four  hours.  These  figures  emphasize  the 
danger  associated  with  phthisical  sputa  unless  most  carefully  dealt  with. 
When  expectorated  and  allowed  to  dry,  the  sputum  rapidly  becomes  dust, 
and  is  distributed  far  and  wide.  The  observations  made  by  Cornet  under 
Koch's  supervision  are  in  this  connection  most  instructive.  He  collected 
the  dust  from  the  walls  and  bedsteads  of  various  localities,  and  determined 
its  virulence  or  innocuousness  by  inoculation  into  susceptible  animals. 
Material  was  gathered  from  21  wards  of  7  hospitals,  3  asylums,  2  prisons, 
from  the  surroundings  of  62  phthisical  patients  in  private  practice,  and 
from  29  other  localities  in  which  tuberculous  patients  were  only  transient 
frequenters  (out-patient  departments,  streets,  etc.).  Of  118  dust  samples 
from  hospital  wards  or  the  rooms  of  phthisical  patients,  40  were  infective 
and  produced  tuberculosis.  Negative  results  were  obtained  with  the  29 
dust  samples  from  the  localities  occasionally  occupied  by  consumptives. 
Virulent  bacilli  were  obtained  from  the  dust  of  the  walls  of  15  out  of  21 
medical  wards.  It  is  interesting  to  note  that  in  2  wards  with  many  phthis- 
ical patients  the  results  were  negative,  indicating  that  the  dust  in  such 
regions  is  not  necessarily  infective.  The  infectiousness  of  the  dust  of  the 
medical  and  surgical  divisions  of  a  hospital  is  in  the  proportion  of  7.6.6  to 
12.5.  In  a  room  in  which  a  tuberculous  woman  had  lived  the  dust  from 
the  wall  in  the  neighborhood  of  the  bed  was  infective  six  weeks  after  her 
death.  No  bacilli  were  found  in  the  dust  of  an  inhalation-chamber  for 
consumptives.  The  experiments  of  Strauss  at  the  Charite  Hospital,  Paris, 
are  important.  In  the  nostrils  of  29  assistants,  nurses,  and  ward-tenders 
he  placed  plugs  of  cotton-wool  to  collect  the  dust  of  the  wards.  In  9  of 
the  29  cases  these  contained  tubercle  bacilli  and  proved  infective  to  ani- 
mals. The  question  of  the  increase  of  tuberculosis  among  the  permanent 
residents  of  health  resorts  frequented  by  consumptives  is  one  of  great 
interest.  Gardiner  has  studied  the  problem  at  Colorado  Springs,  in 
which  for  twenty  years  tuberciilous  patients  have  been  living,  and  he 


262  SPECIFIC  INFECTIOUS  DISEASES. 

finds  the  number  of  cases  of  tuberculosis  originating  in  the  city  to  be  very 
small. 

Pseudo-tuberculosis. — While  lesions  resembling  the  nodules  of  tubercu- 
losis, but  due  to  a  variety  of  bacteria,  protozoa,  and  nematodes,  are  not  un- 
common in  animals,  pseudo-tuberculous  processes  are  very  rare  in  human 
beings.  Flexner  *  has  described,  under  the  name  pseudo-tuberculosis 
hominis  streptothrica,  a  condition  in  human  beings  in  which  the  lungs  pre- 
sented the  appearance  of  a  caseous  pneumonia  and  numerous  tubercle-like 
nodules  existed  in  the  peritonaeum.  The  micro-organism  found  in  the 
lesions  was  a  streptothrix,  which  differed  greatly  from  the  known  forms 
of  the  bacillus  tuberculosis  and  streptothrix  actinomyces. 

4.  Modes  of  Infection. — (a)  Hereditary  Transmission. — The  possible 
methods  of  transmission  of  the  germ  in  direct  inheritance  are  three — 
transmission  by  the  sperm,  transmission  by  the  ovum,  and  transmission 
through  the  blood  by  means  of  the  placenta. 

There  is  no  clinical  evidence  to  support  the  view  that  direct  transmis- 
sion can  occur  through  the  sperm.  In  order  that  the  disease  could  be  trans- 
mitted by  the  sperm  it  would  be  necessary  that  the  tubercle  bacilli  should 
lodge  in  the  individual  spermatozoon  which  fecundates  the  ovum.  The 
chances  that  such  a  thing  could  occur  are  extremely  small,  looking  at  the 
subject  from  a  numerical  point  of  view,  although  we  know  that  tubercle 
bacilli  do  occasionally  exist  in  the  semen;  they  become  still  smaller  when 
we  consider  that  the  spermatozoon  is  made  up  of  nuclear  material,  which 
the  tubercle  bacillus  is  never  known  to  attack.  Experimentation  is  all 
opposed  to  sperm  transmission,  the  work  of  Gartner  and  others  showing 
that  the  young  of  healthy  female  rabbits  impregnated  by  tuberculous  males 
are  never  tuberculous,  even  though  the  females  themselves  often  contract 
the  disease.  • 

^  The  possibility  of  transmission  by  the  ovum  must  be  accepted.  Baum- 
garten  has  in  one  instance  been  able  to  detect  the  tubercle  bacillus  in  the 
ovum  of  a  female  rabbit  which  he  had  artificially  fecundated  with  tubercu- 
lous semen.  The  work  of  Pasteur  on  pebrine  has  shown  the  possibility  of 
this  form  of  transmission  in  the  lower  forms,  though  the  question  as  to 
what  effect  such  inoculation  would  have  upon  the  human  ovum  cannot  of 
course  be  answered. 

Probably  the  almost  constant  method  of  transmission  in  congenital 
tuberculosis  is  through  the  blood  current,  the  tubercle  bacilli  penetrating 
by  way  of  the  placenta.  Certain  authors  hold  that  in  these  cases  the  pla- 
centa itself  is  invariably  the  seat  of  tuberculosis,  and  tubercles,  indeed, 
have  been  demonstrated  in  several  cases;  but  there  are  undoubted  instances 
in  which,  with  an  apparently  sound  placenta,  both  the  placental  blood  and 
the  foetal  organs  contained  tubercle  bacilli,  notwithstanding  the  fact  that 
the  organs  also  appeared  normal. 

Possible  Latency  of  the  Tubercle  Germs. — Baumgarten  and  his  followers 
■assume  that  the  tubercle  bacilli  can  lie  latent  in  the  tissues  and  subse- 
quently develop  when,  for  some  reason  or  other,  the  individual  resistance 


*  Journal  of  Experimental  Medicine,  1898. 


TUBERCULOSIS.  263 

is  lowered.  He  likens  such  cases  of  latent  tuberculosis  to  the  late  heredi- 
tary forms  of  syphilis,  and  explains  the  lack  of  development  of  the  germs 
by  the  greater  resisting  power  of  the  tissues  of  children.  In  the  discussion 
on  latency  before  the  Eoyal  Medical  and  Chirurgical  Society  of  London, 
Kingston  Fowler  expressed  the  sensible  opinion  that  it  was  not  necessary 
seriously  to  consider  the  question  of  latency  in  tuberculosis  until  direct 
transmission  from  mother  to  child  was  proved  to  be  of  frequent  occur- 
rence. Baumgarten  bases  his  belief  in  germ  transmission  upon  two  main 
factors — the  great  frequency  of  the  disease  in  early  life  and  the  localization 
of  tuberculous  lesions  in  children. 

The  mortality  from  tuberculosis  in  the  first  years  of  life  is  relatively 
high.  Of  2,576  autopsies  made  on  children,  27.8  per  cent  who  died  in  the 
first  year  were  tuberculous  (Botz).  Of  182  autopsies  on  children  one  year 
or  under,  17  were  tuberculous  (Comby).  The  localization  of  tuberculous 
lesions  in  children  in  the  bones  or  joints  is  very  common,  Cnopp's  sta- 
tistics showing  that  out  of  298  tuberculous  children  of  from  a  few  days 
to  twelve  years  of  age,  147  had  bone  or  joint  tuberculosis,  and  only  8  of 
these  showed  evidence  of  visceral  disease.  Baumgarten  is  of  the  opinion 
that  the  accidental  conveyance  of  tubercle  bacilli  to  these  points  would  not 
account  for  such  a  large  proportion  of  cases,  and  expresses  the  view  that 
the  bacilli  have  been  present  since  birth  and  have  developed  when  favor- 
able conditions  offered.  The  evidence  in  favor  of  Baumgarten's  view  is 
both  clinical  and  experimental. 

The  clinical  evidence  exists  in  the  form  of  undoubted  cases  of  con- 
genital tuberculosis,  of  which  there  are  now,  in  man  alone,  about  20  ex- 
amples in  the  literature;  besides  these,  a  number  of  spontaneous  cases  of 
congenital  tuberculosis  in  the  lower  animals  have  been  reported. 

A  number  of  laboratory  workers  have  been  able  to  show  that  congenital 
tuberculosis  can  be  produced  experimentally,  the  most  prominent  of  these 
being  Gartner,  who  was  able  to  cause  tuberculosis  in  young  mice  by  inocu- 
lating the  mother  with  tuberculosis,  either  into  the  peritoneal  cavity  or 
into  the  blood  stream.  Mafucci  has  shown  that  after  injecting  eggs  with 
avian  tuberculosis  the  disease  may  remain  latent  in  the  chick  for  weeks  or 
even  months. 

Against  Baumgarten's  theory  are  the  facts  that  the  percentage  of  cases 
of  congenital  tuberculosis  is  extremely  small,  and  that  in  the  great  majority 
of  instances  the  organs  of  foetuses  born  of  tuberculous  mothers  give  nega- 
tive results  when  inoculated  into  guinea-pigs. 

No  circumstance,  perhaps,  has  contributed  more  to  the  belief  in  the 
hereditary  transmission  of  the  disease  than  the  frequency  with  which  tuber- 
culosis is  met  with  in  the  ascendants  of  those  affected.  The  estimates  range 
from  10  per  cent  to  25  per  cent,  or  even  in  some  instances  to  50  per  cent. 
Some  of  the  statistics  on  this  point  are  worth  quoting:  In  1,000  cases  Wil- 
liams found  48.4  per  cent  with  family  predisposition,  12  per  cent  with 
parental,  1  per  cent  with  grandparental,  and  34.4  per  cent  with  collateral 
heredity.  Of  250  cases  in  which  Solly  made  very  careful  inquiries  on  this 
point,  there  were  28.8  per  cent  with  parental,  7.6  per  cent  with  grand- 
parental,  and  19.2  per  cent  with  a  history  of  collateral  heredity.     Of  427 


264  SPECIFIC  INFECTIOUS  DISEASES. 

cases  at  the  Johns  Hopkins  Hospital,  there  were  53  in  which  the  mother 
had  had  tuberculosis,  52  in  which  the  father  had  been  affected,  and  105  in 
which  a  brother  or  sister  had  had  the  disease.  The  question  of  family  in- 
fection is  the  all-important  one,  and  Hilton  Fagge  very  wisely  remarks  that 
it  is  impossible  to  draw  a  line  between  hereditary  and  accidental  tubercu- 
losis, as  naturally  the  children  of  an  affected  parent  are  more  liable  to  acci- 
dental contamination.  In  a  recent  careful  study  of  heredity  in  phthisis. 
Squire  concludes  that  there  is  but  a  small  difference  between  the  incidence 
of  the  disease  in  the  offspring  of  phthisical  and  non-phthisical  parents. 

While  the  demonstration  of  the  contagiousness  of  tuberculosis  has  in 
some  quarters  intensified  the  dread  with  which  the  disease  is  regarded, 
the  terrible  Ate  of  hereditary  transmission  has  been  in  great  part  abolished, 
to  the  great  gain  of  suffering  humanity. 

(&)  Inoculation. — The  infective  nature  of  tuberculosis  was  first  demon- 
strated by  Villemin,  who  showed  conclusively  in  1865  that  it  could  be  trans- 
mitted to  animals  by  inoculation.  The  beautiful  experiments  of  Cohnheim 
and  Salamonson,  who  produced  tuberculosis  in  the  eyes  of  guinea-pigs  and 
rabbits  by  inoculating  fresh  tubercle  into  the  anterior  chamber,  confirmed 
and  extended  Villemin's  original  observations  and  paved  the  way  for  the 
reception  of  Koch's  announcement.  It  is  now  universally  conceded  that 
only  tuberculous  matter  can  produce,  when  inoculated,  tuberculosis.  In 
man  tuberculosis  is  not  often  transmitted  by  inoculation,  and  when  it  does 
occur  the  disease  usually  remains  local.  This  mode  of  infection  is  seen  in 
persons  whose  occupation  brings  them  in  contact  with  dead  bodies  or  ani- 
mal products.  Demonstrators  of  morbid  anatomy,  butchers,  and  handlers 
of  hides  are  subject  to  a  local  tubercle  of  the  skin,  which  forms  a  reddened 
mass  of  granulation  tissue,  usually  capping  the  dorsal  surfaces  of  the  hands 
or  fingers.  This  is  the  so-called  post-mortem  wart,  the  verruca  necrogenica 
of  Wilks.  The  demonstration  of  its  nature  is  shown  by  the  presence  of 
tubercle  bacilli,  and  by  inoculation  experiments  in  animals. 

The  statement  that  Laennec  contracted  phthisis  from  this  source  is 
probably  false,  since  he  did  not  die  until  twenty  years  after  the  inocula- 
tion and  in  the  interval  presented  no  manifestations.  The  possibility,  how- 
ever, of  general  infection  must  be  borne  in  mind.  Gerber  reports  that 
after  accidental  inoculation  in  the  hand  from  a  case  of  phthisis  he  had 
for  months  a  "  Leichen-tubercle,"  which  was  excised.  Shortly  afterward 
the  lymph-glands  of  the  axilla  became  enlarged  and  painful,  and  when  re- 
moved showed  characteristic  tuberculous  changes,  with  bacilli. 

In  the  performance  of  the  rite  of  circumcision  children  have  been  acci- 
dentally inoculated.  Infection  in  these  cases  is  probably  always  associated 
with  disease  in  the  operator,  and  occurs  in  connection  with  the  habit  of 
cleansing  the  wound  by  suction. 

Other  means  of  inoculation  have  been  described:  as  the  wearing  of 
ear-rings,  washing  the  clothes  of  phthisical  patients,  the  bite  of  a  tubercu- 
lous subject,  or  inoculation  from  a  cut  by  a  broken  spit-glass  of  a  consump- 
tive; and  Czerny  has  reported  two  cases  of  infection  by  transplantation  of 
Bkin. 

It  has  been  urged  by  the  opponents  of  vaccination  that  tuberculosis,  as 


TUBERCULOSIS.  265 

well  as  syphilis,  may  be  thus  conveyed,  but  of  this  there  is  no  evidence. 
Lymph  of  revaecinated  consumptives  is  non-infective.  Lupus  has  origi- 
nated at  the  site  of  vaccination  in  a  few  cases  (C.  Fox,  Graham  Little).  It 
may  be  said,  on  the  whole,  that  inoculation  in  man  plays  a  trifling  role  in 
the  transmission  of  tuberculosis. 

(c)  Infection  hy  Inhalation. — A  belief  in  the  contagiousness  of  pul- 
monary tuberculosis  has  existed  from  the  days  of  the  early  Greek  physi- 
cians, and  has  persisted  among  the  Latin  races.  The  investigations  of 
Cornet  afford  conclusive  proof  that  the  dust  of  a  room  or  other  locality 
frequented  by  patients  with  pulmonary  tuberculosis  is  infective.  The 
bacilli  are  attached  to  fine  particles  of  dust  and  in  this  way  gain  entrance 
to  the  system  through  the  lungs. 

Fliigge  denies  that  the  bacillus-containing  dust  is  the  dangerous  ele- 
ment in  infection.  Experimentally  he  has  only  succeeded  in  producing 
the  disease  when  there  is  some  lesion  in  the  respiratory  tract.  He  thinks 
that  the  danger  of  infection  by  the  dry  sputum  is  very  improbable.  On 
the  other  hand,  he  thinks  that  the  infection  is  chiefly  conveyed  by  the  free, 
finely  divided  particles  of  sputum  produced  in  the  act  of  coughing,  and 
that  these  tiny  fragments  are  suspended  in  the  atmosphere.  Those  who 
cough  very  much  and  with  the  mouth  open  are  most  liable  to  infect  the 
surrounding  air. 

It  is  well  remarked  by  Cornet,  "  The  consumptive  in  himself  is  almost 
harmless,  and  only  becomes  harmful  through  bad  habits."  It  has  been 
fully  shown  that  the  expired  air  of  consumptives  is  not  infective.  The 
virus  is  only  contained  in  the  sputum,  which  when  dry  is  widely  dissemi- 
nated in  the  form  of  dust,  and  constitutes  the  great  medium  for  the  trans- 
mission of  the  disease.  "  In  order  to  be  air-borne  the  sputum  must  be 
dried  and  broken  up  into  dust.  If  discharged  into  a  handkerchief,  it 
speedily  dries,  especially  if  it  is  put  into  the  pocket  or  beneath  the  pillow. 
In  the  last  stages  of  consumption  the  patient  becomes  weak,  the  sputum 
is  expelled  imperfectly,  pillows,  sheets,  and  handkerchiefs  are  soiled.  If  a 
male,  the  beard  or  moustache  is  smeared.  Even  in  the  hands  of  the  cleanly, 
without  special  precautions,  such  circumstances  all  tend  to  the  production 
around  the  patient  of  a  halo  of  infected  dust  maintained  by  every  process 
of  bedmaking  or  of  cleaning  which  includes  the  pernicious  process  happily 
described  as  '  dusting.^  In  the  hands  of  the  careless  and  the  dirty  the  in- 
fectivity  is,  of  course,  greatly  aggravated.  It  attains  its  maximum  of  in- 
tensity where  the  filthy  habit  of  spitting  on  the  floor  prevails,  especially 
if  it  is  carpeted  "  (James  B.  Eussell). 

The  following  are  some  of  the  facts  in  favor  of  infection  by  inhala- 
tion: 

(1)  Primary  tuberculous  lesions  are  in  a  majority  of  all  cases  connected 
with  the  respiratory  system.  The  frequency  with  which  foci  are  met  with 
in  the  lungs  and  in  the  bronchial  glands  is  extraordinary,  and  the  statis- 
tics of  the  Paris  morgue  show  that  a  considerable  proportion  of  all  persons 
dying  of  accident  or  by  suicide  present  evidences  of  the  disease  in  these 
parts.  The  post-mortem  statistics  of  hospitals  show  the  same  widespread 
prevalence  of  infection  through  the  air-passagea.    Biggs  reports  that  more 


266  SPECIFIC  INFECTIOUS  DISEASES. 

than  60  per  cent  of  his  post  mortems  showed  lesions  of  pulmonary  tuber- 
culosis. In  125  autopsies  at  the  Foundling  Hospital,  New  York,  the  bron- 
chial glands  were  tuberculous  in  every  case.  In  adults  the  bronchial  glands 
may  be  infected  and  the  individual  remain  in  good  health.  H.  P.  Loomis 
found  in  8  of  30  cases  in  which  there  were  no  signs  of  old  or  recent  tuber- 
culous lesions  that  the  bronchial  glands  were  infective  to  rabbits. 

(2)  The  greater  prevalence  of  tuberculosis  in  institutions  in  which  the 
residents  are  confined  and  restricted  in  the  matter  of  fresh  air  and  a  free 
open  life — conditions  which  would  favor,  on  the  one  hand,  the  presence 
of  the  bacilli  in  the  atmosphere,  and,  on  the  other,  lower  the  vital  resist- 
ance of  the  individual.  The  investigations  of  Cornet  upon  the  death-rate 
from  consumption  among  certain  religious  orders  devoted  to  nursing  give 
some  striking  facts  in  illustration  of  this.  In  a  review  of  38  cloisters,  em- 
bracing the  average  number  of  4,028  residents,  among  2,099  deaths  in  the 
course  of  twenty-five  years,  1,320  (62.88  per  cent)  were  from  tuberculosis. 
In  some  cloisters  more  than  three  fourths  of  the  deaths  are  from  this  dis- 
ease, and  the  mortality  in  all  the  residents,  up  to  the  fortieth  year,  is  greatly 
above  the  average,  the  increase  being  due  entirely  to  the  prevalence  of 
tuberculosis.  It  has  been  stated  that  nurses  are  not  more  prone  to  the  dis- 
ease than  other  individuals,  but  Cornet  says  that  of  100  nurses  deceased,  63 
died  of  tuberculosis.  The  more  perfect  the  prophylaxis  and  hygienic  ar- 
rangements of  an  asylum  or  institution,  the  lower  the  death-rate  from 
tuberculosis.  The  mortality  in  prisons  has  been  shown  by  Baer  to  be 
four  times  as  great  as  outside.  The  death-rate  from  phthisis  is  estimated 
at  15  per  cent  of  the  total  mortality,  while  in  prisons  it  constitutes  from  40 
to  50  per  cent,  and  in  some  countries,  as  Austria,  over  60  per  cent.  Flick 
has  studied  the  distribution  of  the  deaths  from  tuberculosis  in  a  single 
city  ward  in  Philadelphia  for  twenty-five  years.  His  researches  go  far  to 
show  that  it  is  a  house  disease.  About  33  per  cent  of  infected  houses  have 
had  more  than  one  case.  Less  than  one  third  of  the  houses  of  the  ward 
became  infected  with  tuberculosis  during  the  twenty-five  years  prior  to 
1888.  Yet  more  than  one  half  of  the  deaths  from  this  disease  during  the 
year  1888  occurred  in  those  infected  houses.  There  are,  however,  opposing 
facts.  The  statistics  of  the  Brompton  Consumption  Hospital  show  that 
doctors,  nurses,  and  attendants  are  rarely  attacked.  Dettweiler  claims  that 
no  case  of  tuberculosis  has  been  contracted  among  his  nurses  or  attendants 
at  Falkenstein.  On  the  other  hand,  in  the  Paris  hospitals  tuberculosis 
decimates  the  attendants. 

(3)  Special  danger  exists  when  the  contact  is  very  intimate,  such,  for 
instance,  as  between  man  and  wife.  On  this  point  much  difference  of 
opinion  exists,  but  the  figures  seem  to  indicate  that  under  these  circum- 
stances the  husband  or  wife  is  much  more  liable  subsequently  to  die  of 
consumption.  Of  427  cases  of  pulmonary  tuberculosis  at  the  Johns  Hop- 
kins Hospital,  in  25  either  husband  or  wife  had  been  affected  with  it  or 
had  died  of  tuberculosis.  In  response  to  a  question  as  to  contagion,  asked 
by  the  Collective  Investigation  Committee  of  the  British  Medical  Associa- 
tion, there  were  261  replies  in  the  affirmative,  among  which  were  158  cases 
of  supposed  contagion  through  marriage.    Weber's  cases  are  of  special  in- 


TUBERCULOSIS.  267 

terest.     One  of  his  patients  lost  four  wives  in  succession,  one  lost  three, 
and  four  lost  two  each. 

The  all-important  question  of  infection  by  the  milk  of  tuberculous 
cows  has  been  reopened  by  Koch,  who  claims  that  as  butter  and  milk  so 
frequently  contain  tubercle  bacilli,  if  human  tuberculosis  often  came  from 
this  source  primary  intestinal  tuberculosis  should  be  common,  whereas  it 
is  very  rare.  He  has  seen  two  cases  only.  There  have  been  ten  cases 
only  in  ten  years  at  the  Charite  Hospital.  Of  3,104  cases  of  tubercu- 
losis in  children,  there  were'  only  16  cases  of  primary  intestinal  in- 
fection. Bovaird's  statistics  on  this  point  show  remarkable  differences 
in  different  countries:  Germany  4  per  cent,  England  18  per  cent, 
America  1  per  cent.  It  is  diflBcult  to  reconcile  these  percentages  with 
Woodhead's  figures  of  involvement  of  the  mesenteric  glands  in  100  of 
127  cases  of  tuberculosis  in  children.  The  truth  is  that  post-mortem  re- 
turns are  not  worth  quoting  unless  the  post  mortems  were  made  with 
the  specific  object  of  finding  tuberculous  lesions,  as  in  Naegli's  study  from 
Eibbert's  laboratory  (see  p.  332).  Koch  states  that  the  question  is  not  abso- 
lutely decided,  but  he  asserts  that  "  infection  of  human  beings  from  this 
source  (milk,  etc.)  is  of  very  rare  occurrence,"  not  more  common  than  the 
hereditary  transmission,  and  he  adds — and  this  is  a  vital  point — that  it  is 
"  not  advisable  to  take  any  measures  against  it."  In  the  present  unsettled 
state  of  the  question  there  should  be  no  relaxation  of  protective  measures. 
The  experimental  production  of  intestinal  tuberculosis  in  pigs  and  calves 
is  proved,  and  it  is  quite  possible  that  the  bacilli  may  pass  through  an  intact 
intestinal  mucosa  and  produce  lesions  elsewhere. 

(e)  Infection  hy  Meat. — The  meat  of  tuberculous  animals  is  not  neces- 
sarily infective.  The  results  of  experiments  with  the  flesh  of  cows  are 
not  in  accord.  This  mode  of  infection  probably  plays  a  minor  role  in  the 
etiology  of  human  tuberculosis,  as  usually  the  flesh  is  thoroughly  cooked 
before  eating.  The  possibility,  however,  must  be  borne  in  mind,  and  it 
would  certainly  be  safer  in  the  interests  of  a  community  to  confiscate  the 
carcasses  of  all  tuberculous  animals.  Experiments  in  Bollinger's  labora- 
tory show  that  the  flesh  of  tuberculous  subjects  is  very  infective  to  guinea- 
pigs.  Martin  suggests  that  when  the  meat  is  infective  it  commonly  ac- 
quires this  property  by  accidental  contamination  with  tuberculous  matter 
during  its  removal. 

5.  Conditions  Influencing  Infection. — (a)  General — Environment  is  an 
all-important  predisposing  factor.  Dwellers  in  cities  are  much  more  prone 
to  the  disease  than  residents  of  the  country.  Not  only  is  the  liability  to 
infection  very  much  greater,  but  the  conditions  of  life  are  sucli  that  the 
powers  of  resistance  are  apt  to  be  weakened.  As  already  stated,  sunlight 
is  one  of  the  most  powerful  agents  in  destroying  the  tubercle  bacillus,  so 
that  in  imperfectly  ventilated  dwellings  and  workshops,  and  in  residences 
in  close,  dark  alleys,  and  in  tenement  houses  the  liability  to  infection  is 
very  much  increased.  The  influence  of  environment  was  never  better 
demonstrated  than  in  the  now  well-known  experiment  of  Trudeau,  who 
found  that  rabbits  inoculated  with  tuberculosis  if  confined  in  a  dark,  damp 
place  without  sunlight  and  fresh  air  rapidly  succumbed,  while  others 
17 


268  SPECIFIC  INFECTIOUS  DISEASES. 

treated  in  the  same  way,  but  allowed  to  run  wild,  either  recovered  or  showed 
very  slight  lesions.  The  occupants  of  prisons,  asylums,  and  poorhouses, 
too  often,  indeed,  in  barracks  and  large  workshops,  are  in  the  position  of 
Trudeau's  rabbits  in  the  cellar,  and  under  conditions  most  favorable  to 
foster  the  development  of  the  bacilli  which  may  have  lodged  in  their  tissues. 
The  frequent  respiration  of  air  already  breathed,  upon  which  MacCormao 
of  Belfast  laid  so  much  stress,  appears  to  render  the  lungs  less  capable  of 
resisting  infection. 

Soil  and  locality  are  believed  by  many  to  have  a  very  important  bearing 
on  the  development  of  tuberculosis.  The  observations  of  Henry  I.  Bow- 
ditch  in  this  country  and  of  Buchanan  in  England  show  that  the  disease 
prevails  more  widely  in  the  wet,  ill-drained  districts — an  increase  which  is 
associated  with  heightened  vulnerability  and  greater  liability  to  catarrhal 
affections  of  all  kinds.  The  influence  of  the  dwelling  has  been  already 
referred  to  in  connection  with  Flick's  work.  No  single  condition  is  of 
greater  importance  than  that  which  relates  to  the  proper  arrangement  and 
ventilation  of  the  dwelling  houses. 

(&)  Individual  Predisposition. — The  fathers  of  medicine,  more  particu- 
larly Hippocrates,  Areteeus,  and  Galen,  laid  great  stress  upon  the  bodily 
conformation  of  those  prone  to  consumption.  A  great  deal  was  written 
on  the  so-called  habitus  pJitliisicus,  which  Hippocrates  described  in  the  fol- 
lowing terms:  "  The  form  of  body  peculiar  to  subjects  of  phthisical  com- 
plaints was  the  smooth,  the  whitish,  that  resembling  the  lentil;  the  red- 
dish, the  blue-eyed,  the  leuco-phlegmatic;  and  that  with  the  scapulae  hav- 
ing the  appearance  of  wings."  Undoubtedly  the  long,  narrow,  flat  chest 
with  depressed  sternum  is  commonly  enough  seen  in  tuberculous  patients, 
but  there  are  only  too  many  individuals  with  perfectly  well-shaped  chests 
who  fall  victims  annually  to  the  disease.  The  tuberculous  or  scrofulous 
diathesis,  upon  which  formerly  so  much  stress  was  laid,  is  now  regarded 
simply  as  an  indication  of  a  type  of  conformation  in  which  the  tissues  are 
more  vulnerable  and  less  capable  of  resisting  infection.  Beneke's  investi- 
gations on  the  viscera  of  phthisical  patients  indicate  that  the  heart  is  rela- 
tively small,  the  arteries  proportionately  narrow,  and  the  pulmonary  artery 
relatively  wider  than  the  aorta.  He  suggests  that  this  may  lead  to  increase 
in  the  intrapulmonary  blood  pressure,  and  so  favor  catarrhal  processes. 
The  lung  volume  he  found  relatively  greater  in  those  affected  with  tubercu- 
losis. A  study  of  the  composite  portraiture  of  pulmonary  tuberculosis  has 
been  made  by  Galton  and  Mahomed.  In  442  patients  they  separated  two 
types  of  face — one  ovoid  and  narrow,  the  other  broad  and  coarse-featured. 
This  corresponds  in  an  interesting  way  to  the  diathetic  states  formerly 
recognized — namely,  the  tuberculous,  with  thin  skin,  bright  eyes,  oval  face, 
and  long,  thin  bones;  and  the  scrofulous,  with  thick  lips  and  nose,  opaque 
skin,  large,  thick  bones,  and  heavy  figure.  These  conditions,  on  which  so 
much  stress  was  formerly  laid,  indicate,  as  Fagge  states,  nothing  more  than 
delicacy  of  constitution,  incomplete  growth,  and  imperfect  development. 

(c)  Influence  of  Age. — No  age  is  exempt.  The  disease  is  met  with  in 
the  suckling  and  in  the  octogenarian.  Pulmonary  tuberculosis  occurs  most 
frequently,  as  stated  by  Hippocrates,  from  the  eighteenth  to  the  thirty- 


TUBERCULOSIS.  269 

fifth  year.  From  the  fifth  to  the  tenth  year  individuals  are  less  prone  to 
the  disease.  At  different  ages  different  organs  are  more  prone  to  be  in- 
volved. During  the  first  decade  the  bones,  meninges,  and  lymph-glands 
are  more  frequently  affected  than  at  subsequent  periods. 

(d)  Sex. — The  influence  of  sex  is  very  slight.  Women  are  perhaps 
somewhat  more  frequently  attacked  than  men,  possibly  from  the  fact 
that  in  a  more  sedentary,  indoor  life  they  are  more  liable  to  infection. 
Pregnancy  and  lactation  also  are  two  conditions  which  are  apt  to  lower, 
perhaps,  the  resistance  of  the  organism. 

(e)  Bace. — The  negro,  who  it  is  stated  is  not  specially  prone  to  the  dis- 
ease in  Africa,  is  in  America  and  in  the  West  Indies  very  subject  to  tuber- 
culosis. The  relative  immunity  of  the  Jews  has  been  mentioned  (page 
259). 

(/)  Occupation  is  an  important  predisposing  factor.  The  inhalation 
of  impure  air  in  occupations  associated  with  a  very  dusty  atmosphere 
renders  the  lungs  less  capable  of  resisting  infection.  The  incidence  of 
pulmonary  tuberculosis  among  the  workers  in  mills  and  factories  is  very 
high,  and  certain  occupations,  such  as  those  of  glass-workers,  stone-cutters, 
and  coal-miners,  and  the  whole  group  of  trades,  which  lead  to  pneumono- 
koniosis,  favor  the  development  of  tuberculosis. 

{g)  Certain  local  conditions  influence  infection,  among  which  the  fol- 
lowing are  the  most  important: 

Catarrhal  bronchitis.  The  influence  of  catarrh  of  the  respiratory  pas- 
sages in  pulmonary  tuberculosis  is  well  recognized.  How  often  is  a  neg- 
lected cold  blamed  as  the  starting-point  of  the  disease!  It  seems  to  act 
by  lowering  the  resistance  and  favoring  the  conditions  which  enable  the 
bacilli  either  to  enter  the  system  or,  when  once  in  it,  to  develop.  The 
liability  of  lymphatic  tuberculosis  in  children  is  probably  associated  with 
the  common  catarrhal  processes  in  the  tonsils,  throat,  and  bronchi. 

Certain  of  the  specific  fevers  predispose  to  tuberculosis,  among  which 
measles  and  whooping-cough  stand  pre-eminent.  They  are  often  associ- 
ated with  a  bronchial  catarrh.  In  some  of  the  cases  it  is  probably  not  a 
fresh  infection  which  follows,  but  the  blazing  of  a  smouldering  fire.  Ty- 
phoid fever  is  thought  by  some  to  predispose  to  tuberculosis,  but  my  experi- 
ence is  opposed  to  this  view.  Of  other  affections,  influenza,  variola,  and 
syphilis  are  all  believed  to  favor  the  development  of  the  disease.  Diabetes, 
as  is  well  known,  very  often  terminates  in  pulmonary  tuberculosis,  par- 
ticularly in  young  persons. 

Chronic  heart-disease,  arterio-sclerosis,  aneurism  of  the  aorta,  forms  of 
chronic  nephritis,  cirrhosis  of  the  liver,  and  the  various  forms  of  cerebro- 
spinal sclerosis,  all  are  conditions  which  favor  infection.  It  is  remarkable 
in  how  many  of  the  subjects  of  these  disorders  in  general  hospital  practice 
the  fatal  event  is  a  terminal  acute  tuberculosis,  most  frequently  of  the 
serous  membranes.  Subjects  of  congenital  or  acquired  contraction  of  the 
orifice  of  the  pulmonary  artery  usually  die  of  tuberculosis.  On  the  other 
hand,  mitral  valve  disease,  particularly  stenosis,  is  stated  to  antagonize  the 
disease  (J.  E.  Graham).  In  children  catarrhal  entero-colitis  probably  favors 
the  development  of  tabes  mesenterica. 


270  SPECIFIC  INFECTIOUS  DISEASES. 

The  influence  of  hsemoptysis  and  pleurisy  will  be  referred  to  later. 

Trauma. — The  relation  of  injury  to  tuberculosis  is  well  known.  A  blow 
upon  the  chest  may  cause  a  pulmonary  or  pleural  tuberculosis;  injury  to 
the  knee,  a  tuberculous  arthritis;  a  blow  on  the  head,  tuberculous  meningi- 
tis. Probably  in  these  cases  the  injured  part  is  for  a  time  a  locus  minoris 
resistentice,  and  if  bacilli  are  present  they  may  receive  a  stimulus  to  growth 
or  under  the  altered  conditions  become  capable  of  multiplying.  Mendels- 
sohn reports  9  cases  in  which,  without  fracture  of  the  rib  or  laceration  of 
the  lung,  tuberculosis  developed  shortly  after  contusion  of  the  chest.  The 
whole  question  is  very  fully  discussed  by  Stern  in  his  recent  work  on  the 
relation  of  internal  disease  to  injury,  already  referred  to  in  the  section  on 
Pneumonia.  The  relation  of  surgical  intervention  in  local  tuberculosis  to 
the  generalization  of  the  disease  is  important.  An  existing  lesion  may  be 
aggravated,  and  fresh  local  lesions  may  appear,  and,  most  serious  of  all, 
acute  miliary  tuberculosis  may  follow. 

General  Morbid  Anatomy  and  Histology  of  Tuberculous 
Liesions. 

(1)  Distribution  of  the  Tubercles  in  the  Body, — The  organs  of  the 
body  are  variously  affected  by  tuberculosis.  In  adults,  the  lungs  may  be 
regarded  as  the  seat  of  election;  in  children,  the  lymph-glands,  bones,  and 
joints.  In  1,000  autopsies  there  were  275  cases  with  tuberculous  lesions. 
With  but  two  or  three  exceptions  the  lungs  were  affected.  The  distribu- 
tion in  the  other  organs  was  as  follows:  Pericardium,  7;  peritonaeum,  36; 
brain,  31;  spleen,  23;  liver,  12;  kidneys,  32;  intestines,  65;  heart,  4;  and 
generative  organs,  8. 

The  tuberculosis  which  comes  under  the  care  of  the  surgeon  has  a  dif- 
ferent distribution,  as  shown  by  the  following  figures  from  the  Wiirzburg 
clinic.  Among  8,873  patients,  1,287  were  tuberculous,  with  the  following 
distribution  of  lesions:  Bones  and  joints,  1,037;  lymph-glands,  196;  skin 
and  connective  tissues,  77;  mucous  membranes,  10;  genito-urinary  or- 
gans, 20. 

(2)  The  Changes  produced  by  the  Tubercle  Bacilli. 

(a)  The  Nodular  Tubercle. — The  body  which  we  term  a  "  tubercle " 
presents  in  its  early  formation  nothing  distinctive  or  peculiar,  either  in  its 
components  or  in  their  arrangement.  Identical  structures  are  produced  by 
other  parasites,  such  as  the  actinomyces,  and  by  the  strongylus  in  the  lungs 
of  sheep. 

The  researches  of  Baumgarten  have  enabled  us  to  follow  in  detail  the 
evolution  of  a  tubercle. 

(a)  The  multiplication  of  the  tubercle  bacilli,  which  is  rapid  and  is 
accompanied  by  their  dissemination  in  the  surrounding  tissues  partly  by 
growth,  partly  in  the  lymph  currents. 

(/?)  The  multiplication  of  the  fixed  cells,  especially  those  of  connective 
tissue  and  the  endothelium  of  the  capillaries,  and  the  gradual  production 
from  them  of  rounded,  cuboidal,  or  polygonal  bodies  with  vesicular  nuclei 
• — ^the  epithelioid  cells — inside  some  of  which  the  bacilli  are  soon  seen. 

(y)  From  the  vessels  of  the  infected  focus,  leucocytes,  chiefly  poly- 


TUBERCULOSIS.  2Yl 

nuclear,  migrate  in  numbers  and  accumulate  about  the  focus  of  infection. 
They  do  not  subdivide.  Many  undergo  rapid  destruction.  Later,  as  the 
little  tubercle  grows,  the  leucocytes  are  chiefly  of  the  mononuclear  variety 
(lymphocytes),  which  do  not  undergo  the  rapid  degeneration  of  the  poly- 
nuclear  forms. 

(8)  A  reticulum  of  fibres  is  formed  by  the  fibrillation  and  rarefaction 
of  the  connective-tissue  matrix.  This  is  most  apparent,  as  a  rule,  at  the 
margin  of  the  growth. 

(e)  In  some,  but  not  all,  tubercles  giant  cells  are  formed  by  an  increase 
in  the  protoplasm  and  in  the  nuclei  of  an  individual  cell,  or  possibly  by 
the  fusion  of  several  cells.  The  giant  cells  seem  to  be  in  inverse  ratio  to 
the  number  and  virulence  of  the  bacilli.  In  lupus,  joint  tuberculosis, 
and  scrofulous  glands,  in  which  the  bacilli  are  scanty,  the  giant  cells  are 
numerous;  while  in  miliary  tubercles  and  all  lesions  in  which  the  bacilli 
are  abundant  the  giant  cells  are  few  in  number. 

The  bacilli  then  cause,  in  the  first  place,  a  proliferation  of  the  fixed 
elements,  with  the  production  of  epithelioid  and  giant  cells;  and,  secondly, 
an  inflammatory  reaction,  associated  with  exudation  of  leucocytes.  How 
far  the  leucocytes  attack  and  destroy  the  bacilli  has  not  been  definitely 
settled — Metschnikoff  claiming,  Baumgarten  denying,  an  active  phago- 
cytosis. 

(3)  The  Degeneration  of  Tubercle. — There  are  two  chief  forms  of  de- 
generation: 

(a)  Caseation. — At  the  central  part  of  the  growth,  owing  to  the  direct 
action  of  the  bacilli  or  their  products,  a  process  of  coagulation  necrosis 
goes  on  in  the  cells,  which  lose  their  outline,  become  irregular,  no  longer 
take  stains,  and  are  finally  converted  into  '  a  homogeneous,  structureless 
substance.  Proceeding  from  the  centre  outward,  the  tubercle  may  be  grad- 
ually converted  into  a  yellowish-gray  body,  in  which,  however,  the  bacilli 
are  still  abundant.  No  blood-vessels  are  found  in  them.  Aggregated  to- 
gether these  form  the  cheesy  masses  so  common  in  tuberculosis,  which 
may  undergo  softening,  fibroid  limitation  (encapsulation),  or  calcification. 

(b)  Sclerosis. — With  the  necrosis  of  the  cell  elements  at  the  centre  of  the 
tubercle,  hyaline  transformation  proceeds,  together  with  great  increase  in 
the  fibroid  elements;  so  that  the  tubercle  is  converted  into  a  firm,  hard 
structure.  Often  the  change  is  rather  of  a  fibro-caseous  nature;  but  the 
sclerosis  predominates.  In  some  situations,  as  in  the  peritongeum,  this 
seems  to  be  the  natural  transformation  of  tubercle,  and  it  is  by  no  means 
rare  in  the  lungs. 

In  all  tubercles  two  processes  go  on:  the  one — caseation — destructive 
and  dangerous;  and  the  other — sclerosis — conservative  and  healing.  The 
ultimate  result  in  a  given  case  depends  upon  the  capabilities  of  the  body 
to  restrict  and  limit  the  growth  of  the  bacilli.  There  are  tissue-soils  in 
which  the  bacilli  are,  in  all  probability,  killed  at  once — the  seed  has  fallen 
ly  the  tcayside.  There  are  others  in  which  a  lodgment  is  gained  and  more 
or  less  damage  done,  but  finally  the  day  is  with  the  conservative,  protecting 
forces — the  seed  has  fallen  upon  stony  ground.  Thirdly,  there  are  tissue- 
soils  in  which  the  bacilli  grow  luxuriantly,  caseation  and  softening,  not 


272  SPECIFIC  INFECTIOUS  DISEASES. 

limitation  and  sclerosis,  prevail,  and  the  day  is  with  the  invaders — the  seed 
has  fallen  upon  good  ground. 

The  action  of  the  bacilli  injected  directly  into  the  blood-vessels  illus- 
trates many  points  in  the  histology  and  pathology  of  tuberculosis.  If  into 
the  vein  of  a  rabbit  a  pure  culture  of  the  bacilli  is  injected,  the  microbes 
accumulate  chiefly  in  the  liver  and  spleen.  The  animal  dies  usually  with- 
in two  weeks,  and  the  organs  apparently  show  no  trace  of  tubercles.  Micro- 
scopically, in  both  spleen  and  liver  the  young  tubercles  in  process  of  forma- 
tion are  very  numerous,  and  karyokinesis  is  going  on  in  the  liver-cells. 
After  an  injection  of  a  more  dilute  culture,  or  one  whose  virulence  has 
been  mitigated  by  age,  instead  of  dying  within  a  fortnight  the  animal  sur- 
vives for  five  or  sis  weeks,  by  which  time  the  tubercles  are  apparent  in  the 
spleen  and  liver,  and  often  in  the  other  organs. 

(4)  The  diffused  Inflammatory  Tubercle. — This  is  most  frequently  seen  in 
the  lungs.  Only  a  great  master  like  Virchow  could  have  won  the  profes- 
sion from  a  belief  in  the  unity  of  phthisis,  which  the  genius  of  Laennec 
had,  on  anatomical  ground,  announced.  Here  and  there  a  teacher,  as 
Wilson  Fox,  protested,  but  the  heresy  prevailed,  and  we  repeated  the  strik- 
ing aphorism  of  Niemeyer,  "  The  greatest  evil  which  can  happen  to  a  con- 
sumptive is  that  he  should  become  tuberculous."  It  was  thought  that  the 
products  of  any  simple  inflammation  might  become  caseous,  and  that  ordi- 
nary catarrhal  pneumonia  terminated  in  phthisis.  It  was  peculiarly  fitting 
that  from  Germany,  in  which  the  dualistie  heresy  arose,  the  truth  of  Laen- 
nec's,  views  should  receive  incontestable  proof,  in  the  demonstration  by 
Koch  of  the  etiological  unity  of  all  the  various  processes  known  as  tuber- 
culous and  scrofulous. 

Infiltrated  tubercle  results  from  the  fusion  of  many  small  foci  of  in- 
fection— so  small  indeed  that  they  may  not  be  visible  to  the  naked  eye,  but 
which  histologically  are  seen  to  be  composed  of  scattered  centres,  sur- 
rounded by  areas  in  which  the  air-cells  are  filled  with  the  products  of  exu- 
dation and  of  the  proliferation  of  the  alveolar  epithelium.  Under  the  influ- 
ence of  the  bacilli,  caseation  takes  place,  usually  in  small  groups  of  lobules, 
occasionally  in  an  entire  lobe,  or  even  the  greater  part  of  a  lung.  In  the 
early  stage  of  the  process,  the  tissue  has  a  gray  gelatinous  appearance,  the 
gray  infiltration  of  Laennec.  The  alveoli  contain  a  sero-fibrinous  fluid  with 
cells,  and  the  septa  are  also  infiltrated.  These  cells  accumulate  and  undergo 
coagulation  necrosis,  forming  areas  of  caseation,  the  infiltration  tuberculeuse 
jaune  of  Laennec,  the  scrofulous  or  cheesy  pneumonia  of  later  writers. 
There  may  also  be  a  diffuse  infiltration  and  caseation  without  any  special 
foci,  a  widespread  tuberculous  pneumonia  induced  by  the  bacilli. 

After  all,  the  two  processes  are  identical.  As  Baumgarten  states: 
"  There  is  no  well-marked  difference  between  miliary  tubercle  and  chronic 
caseous  pneumonia.  Speaking  histologically,  miliary  tuberculosis  is  noth- 
ing else  than  a  chronic  caseous  miliary  pneumonia,  and  chronic  caseous 
pneumonia  is  nothing  but  a  tuberculosis  of  the  lungs." 

(5)  Secondary  Inflammatory  Processes. — {a)  The  irritation  caused  by 
the  bacilli  invariably  produces  an  inflammation  which  may,  as  has  been 
described,  be  limited  to  exudation  of  leucocytes  and  serum,  but  may  also  be 


TUBERCULOSIS.  2Y3 

much  more  extensive,  and  which  varies  with  varying  conditions.  "We  find, 
for  example,  about  the  smaller  tvibercles  in  the  lungs,  pneumonia — either 
catarrhal  or  fibrinous,  proliferation  of  the  connective-tissue  elements  in  the 
septa  (which  also  become  infiltrated  with  round  cells),  and  changes  in  the 
blood  and  lymph-vessels. 

(b)  In  processes  of  minor  intensity  the  inflammation  is  of  the  slow 
reactive  nature,  which  results  in  the  production  of  a  cicatricial  connective 
tissue  which  limits  and  restricts  the  development  of  the  tubercles  and  is 
the  essential  conservative  element  in  the  disease.  It  is  to  be  remembered 
that  in  chronic  pulmonary  tuberculosis  much  of  the  fibroid  tissue  which  is 
present  is  not  in  any  way  associated  with  the  action  of  the  bacilli. 

(c)  Suppuration.  Do  the  bacilli  themselves  induce  suppuration?  In 
so-called  cold  tuberculous  abscess  the  material  is  not  histologically  pus, 
but  a  debris  consisting  of  broken-down  cells  and  cheesy  material.  It  is 
moreover  sterile — that  is,  does  not  contain  the  usual  pus  organisms.  The 
products  of  the  tubercle  bacilli  are  probably  able  to  induce  suppuration, 
as  in  joint  and  bone  tuberculosis  pus  is  frequently  produced,  although  this 
may  be  due  to  a  mixed  infection.  Koch,  it  will  be  remembered,  states 
that  the  "  tuberculin  "  is  one  of  the  best  agents  for  the  production  of  ex- 
perimental suppuration.  In  tuberculosis  of  the  lungs  the  suppuration  is 
largely  the  result  of  an  infection  with  pus  organisms. 

II.  Acute  Miliary  Tubeeculosis. 

The  modern  knowledge  of  this  remarkable  form  dates  from  the  state- 
ment of  Buhl  (1856),  that  miliary  tuberculosis  is  a  specific  infection  de- 
pendent on  the  presence  in  the  body  of  an  unencapsulated  yellow  tubercle, 
or  a  tuberculous  cavity  in  the  lung;  and  that  it  bears  the  same  relation  to 
the  primary  lesion  as  pyaemia  does  to.  a  focus  of  suppuration. 

Carl  Weigert  established  the  truth  of  this  brilliant  conception  by  dem- 
onstrating the  association  of  miliary  tuberculosis  with  tuberculosis  of  the 
blood  vessels.  There  are  two  groups  of  vessel  tubercle — the  tuberculous 
periangitis  in  which  there  is  invasion  of  the  adventitia,  and  the  endangitis 
in  which  the  tubercles  start  in  the  intima.  The  parts  most  frequently 
affected  are  the  pulmonary  veins  and  the  thoracic  duct,  less  often  the  jugu- 
lar vein,  the  suprarenal  and  the  vena  cava  superior,  and  the  sinuses  of  the 
dura  mater,  the  aorta,  and  the  endocardium.  To  the  branches  of  the  pul- 
monary veins  it  is  not  uncommon  to  find  caseous  glands  adherent,  penetrat- 
ing the  walls  and  showing  a  growth  of  miliary  tubercles  in  the  intima.  A 
special  interest  belongs  to  tuberculosis  of  the  thoracic  duct,  first  accurately 
described  and  thoroughly  studied  by  Sir  Astley  Cooper.  Benda  in  a  series 
of  19  cases  of  vessel  tuberculosis  found  in  many  instances  an  enormous  num- 
ber of  bacilli,  particularly  in  the  caseous  tubercles  of  the  thoracic  duct. 

Access  of  the  bacilli  to  the  blood  may  take  place  by  the  perforation  of 
an  extra-vascular  caseous  mass  into  the  lumen,  or  by  the  softening  and 
ulceration  of  a  focus  of  tuberculous  endangitis.  The  bacilli  do  not  increase 
in  the  blood,  but  settle  in  the  different  organs,  producing  a  generalized 
tuberculosis,  of  which  Weigert  recognizes  three  types  or  grades:  I.  The 


2Y4  SPECIFIC  INFECTIOUS  DISEASES. 

acute  general  miliary  tuberculosis,  in  which  the  various  organs  of  the  body 
are  stuffed  with  miliary  and  submiliary  nodules.  II.  A  second  form 
characterized  by  a  small  number  of  tubercles  in  one  or  many  organs. 
III.  The  occurrence  of  numerous  tuberculous  foci  widely  spread  through- 
out the  body,  but  in  a  more  chronic  form;  the  tubercles  are  larger  and 
many  are  caseous.  It  is  the  chronic  generalized  tuberculosis  of  children. 
Transitional  forms  between  these  groups  occur.  In  the  first  variety,  which 
we  are  here  considering,  there  is  an  eruption  into  the  circulation  of  an 
enormous  number  of  bacilli.  Benda  suggests  in  explanation  of  the  pro- 
found toxaemia  seen  in  certain  cases  (the  typhoid  form)  that  in  addition 
the  blood  is  surcharged  with  toxines  from  a  large  caseous  focus  which  has 
eroded  the  vessel. 

Clinical  Forms. — The  cases  may  be  grouped  into  those  with  the ' 
symptoms  of  an  acute  general  infection — the  typhoid  form;  cases  in  which 
pulmonary  symptoms  predominate;  and  cases  in  which  the  cerebral  or  cere- 
hro-spinal  symptoms  are  marked — tuberculous  meningitis. 

Other  forms  have  been  recognized,  but  this  division  covers  a  large  ma- 
jority of  the  cases. 

Taking  any  series  of  cases  it  will  be  found  that  the  meningeal  form  of 
acute  tuberculosis  exceeds  in  numbers  the  cases  with  general  or  marked 
pulmonary  symptoms. 

1.  General  or  Typhoid  Form. — Symptoms. — The  patient  here  presents 
the  symptoms  of  a  profound  infection  with  few  if  any  local  signs.  The 
cases  simulate  and  are  frequently  mistaken  for  typhoid  fever.  After  a 
period  of  failing  health,  with  loss  of  appetite,  the  patient  becomes  fever- 
ish and  weak.  Occasionally  the  disease  sets  in  more  abruptly,  but  in  many 
instances  the  anamnesis  closely  resembles  that  of  typhoid  fever.  Nose- 
bleeding,  however,  is  rare.  The  temperature  increases,  the  pulse  becomes 
rapid  and  feeble,  the  tongue  dry;  delirium  becomes  marked  and  the  cheeks 
are  flushed.  The  pulmonary  symptoms  may  be  very  slight;  usually  bron- 
chitis exists,  but  is  not  more  severe  than  is  common  with  typhoid  fever. 
The  pulse  is  seldom  dicrotic,  but  is  rapid  in  proportion  to  the  pyrexia.  Per- 
haps the  most  striking  feature  of  the  temperature  is  the  irregularity;  and 
if  seen  from  the  outset  there  is  not  the  steady  ascent  noted  in  typhoid  fever. 
There  is  usually  an  evening  rise  to  103°,  sometimes  104°,  and  a  morning 
remission  of  from  two  to  three  degrees.  Sometimes  the  pyrexia  is  intermit- 
tent, and  the  thermometer  may  register  below  normal  during  the  early 
morning  hours.  The  inverse  type  of  temperature,  in  which  the  rise  takes, 
place  in  the  morning,  is  held  by  some  writers  to  be  more  frequent  in  gen- 
eral tuberculosis  than  in  other  diseases.  In  rare  instances  there  may  be 
little  or  no  fever.  On  two  occasions  I  have  had  a  patient  admitted  to  my 
wards  in  a  condition  of  profound  debility,  with  a  history  of  illness  of  from' 
three  to  four  weeks'  duration,  with  rapid  pulse,  flushed  cheeks,  dry  tongue, 
and  very  slight  elevation  in  temperature,  in  whom  (post  mortem)  the  con- 
dition proved  to  be  general  tuberculosis.  In  one  instance  there  was  tol- 
erably extensive  disease  at  the  right  apex.  Eeinhold,  from  Biiumler's 
clinic,  has  recently  called  attention  to  these  afebrile  forms  of  acute  tuber- 
culosis.    In  9  of  52  cases  there  was  no  fever,  or  only  a  transient  rise. 

In  a  considerable  number  of  these  cases  the  respirations  are  increased 


TUBERCULOSIS.  275 

in  frequency,  particularly  in  the  early  stage,  and  there  may  be  signs  of  dif- 
fuse bronchitis  and  slight  cyanosis.  Cheyne-Stokes  breathing  develops 
toward  the  close. 

Active  delirium  is  rare.  More  commonly  there  are  torpor  and  dulness, 
gradually  deepening  into  coma,  in  which  the  patient  dies.  In  some  cases 
the  pulmonary  symptoms  become  more  marked;  in  others,  meningeal  or 
cerebral  features  develop. 

Diagnosis. — The  differential  diagnosis  between  general  miliary  tuber- 
culosis without  local  manifestations  and  typhoid  fever  is  extremely  diffi- 
cult. A  point  of  importance,  to  which  reference  has  already  been  made, 
is  the  irregularity  of  the  temperature  curve.  The  greater  frequency  of 
the  respirations  and  the  tendency  to  slight  cyanosis  is  much  more  com- 
mon in  tuberculosis.  There  are  cases,  however,  of  typhoid  fever  in  which 
the  initial  bronchitis  is  severe  and  may  lead  to  dyspnoea  and  disturbed 
oxygenation.  The  cough  may  be  slight  or  absent.  Diarrhoea  is  rare  in 
tuberculosis;  the  bowels  are  usually  constipated;  but  diarrhoea  may  occur 
and  persist  for  days.  In  certain  cases  the  diagnosis  has  been  complicated 
still  further  by  the  occurrence  of  blood  in  the  stools.  Enlargement  of  the 
spleen  occurs  in  general  tuberculosis,  but  is  neither  so  early  nor  so  marked 
as  in  typhoid  fever.  In  children,  however,  the  enlargement  may  be  con- 
siderable. The  urine  may  show  traces  of  albumin,  and  unfortunately 
Ehrlich's  diazo-reaction,  which  is  so  constant  in  typhoid  fever,  is  also  met 
with  in  general  tuberculosis.  The  absence  of  the  characteristic  roseola  is 
an  important  feature.  Occasionally  in  acute  tuberculosis  reddish  spots 
may  develop  and  for  a  time  cause  difficulty,  but  they  do  not  come  out  in 
crops,  and  rarely  have  the  characters  of  the  true  typhoid  eruption.  Herpes 
is  perhaps  more  common  in  tuberculosis.  Toward  the  close,  petechias  may 
appear  on  the  skin,  particularly  about  the  wrists.  A  rare  event  is  Jaundice, 
due  possibly  to  the  eruption  of  tubercles  in  the  liver.  It  is  to  be  remem- 
bered that  the  lesions  of  acute  tuberculosis  and  of  typhoid  fever  have  been 
demonstrated  in  the  same  body. 

A  negative  Widal  test  and  the  absence  of  typhoid  bacilli  in  bloods 
cultures  may  be  of  decisive  importance  in  these  doubtful  cases.  In  very  rare 
instances  tubercle  bacilli  have  been  found  in  the  blood.  Leucocytosis  is 
more  common  in  miliary  tuberculosis  than  in  typhoid  fever  in  which  leu- 
copenia  is  the  rule.  Careful  examination  of  the  eyes  may  show  choroidal 
tubercles,  though  I  have  never  known  a  diagnosis  made  on  their  presence 
alone.  In  the  fluid  obtained  by  lumbar  puncture  the  tubercle  bacilli  may 
be  abundant  and,  as  in  a  recent  case,  clinch  at  once  the  diagnosis. 

2.  Pulmonary  Form. — Symptoms. — From  the  outset  the  pulmonary 
symptoms  are  marked.  The  patient  may  have  had  a  cough  for  months  or 
for  years  without  much  impairment  of  health,  or  he  may  be  known  to  be 
the  subject  of  chronic  pulmonary  tuberculosis.  In  other  instances,  particu- 
larly in  children,  the  affection  follows  measles  or  whooping-cough,  and 
is  of  a  distinctly  broncho-pneumonic  type.  The  disease  begins  with  the 
symptoms  of  diffuse  bronchitis.  The  cough  is  marked,  the  expectoration 
muco-purulent,  occasionally  rusty.  Haemoptysis  has  been  noted  in  a  few 
instances.     From  the  outset  dyspnoea  is  a  striking  feature  and  may  be  out 


276  SPECIFIC  INFECTIOUS  DISEASES. 

of  proportion  to  the  intensity  of  the  physical  signs.  There  is  more  or  less 
cyanosis  of  the  lips  and  finger-tips,  and  the  cheeks  are  suffused.  Apart 
from  emphysema  and  the  later  stages  of  severe  pneumonia  I  know  of  no 
other  pulmonary  condition  in  which  the  cyanosis  is  so  marked.  The  phys- 
ical signs  are  those  of  bronchitis.  In  children  there  may  be  defective  reso- 
nance at  the  bases,  from  scattered  areas  of  broncho-pneumonia;  or,  what  is 
equally  suggestive,  areas  of  hyper-resonance.  Indeed,  the  percussion  note, 
particularly  in  the  front  of  the  chest,  in  some  cases  of  miliary  tuberculosis, 
is  full  and  clear,  and  it  will  be  noted  (post  mortem)  that  the  lungs  are 
unusually  voluminous.  This  is  probably  the  result  of  more  or  less  wide- 
spread acute  emphysema.  On  auscultation,  the  rales  are  either  sibilant- 
and  sonorous  or  small,  fine,  and  crepitant.  There  may  be  fine  crepitation 
from  the  occurrence  of  tubercles  on  the  pleura  (Jlirgensen).  In  children 
there  may  be  high-pitched  tubular  breathing  at  the  bases  or  toward  the 
root  of  the  lung.  Toward  the  close  the  rales  may  be  larger  and  more  mu- 
cous. The  temperature  rises  to  102°  or  103°,  and  may  present  the  inverse 
type.  The  pulse  is  rapid  and  feeble.  In  the  very  acute  cases  the  spleen 
is  always  enlarged.  The  disease  may  prove  fatal  in  ten  or  twelve  days,  or 
may  be  protracted  for  weeks  or  even  months. 

Diagnosis. — The  diagnosis  of  this  form  offers  less  difficulty  and  is  more 
frequently  made.  There  is  often  a  history  of  previous  cough,  or  the  patient 
is  known  to  be  the  subject  of  local  disease  of  the  lung,  or  of  the  Ijonph- 
glands,  or  of  the  bones.  In  children  these  symptoms  following  measles 
or  whooping-cough  indicate  in  the  majority  of  cases  acute  miliary  tuber- 
culosis, with  or  without  broncho-pneumonia.  Occasionally  the  sputum  eon- 
tains  tubercle  bacilli. 

The  choroidal  tubercle  occurs  in  a  limited  number  of  cases  and  may 
help  the  diagnosis.  More  important  in  an  adult  is  the  combination  of 
dyspnoea  with  cyanosis  and  the  signs  of  a  diffuse  bronchitis.  In  some  in- 
stances the  occurrence  of  cerebral  symptoms  at  once  gives  a  clew  to  the 
nature  of  the  trouble. 

3.  Meningeal  Form  (Tiiberculous  Meningitis,  Basilar  Meningitis). — This 
affection,  which  is  also  known  as  acute  hydrocephalus  or  "  water  on  the 
brain,"  is  essentially  an  acute  tuberculosis  in  which  the  membranes  of  the 
brain,  sometimes  of  the  cord,  bear  the  brunt  of  the  attack.  Our  first  ac- 
curate knowledge  of  this  affection  dates  from  the  publication  of  Eobert 
Whytt's  Observations  on  the  Dropsy  of  the  Brain,  Edinburgh,  1768.  The 
literature  is  very  fully  given  in  the  last  edition  of  Barthez  and  Sannee. 

Though  Guersant  had  as  early  as  1827  used  the  name  granular  7nenin- 
gitis  for  this  form  of  inflammation  of  the  meninges,  it  was  not  until  1830 
that  Papavoine  demonstrated  the  nature  of  the  granules  and  noted  their 
occurrence  with  tubercles  in  other  parts. 

In  1832  and  1833,  W.  W.  Gerhard,  of  Philadelphia,  made  a  very  careful 
study  of  the  disease  in  the  Children's  Hospital  at  Paris,  and  his  publica- 
tions, more  than  those  of  any  other  author,  served  to  place  the  disease  on 
a  firm  anatomical  and  clinical  basis. 

There  are  several  special  etiological  factors  in  connection  with  this  form. 
It  is  much  more  common  in  children  than  in  adults.    It  is  rare  during  the 


TUBERCULOSIS.  277 

first  year  of  life,  more  frequent  between  the  second  and  the  fifth  years. 
In  a  majority  of  the  cases  a  focus  of  old  tuberculous  disease  will  be  found, 
commonly  in  the  bronchial  or  mesenteric  glands.  In  a  few  instances  the 
affection  seems  to  be  primary  in  the  meninges.  It  is  very  difficult,  how- 
ever, in  an  ordinary  post  mortem  to  make  an  exhaustive  search,  and  the 
lesion  may  be  in  the  bones,  sometimes  in  the  middle  ear,  or  in  the  genito- 
urinary organs.  In  those  instances  in  which  no  primary  focus  has  been 
discovered  it  has  been  suggested  that  the  bacilli  reach  the  meninges  through 
the  cribriform  plate  of  the  ethmoid  from  the  upper  part  of  the  nostrils,  but 
this  is  not  probable. 

Morbid  Anatomy. — Tuberculous  meningitis  presents  a  very  character- 
istic picture.  The  meninges  at  the  base  are  most  involved,  hence  the  term 
basilar  meningitis.  The  parts  about  the  optic  chiasm,  the  Sylvian  fissures, 
and  the  interpeduncular  space  are  affected.  There  may  be  only  slight  tur- 
bidity and  matting  of  the  membranes,  and  a  certain  stickiness  with  serous 
infiltration;  but  more  commonly  there  is  a  turbid  exudate,  fibrino-purulent 
in  character,  which  covers  the  structures  at  the  base,  surrounds  the  nerves, 
-extends  out  into  the  Sylvian  fissures,  and  appears  on  the  lateral,  rarely  on 
the  upper,  surfaces  of  the  hemispheres.  The  tubercles  may  be  very  appar- 
ent, particularly  in  the  Sylvian  fissures,  appearing  as  small,  whitish  nodules 
on  the  membranes.  They  vary  much  in  number  and  size,  and  may  be 
difficult  to  find.  The  amount  of  exudate  bears  no  definite  relation  to  the 
abundance  of  tubercles.  The  arteries  of  the  anterior  and  posterior  per- 
forated spaces  should  be  carefully  withdrawn  and  searched,  as  upon  them 
nodular  tubercles  may  be  found  when  not  present  elsewhere.  In  doubtful 
cases  the  middle  cerebral  arteries  should  be  very  carefully  removed,  spread 
on  a  glass  plate  with  a  black  background,  and  examined  with  a  low  ob- 
jective. The  tubercles  are  then  seen  as  nodular  enlargements  on  the  smaller 
arteries.  The  lateral  ventricles  are  dilated  (acute  hydrocephalus)  and  con- 
tain a  turbid  fluid;  the  ependyma  may  be  softened,  and  the  septum  lucidum 
and  fornix  are  usually  broken  down.  The  convolutions  are  often  flattened 
and  the  sulci  obliterated  owing  to  the  increased  intra-ventricular  pressure. 
There  is  a  tuberculous  endarteritis  with  the  formation  of  intimal  tuber- 
cles, due  to  implantation  of  bacilli  from  the  blood  (Hektoen).  Prolifera- 
tion in  the  adventitia,  with  invasion  of  the  media  and  intima  are  common, 
forming  nodular  circumscribed  tubercles.  The  lumen  of  the  vessel  is  nar- 
rowed and  thrombosis  may  result.  The  meninges  are  not  alone  involved, 
but  the  contiguous  cerebral  substance  is  more  or  less  cedematous  and  infil- 
trated with  leucocytes,  so  that  anatomically  the  condition  is  in  reality  a 
meningo-encephalitis. 

There  are  instances  in  which  the  acute  process  is  associated  with  chronic 
meningeal  tuberculosis;  cases  which  may  for  months  present  the  clinical 
picture  of  brain  tumor. 

Although  in  a  majority  of  instances  the  process  is  cerebral,  the  spinal 
meninges  may  also  be  involved,  particularly  those  of  the  cervical  cord. 
There  are  cases  indeed  in  which  the  symptoms  are  chiefly  spinal.  A  sailor, 
who  had  fallen  on  the  deck  three  weeks  before  his  death,  was  admitted  to 
the  Montreal  General  Hospital.     He  presented  signs  of  meningitis,  chiefly 


278  SPECIFIC  INFECTIOUS  DISEASES. 

spinal,  which,  were  naturally  attrihuted  to  traumatism.  The  post  mortem 
showed  absence  of  tubercles  and  lymph  at  the  base  of  the  brain,  and  an 
extensive  eruption  of  miliary  tubercles  with  much  turbid  lymph  over  the 
entire  spinal  meninges.  There  were  small  cheesy  masses  at  the  apices  of 
the  lungs. 

Symptoms. — Tuberculous  meningitis  presents  an  extremely  complex 
clinical  picture.    It  will  be  best  to  describe  the  form  found  in  children. 

Prodromal  symptoms  are  common.  The  child  may  have  been  in  fail- 
ing health  for  some  weeks,  or  may  be  convalescent  from  measles  or  whoop- 
ing-cough. In  many  instances  there  is  a  history  of  a  fall.  The  child  gets 
thin,  is  restless,  peevish,  irritable,  loses  its  appetite,  and  the  disposition 
may  completely  change.  Symptoms  pointing  to  the  disease  may  then  set 
in,  either  quite  suddenly  with  a  convulsion,  or  more  commonly  with  head- 
ache, vomiting,  and  fever,  three  essential  symptoms  of  the  onset  which 
are  rarely  absent.  The  pain  may  be  intense  and  agonizing.  The  child 
puts  its  hand  to  its'  head  and  occasionally,  when  the  pain  becomes  worse, 
gives  a  short,  sudden  cry,  the  so-called  hydrocephalic  cry.  Sometimes  the 
child  screams  continuously  until  utterly  exhausted.  I  saw  in  "West  Phil- 
adelphia a  case  of  basilar  meningitis  in  a  girl  of  thirteen,  who  for  three 
days,  when  not  under  the  influence  of  a  powerful  sedative  or  of  chloro- 
form, screamed  at  the  top  of  her  voice  so  as  to  be  heard  a  square  or  more 
away.  The  vomiting  is  without  apparent  cause,  and  is  independent  of  tak- 
ing of  food.  Constipation  is  usually  present.  The  fever  is  slight,  but 
gradually  rises  to  103°  or  103°.  The  pulse  is  at  first  rapid,  subsequently 
irregular  and  slow.  The  respirations  are  rarely  altered.  During  sleep  the 
child  is  restless  and  disturbed.  There  may  be  twitchings  of  the  muscles, 
or  sudden  startings;  or  the  child  may  wake  up  from  sleep  in  great  terror. 
In  this  early  stage  the  pupils  are  usually  contracted.  These  are  the  chief 
symptoms  of  the  initial  stage,  or,  as  it  is  termed,  the  stage  of  irritation. 

In  the  second  period  of  the  disease  these  irritative  symptoms  subside; 
vomiting  is  no  longer  marked,  the  abdomen  becomes  retracted,  boat-shaped 
or  carinated.  The  bowels  are  obstinately  constipated,  the  child  no  longer 
complains  of  headache,  but  is  dull  and  apathetic,  and  when  roused  is  more 
or  less  delirious.  The  head  is  often  retracted  and  the  child  utters  an  occa- 
sional cry.  The  pupils  are  dilated  or  irregular,  and  a  squint  may  develop. 
Sighing  respiration  is  common.  Convulsions  may  occur,  or  rigidity  of 
the  muscles  of  one  side  or  of  one  limb.  The  temperature  is  variable,  rang- 
ing from  100°  to  103.5°.  A  blotchy  erythema  is  not  uncommon  on  the 
skin.  If  the  finger-nail  is  drawn  across  the  skin  of  any  region  a  red  line 
comes  out  quickly,  the  so-called  tache  cerebrate,  which,  however,  has  no  diag- 
nostic significance. 

In  the  final  period,  or  stage  of  paralysis,  the  coma  increases  and  the 
child  cannot  be  roused.  Convulsions  are  not  infrequent,  and  there  are 
spasmodic  contractions  of  the  muscles  of  the  back  and  neck.  Spasms  may 
occur  in  the  limbs  of  one  side.  Optic  neuritis  and  paralysis  of  the  ocular 
muscles  may  be  present.  The  pupils  become  dilated,  the  eyelids  are  only 
partially  closed,  and  the  eyeballs  are  rolled  up  so  that  the  corner  are  only 
uncovered  in  part  by  the  upper  eyelids.     Diarrhoea  may  occur,  the  pulse 


TUBERCULOSIS.  279 

becomes  rapid,  and  the  child  may  sink  into  a  typhoid  state  with  dry  tongue, 
low  delirium,  and  involuntary  passages  of  urine  and  fseces.  The  tempera- 
ture often  becomes  subnormal,  sinking  in  rare  instances  to  93°  or  94°.  In 
some  cases  there  is  an  ante-mortem  elevation  of  temperature,  the  fever  rising 
to  106°.  The  entire  duration  of  the  disease  is  from  a  fortnight  to  three 
or  four  weeks.  A  leucocytosis  is  not  infrequently  present  throughout  the 
disease. 

There  are  cases  of  tuberculous  meningitis  which  pursue  a  more  rapid 
course.  They  set  in  with  great  violence,  often  in  persons  apparently  in 
good  health,  and  may  prove  fatal  within  a  few  days.  In  these  instances, 
more  commonly  seen  in  adults,  the  convex  surface  of  the  brain  is  usually 
involved.  There  are  again  instances  which  are  essentially  chronic  and 
display  symptoms  of  a  limited  meningitis;  sometimes  with  pronounced 
psychical  symptoms,  and  sometimes  with  those  of  cerebral  tumor. 

There  are  certain  features  which  call  for  special  comment. 

The  irregularity  and  slowness  of  the  pulse  in  the  early  and  middle 
stages  of  the  disease  are  points  upon  which  all  authors  agree.  Toward  the 
close,  as  the  heart's  action  becomes  weaker,  the  pulsations  are  more  fre- 
quent. The  temperature  is  usually  elevated,  but  there  are  instances  in 
which  it  does  not  rise  in  the  whole  course  of  the  disease  much  above  100°. 
It  may  be  extremely  irregular,  and  the  oscillations  are  often  as  much  as 
three  or  four  degrees  in  the  day.  Toward  the  close  the  temperature  may 
sink  to  95°,  occasionally  to  94°,  or  there  may  be  hyperpyrexia.  In  a  case 
of  Baumler's  the  temperature  rose  before  death  to  43.7°  C.  (110.7°  F.). 

The  ocular  symptoms  of  the  disease  are  of  special  importance.  In  the 
early  stages  narrowing  of  the  pupils  is  the  rule.  Toward  the  close,  with 
increase  in  the  intra-cranial  pressure,  the  pupils  dilate  and  are  irregular. 
There  may  be  conjugate  deviation  of  the  eyes.  Of  ocular  palsies  the  third 
nerve  is  most  frequently  involved,  sometimes  with  paralysis  of  the  face, 
limbs,  and  hypoglossal  nerve  on  the  opposite  side  (syndrome  of  Weber),  due 
to  a  lesion  limited  to  the  inferior  and  internal  part  of  the  crus.  The 
changes  in  the  eye-grounds  are  very  important.  Neuritis  is  the  most  com- 
mon. According  to  Gowers,  the  disk  at  first  becomes  full  colored  and  has 
hazy  outlines,  and  the  veins  are  dilated.  Swelling  and  striation  become  pro- 
nounced, but  the  neuritis  is  rarely  intense.  Of  26  cases  studied  by  Gar- 
lick,  in  6  the  condition  was  of  diagnostic  value.  The  tubercles  in  the 
choroid  are  rare  and  much  less  frequently  seen  during  life  than  post-mortem 
figures  would  indicate.  Thus  Litten  found  them  (post  mortem)  in  39  out 
of  52  cases.  They  were  present  in  only  1  of  the  26  cases  of  tuberculous 
meningitis  examined  by  Garlick.  Heinzel  examined  with  negative  results 
41  eases. 

Among  the  motor  symptoms  convulsions  are  most  common,  but  there 
are  other  changes  which  deserve  special  mention.  A  tetanic  contraction 
of  one  limb  may  persist  for  several  days,  or  a  cataleptic  condition.  Tremor 
and  athetoid  movements  are  sometimes  seen.  The  paralyses  are  either 
hemiplegias  or  monoplegias.  Hemiplegia  may  result  from  disturbance  in 
the  cortical  branches  of  the  middle  cerebral  artery,  occasionally  from  soften- 
ing in  the  internal  capsule,  due  to  involvement  of  the  central  branches. 


280  SPECIFIC  INFECTIOUS  DISEASES. 

Of  monoplegias,  that  of  the  face  is  perhaps  most  common,  and  if  on  the 
right  side  it  may  occur  with  aphasia.  In  two  of  my  cases  in  adults  aphasia 
developed.  Brachial  monoplegia  may  be  associated  with  it.  In  the  more 
chronic  cases  the  symptoms  persist  for  months,  and  there  may  be  a  char- 
acteristic Jacksonian  epilepsy.  Kernig's  sign  is  present  as  a  rule  (see 
Cerebro-spinal  Fever). 

The  diagnosis  of  tuberculous  meningitis  is  rarely  difficult,  and  points 
upon  which  special  stress  is  to  be  laid  are  the  existence  of  a  tuberculous 
focus  in  the  body,  the  mode  of  onset  and  the  symptoms,  and  the  evidence 
obtained  on  lumbar  puncture.  The  fluid  withdrawn  is  usually  turbid,  and 
in  it,  on  centrifugali^ing,  the  bacilli  may  be  discovered.  A  sterile  fluid, 
which  is  sometimes  present,  also  favors  the  diagnosis  of  tuberculous  menin- 
gitis. 

The  prognosis  in  this  form  of  meningitis  is  always  most  serious.  I  have 
neither  seen  a  case  which  I  regarded  as  tuberculous  recover,  nor  have  I 
seen  post-mortem  evidence  of  past  disease  of  this  nature.  Cases  of  recovery 
have  been  reported  by  reliable  authorities,  but  they  are  extremely  rare,  and 
there  is  always  a  reasonable  doubt  as  to  the  correctness  of  the  diagnosis. 
The  differential  features  and  treatment  will  be  considered  in  connection 
with  acute  meningitis. 

III.    TUBEECTJLOSIS   OF   THE   LYMPHATIC   SYSTEM. 

1.  Tuberculosis  of  the  Lympli-glaiids  (Scrofula). 

Scrofula  is  tubercle,  as  it  has  been  shown  that  the  bacillus  of  Koch  is 
the  essential  element.  Formerly  special  attention  was  given  to  different 
types  of  scrofula,  of  which  two  important  forms  were  recognized — the  san- 
guine, in  which  the  child  was  slightly  built,  tall,  with  small  limbs,  a  fine 
clear  skin,  soft  silky  hair,  and  was  mentally  very  bright  and  intelligent; 
and  the  phlegmatic  type,  in  which  the  child  was  short  and  thick-set,  with 
coarse  features,  muddy  complexion,  and  a  dull,  heavy  aspect.  It  is  not  yet 
definitely  settled  whether  the  virus  which  produces  the  chronic  tuberculous 
adenitis  or  scrofula  differs  from  that  which  produces  tuberculosis  in  other 
parts,  or  whether  it  is  the  local  conditions  in  the  glands  which  account 
for  the  slow  development  and  milder  course.  The  experiments  of  Arloing 
would  indicate  that  the  virus  was  attenuated  or  milder,  for  he  has  shown 
that  the  caseous  material  of  a  lymph-gland  killed  guinea-pigs,  while  rab- 
bits escaped.  The  guinea-pig,  as  is  well  known,  is  the  more  susceptible 
animal  of  the  two.  The  observations  of  Lingard  are  still  more  conclusive, 
as  showing  a  variation  in  the  virulence  of  the  tubercle  bacillus.  Guinea- 
pigs  inoculated  with  ordinary  tubercle  showed  lymphatic  infection  within 
the  first  week,  and  the  animals  died  within  three  months;  infected  with 
material  from  scrofulous  glands,  the  lymphatic  enlargement  did  not  ap- 
pear until  the  second  or  third  week,  and  the  animals  survived  for  six  or 
seven  months.  He  showed,  moreover,  that  the  virulence  of  the  infection  ob- 
tained from  the  scrofulous  glands  increased  in  intensity  by  passing  through 
a  series  of  guinea-pigs.  Eve's  experiments  show  that  scrofulous  material 
invariably  produces  tuberculosis  in  guinea-pigs  and  very  often  in  rabbits. 


TUBERCULOSIS.  281 

Tuberculous  adenitis  is  met  with  at  all  ages.  It  is  more  common  in 
children  than  in  adults,  but  it  is  not  infrequent  in  the  middle  period  of 
life,  and  may  occur  in  old  age. 

The  tubercle  bacillus  is  ubiquitous.  All  are  exposed  to  infection,  and 
upon  the  local  conditions,  whether  favorable  or  unfavorable,  depend  the 
fate  of  those  organisms  which  find  lodgment  in  our  bodies.  It  is  possible, 
of  course,  that  tuberculous  adenitis  may  be  congenital,  but  such  instance* 
must  be  extremely  rare.  A  special  predisposing  factor  in  lymphatic  tuber- 
culosis is  catarrhal  inflammation  of  the  mucous  membranes,  which  in  itself 
excites  slight  adenitis  of  the  neighboring  glands.  In  a  child  with  con- 
stantly recurring  naso-pharyngeal  catarrh,  the  bacilli  which  lodge  on  the 
mucous  membranes  find  in  all  probability  the  gateways  less  strictly  guarded 
and  are  taken  up  by  the  lymphatics  and  passed  to  the  nearest  glands.  The 
importance  of  the  tonsils  as  an  infection-atrium  has  of  late  been  urged. 
In  conditions  of  health  the  local  resistance,  or,  as  some  would  put  it,  the 
phagocytes,  would  be  active  enough  to  deal  with  the  invaders,  but  the  irri- 
tation of  a  chronic  catarrh  weakens  the  resistance  of  the  lymph-tissue  and 
the  bacilli  are  enabled  to  develop  and  gradually  to  change  a  simple  into 
a  tuberculous  adenitis.  The  frequent  association  of  tuberculous  adenitis 
of  the  bronchial  glands  with  whooping-cough  and  with  measles,  and  the 
frequent  development  of  tubercle  in  the  mesenteric  glands  in  children  with 
intestinal  catarrh,  find  in  this  way  a  rational  explanation.  After  all,  as 
Yirchow  pointed  out,  an  increased  vulnerability  of  the  tissue,  however 
brought  about,  is  the  important  factor  in  the  disease. 

The  following  are  some  of  the  features  of  interest  in  tuberculous  ade- 
nitis: 

(a)  The  local  character  of  the  disease.  Thus,  the  glands  of  the  neck,  or 
at  the  bifurcation  of  the  bronchi,  or  those  of  the  mesentery,  may  be  alone 
involved. 

(h)  The  tendency  to  spontaneous  healing.  In  a  large  proportion  of 
the  cases  the  battle  which  ensues  between  the  bacilli  and  the  tissue-cells  is 
long;  but  the  latter  are  finally  successful,  and  we  find  in  the  calcified 
remnants  in  the  bronchial  and  mesenteric  lymph-glands  evidences  of  vic- 
tory. Too  often  in  the  bronchial  glands  a  truce  only  is  declared  and  hos- 
tilities may  break  out  afresh  in  the  form  of  an  acute  tuberculosis. 

(c)  The  tendency  of  tuberculous  adenitis  to  pass  on  to  suppuration. 
The  frequency  with  which,  particularly  in  the  glands  of  the  neck,  we  find 
the  tuberculous  processes  associated  with  pus  is  a  special  feature  of  this 
form  of  adenitis.  In  nearly  all  instances  the  pus  is  sterile.  Whether  the 
suppuration  is  excited  by  the  bacilli  or  by  their  products,  or  whether  it  is 
the  result  of  a  mixed  infection  with  pus  organisms,  which  are  subsequently 
destroyed,  has  not  been  settled. 

(d)  The  existence  of  an  unhealed  focus  of  tuberculous  adenitis  is  a 
constant  menace  to  the  organism.  It  is  safe  to  say  that  in  three  fourths  of 
the  instances  of  acute  tuberculosis  the  infection  is  derived  from  this  source. 
On  the  other  hand,  it  has  been  urged  that  scrofula  in  childhood  gives  a  sort 
of  protection  against  tuberculosis  in  adult  life.  "We  certainly  do  meet  with 
many  persons  of  exceptional  bodily  vigor  who  in  childhood  had  enlarged 


282  SPECIFIC  INFECTIOUS  DISEASES. 

glands,  but  the  evidence  which  Marfan  brings  forward  in  support  of  this 
view  is  not  conclusive. 

Clinical  Forms. — 1.  Generalized   Tuberculous   Lymphadenitis. — In 

exceptional  instances  we  find  diffuse  tuberculosis  of  nearly  all  the  lymph- 
glands  of  the  body  with  little  or  no  involvement  of  other  parts.  The  most 
extreme  cases  of  it,  which  I  have  seen,  have  been  in  negro  patients.  Two 
well-marked  cases  occurred  at  the  Philadelphia  Hospital.  In  a  woman, 
the  chart  from  April,  1888,  until  March,  1889,  showed  persistent  fever, 
ranging  from  101°  to  103°,  occasionally  rising  to  104°.  On  December  16th 
the  glands  on  the  right  side  of  the  neck  were  removed.  After  an  attack 
of  erysipelas,  on  February  17th,  she  gradually  sank  and  died  March  5th. 
The  lungs  presented  only  one  or  two  puckered  spots  at  the  apices.  The 
bronchial,  retro-peritoneal,  and  mesenteric  glands  were  greatly  enlarged 
and  caseous.  There  was  no  intestinal,  uterine,  or  bone  disease.  The  con- 
tinuous high  fever  in  this  case  depended  apparently  upon  the  tuberculous 
adenitis,  which  was  much  more  extensive  than  was  supposed  during  life. 
In  these  instances  the  enlargement  is  most  marked  in  the  retro-peritoneal, 
bronchial,  and  mesenteric  glands,  but  may  be  also  present  in  the  groups  of 
external  glands.  Occurring  acutely,  it  presents  a  picture  resembling  Hodg- 
kin's  disease.  In  a  case  which  died  in  the  Montreal  General  Hospital  this 
diagnosis  was  made.  The  cervical  and  axillary  glands  were  enormously  en- 
larged, and  death  was  caused  by  infiltration  of  the  larynx.  In  infants  and 
children  there  is  a  form  of  general  tuberculous  adenitis  in  which  the  vari- 
ous groups  of  glands  are  successively,  more  rarely  simultaneously,  involved, 
and  in  which  death  is  caused  either  by  cachexia,  or  by  an  acute  infection 
of  the  meninges. 

2.  Local  Tuberculous  Adenitis. — (a)  Cervical — This  is  the  most  com- 
mon form  met  with  in  children.  It  is  seen  particularly  among  the  poor 
and  those  who  live  continuously  in  the  impure  atmosphere  of  badly  venti- 
lated lodgings.  Children  in  foundling  hospitals  and  asylums  are  specially 
prone  to  the  disease.  In  this  country  it  is  most  common  in  the  negro  race. 
As  already  stated,  it  is  often  met  with  in  catarrh  of  the  nose  and  throat,  or 
chronic  enlargement  of  the  tonsils;  or  the  child  may  have  had  eczema 
of  the  scalp  or  a  purulent  otitis. 

The  submaxillary  glands  are  first  involved,  and  are  popularly  spoken 
of  as  enlarged  Jcernels.  They  are  usually  larger  on  one  side  than  on  the 
other.  As  they  increase  in  size,  the  individual  tumors  can  be  felt;  the 
surface  is  smooth  and  the  consistence  firm.  They  may  remain  isolated,  but 
more  commonly  they  form  large,  knotted  masses,  over  which  the  skin  is, 
as  a  rule,  freely  movable.  In  many  cases  the  skin  ultimately  becomes 
adherent,  and  inflammation  and  suppuration  occur.  An  abscess  points  and, 
unless  opened,  bursts,  leaving  a  sinus  which  heals  slowly.  The  disease 
is  frequently  associated  with  coryza,  with  eczema  of  the  scalp,  ear,  or  lips, 
and  with  conjunctivitis  or  keratitis.  When  the  glands  are  large  and  grow- 
ing actively,  there  is  fever.  The  subjects  are  usually  ansemic,  particularly 
if  suppuration  has  occurred.  The  progress  of  this  form  of  adenitis  is  slow 
and  tedious.  Death,  however,  rarely  follows,  and  many  aggravated  cases 
in  children  ultimately  get  well.    Not  only  the  submaxillary  group,  but  the 


TUBERCULOSIS.  283 

glands  above  the  clavicle  and  in  the  posterior  cervical  triangle,  may  be 
involved.  In  other  instances  the  cervical  and  axillary  glands  are  involved 
together,  forming  a  continuous  chain  which  extends  beneath  the  clavicle 
and  the  pectoral  muscle.  With  them  the  bronchial  glands  may  also  be 
enlarged  and  caseous.  Kot  infrequently  the  enlargement  of  the  supra- 
clavicular and  axillary  group  of  glands  on  one  side  precedes  the  develop- 
ment of  a  tuberculous  pleurisy  or  of  pulmonary  tuberculosis. 

(b)  Tracheo-hronchial. — The  mediastinal  lymph-glands  constitute  filters 
in  which  lodge  the  various  foreign  particles  which  escape  the  normal 
phagocytes  of  bronchi  and  lungs.  Among  these  foreign  particles,  and  prob- 
ably attached  to  them,  tubercle  bacilli  are  not  uncommon,  and  we  find 
tubercles  and  caseous  matter  with  great  frequency  in  the  mediastinal 
glands,  particularly  those  about  the  bronchi.  It  is  stated  that  this  process 
is  always  secondary  to  a  focus,  however  small,  in  the  lungs,  but  my  experi- 
ence does  not  bear  out  such  a  statement.  As  already  mentioned,  North- 
rup  found  them  involved  in  every  one  of  127  cases  at  the  New  York  Found- 
ling Hospital.  This  tuberculous  adenitis  may,  in  the  bronchial  glands, 
attain  the  dimensions  of  a  tumor  of  large  size.  But  even  when  this  occurs 
there  may  be  no  pressure  symptoms.  In  children  the  bronchial  adenitis 
is  apt  to  be  associated  with  suppuration.  The  efi^ects  of  these  enlarged 
glands  are  very  varied,  and  for  full  details  the  reader  is  referred  to  the 
elaborate  section  in  the  Traite  of  Barthez  and  Sannee  (tome  iii).  It  is  suf- 
ficient here  to  say  that  there  are  instances  on  record  of  compression  of  the 
superior  cava,  of  the  pulmonary  artery,  and  of  the  azygos  vein.  The  trachea 
and  bronchi,  though  often  flattened,  are  rarely  seriously  compressed.  The 
pneumogastric  nerve  may  be  involved,  particularly  the  recurrent  laryngeal 
branch.  More  important  really  are  the  perforations  of  the  enlarged  and 
softened  glands  into  the  bronchi  or  trachea,  or  a  sort  of  secondary  cyst 
may  be  formed  between  the  lung  and  the  trachea.  Asphyxia  has  been 
caused  by  blocking  of  the  larynx  by  a  caseous  gland  which  has  ulcerated 
through  the  bronchus  (Voelcker),  and  Cyril  Ogle  has  reported  a  case  in 
which  the  ulcerated  gland  practically  occluded  both  bronchi.  Perfora- 
tions of  the  vessels  are  much  less  common,  but  the  pulmonary  artery  and 
the  aorta  have  been  opened.  Perforation  of  the  oesophagus  has  been  de- 
scribed in  several  cases.  One  of  the  most  serious  effects  is  infection  of  the 
lung  or  pleura  by  the  caseous  glands  situated  deep  along  the  bronchi.  This 
may,  as  is  often  clearly  seen,  be  by  direct  contact,  and  it  may  be  difficult 
to  determine  in  some  sections  where  the  caseous  bronchial  gland  terminates 
and  the  pulmonary  tissue  begins.  In  other  instances  it  takes  place  along 
the  root  of  the  lung  and  is  subpleural.  Among  other  sequences  may  be 
mentioned  diverticulum  of  the  oesophagus  following  adhesion  of  an  enlarged 
gland  and  its  subsequent  retraction;  and,  in  the  case  of  the  anterior  medi- 
astinal and  aortic  groups,  the  frequent  production  of  pericarditis,  either 
by  contact  or  by  rupture  of  a  softened  gland  into  the  sac. 

A  serious  danger  is  systemic  infection,  which  takes  place  through  the 
vessels. 

(c)   Mesenteric;  Tabes   mespnterica. — In   this  affection,   the   abdominal 
scrofula  of  old  writers,  the  glands  of  the  mesentery  and  retro-peritonaeum 
18 


284  SPECIFIC  INFECTIOUS  DISEASES. 

become  enlarged  and  caseate;  more  rarely  they  suppurate  or  calcify.  A 
slight  tuberculous  adenitis  is  extremely  common  in  children,  and  is  often 
accidentally  found  (post  mortem)  when  the  children  have  died  of  other 
diseases.  It  may  be  a  primary  lesion  associated  with  intestinal  catarrh,  or 
it  may  be  secondary  to  tuberculous  disease  of  the  intestines. 

The  primary  cases  are  very  common  in  children,  as  may  be  gathered 
from  "Woodhead's  figures,  already  given.  The  general  involvement  of  the 
glands  interferes  seriously  with  nutrition,  and  the  patients  are  puny,  wasted, 
and  angemic.  The  abdomen  is  enlarged  and  tympanitic;  diarrhoea  is  a  con- 
stant feature;  the  stools  are  thin  and  offensive.  There  is  moderate  fever, 
but  the  general  wasting  and  debility  are  the  most  characteristic  features. 
The  enlarged  glands  cannot  often  be  felt,  owing  to  the  distended  condi- 
tion of  the  bowels.  These  cases  are  often  spoken  of  as  consumption  of  the 
bowels,  but  in  a  majority  of  them  the  intestines  do  not  present  tuberculous 
lesions.  In  a  considerable  number  of  the  cases  of  tabes  mesenterica  the 
peritongeum  is  also  involved,  and  in  such  the  abdomen  is  large  and  hard, 
and  nodules  may  be  felt. 

In  adults  tuberculous  disease  of  the  mesenteric  glands  may  occur  as  a 
primary  affection,  or  in  association  with  pulmonary  disease.  Gairdner 
gives  a  remarkable  instance  of  the  kind  in  a  man  aged  twenty-one.  In- 
stances of  this  sort  are  not  uncommon  in  the  literature.  Large  tumors 
may  exist  without  tuberculous  disease  in  the  intestines  or  in  any  other 
part. 

The  diagnosis  of  local  and  general  tuberculous  adenitis  from  lymphade- 
noma  will  be  subsequently  considered. 

2.  Tuberculosis  of  the  Serous  Membranes. 

General  Serous  Membrane  Tuberculosis  (Polyorrhomenitis). — The  se- 
rous membranes  may  be  chiefly  involved,  simultaneously  or  consecutively, 
presenting  a  distinctive  and  readily  recognizable  clinical  type  of  tuber- 
culosis. There  are  three  groups  of  cases.  First,  those  in  which  an  acute 
tuberculosis  of  the  peritonaeum  and  pleurse  develops  rapidly,  caused  by  local 
disease  of  the  tubes  in  women,  or  of  the  mediastinal  or  bronchial  lymph- 
glands.  Secondly,  cases  in  which  the  disease  is  more  chronic,  with  exuda- 
tion into  both  peritongeum  and  pleurae,  the  formation  of  cheesy  masses,  and 
the  occurrence  of  ulcerative  and  suppurative  processes.  Thirdly,  there  are 
cases  in  which  the  pleuro-peritoneal  affection  is  still  more  chronic,  the  tu- 
bercles hard  and  fibroid,  the  membranes  much  thickened,  and  with  little  or 
no  exudate.  In  any  one  of  these  three  forms  the  pericardium  may  be  in- 
volved with  the  pleurae  and  peritonasum.  It  is  important  to  bear  in  mind 
that  there  may  be  in  these  cases  no  visceral  tuberculosis. 

Tuberculosis  of  the  Pleura. — 1.  Acute  tuberculous  pleurisy.  It  is  dif- 
ficult in  the  present  state  of  our  knowledge  to  estimate  the  proportion  of 
instances  of  acute  pleurisy  due  to  tuberculosis  (see  Acute  Pleurisy).  The 
cases  are  rarely  fatal.  In  the  study  of  those  in  the  Johns  Hopkins  Hos- 
pital, which  I  made  for  the  Shattuck  Lecture  (Boston  Med.  and  Surg. 
Journal,  1893),  there  were  three  groups  of  cases:  (a)  Acute  tuberculous 
pleurisy  with  subsequent  chronic  course.  (h)  Secondary  and  terminal 
forms  of  acute  pleurisy  (these  are  not  uncommon  in  hospital  practice). 


TUBERCULOSIS.  285 

And  (c)  a  form  of  aciite  tuberculous  suppurative  pleurisy.  A  considerable 
number  of  the  purulent  pleurisies,  designated  as  latent  and  chronic,  are 
caused  by  tubercle  bacilli,  but  the  fact  is  not  so  widely  recognized  that 
there  is  an  acute,  ulcerative,  and  suppurative  disease  which  may  run  a  very 
rapid  course.  The  pleurisy  sets  in  abruptly,  with  pain  in  the  side,  fever, 
cough,  and  sometimes  with  a  chill.  There  may  be  nothing  to  suggest  a 
tuberculous  process,  and  the  subject  may  have  a  fine  physique  and  come 
of  healthy  stock.  2.  The  subacute  and  chronic  tuberculous  pleurisies  are 
more  common.  The  largest  group  of  cases  comprises  those  with  sero- 
fibrinous ejfusion.  The  onset  is  insidious,  the  true  character  of  the  disease 
is  frequently  overlooked,  and  in  almost  every  instance  there  are  tubercu- 
lous foci  in  the  lungs  and  in  the  bronchial  glands.  These  are  cases  in 
which  the  termination  is  often  in  pulmonary  tuberculosis  or  general 
miliary  tuberculosis.  In  not  a  few  of  them  the  exudate  becomes  puru- 
lent. 

And,  lastly,  there  is  a  chronic  adhesive  pleurisy,  a  primary  proliferative 
form  which  is  of  long  standing,  may  lead  to  very  great  thickening  of  the 
membrane,  and  sometimes  to  invasion  of  the  lung.  For  a  fuller  considera- 
tion the  reader  is  referred  to  my  Shattuck  Lecture  or  to  the  section  on 
tuberculosis  in  Loomis  and  Thompson's  System  of  Medicine. 

Secondary  tuberculous  pleurisy  is  very  common.  The  visceral  layer  is 
always  involved  in  pulmonary  tuberculosis.  Adhesions  usually  form  and 
a  chronic  pleurisy  results,  which  may  be  simple,  but  usually  tubercles  are 
scattered  through  the  adhesions.  An  acute  tuberculous  pleurisy  may  re- 
sult from  direct  extension.  The  fluid  may  be  sero-fibrinous  or  hemor- 
rhagic, or  may  become  purulent.  And,  lastly,  a  very  common  event  in 
pulmonary  tuberculosis  is  the  perforation  of  a  superficial  spot  of  softening, 
and  the  production  of  pyo-pneumotliorax. 

The  general  symptomatology  of  these  forms  will  be  considered  under 
disease  of  the  pleura. 

Tuberculosis  of  the  Pericardium, — Miliary  tubercles  may  occur  as  a 
part  of  a  general  infection,  but  the  term  is  properly  limited  to  those  cases 
in  which,  either  as  a  primary  or  secondary  process,  there  is  extensive  dis- 
ease of  the  membrane.  Tuberculosis  is  not  so  common  in  the  pericardium 
as  in  the  pleura  and  peritonaeum,  but  it  is  certainly  more  common  than 
the  literature  would  lead  us  to  suppose.  Seventeen  cases  had  come  under 
my  observation  to  January,  1893  (American  Journal  of  the  Medical  Sci- 
ences). 

We  may  recognize  four  groups  of  cases:  First,  those  in  which  the  con- 
dition is  entirely  latent,  and  the  disease  is  discovered  accidentally  in 
individuals  who  have  died  of  other  affections  or  of  chronic  pulmonary 
tuberculosis. 

A  second  group,  in  which  the  symptoms  are  those  of  cardiac  insuf- 
ficiency following  the  dilatation  and  hypertrophy  consequent  upon  a 
chronic  adhesive  pericarditis.  The  symptoms  are  those  of  cardiac  dropsy, 
and  suggest  either  idiopathic  hypertrophy  and  dilatation,  or,  if  there  is  a 
lf)ud  blowing  systolic  murmur  at  the  apex,  mitral  valve  disease,  either  in- 
sufficiency or  stenosis.     There  are  cases  of  adherent  pericardium  in  which 


286  SPECIFIC  INFECTIOUS  DISEASES. 

a  bruit  is  heard  which  resembles  the  rumbling  presystolic  murmur  (Hale 
White).     The  condition  of  adherent  pericardium  is  usually  overlooked. 

In  a  third  group  the  clinical  picture  is  that  of  an  acute  tuberculosis, 
either  general  or  with  cerebro-spinal  manifestations,  which  has  had  its 
origin  from  the  tuberculous  pericardium  or  tuberculous  mediastinal  lymph- 
glands. 

A  fourth  group,  with  symptoms  of  acute  pericarditis,  includes  cases  in 
which  the  affection  is  acute  and  accompanied  with  more  or  less  exudation 
of  a  sero-fibrinous,  hsemorrhagic,  or  purulent  character.  There  may  be  no 
suspicion  whatever  of  the  tuberculous  nature  of  the  trouble. 

{d)  Tuberculosis  of  the  Peritonseum. — In  connection  with  miliary  and 
chronic  pulmonary  tuberculosis  it  is  not  uncommon  to  find  the  peritonseum 
studded  with  small  gray  granulations.  They  are  constantly  present  on 
the  serous  surface  of  tuberculous  ulcers  of  the  intestines.  Apart  from 
these  conditions  the  membrane  is  often  the  seat  of  extensive  tuberculous 
disease,  which  occurs  in  the  following  forms: 

(1)  Acute  miliary  tuberculosis  with  sero-fibrinous  or  bloody  exudation. 

(2)  Chronic  tuberculosis,  characterized  by  larger  growths,  which  tend 
to  caseate  and  ulcerate.  It  may  lead  to  perforation  of  the  intestinal  coils. 
The  exudate  is  purulent  or  sero-purulent,  and  is  often  sacculated. 

(3)  Chronic  fibroid  tuberculosis,  which  may  be  subacute  from  the  onset, 
or  which  may  represent  the  final  stage  of  an  acute  miliary  eruption.  The 
tubercles  are  hard  and  pigmented.  There  is  little  or  no  exudation,  and 
the  serous  surfaces  are  matted  together  by  adhesions. 

The  process  may  be  primary  and  local,  which  was  the  case  in  5  of  my 
17  post  mortems.  In  children  the  infection  appears  to  pass  from  the  intes- 
tines, and  in  adults  this  is  the  source  in  the  eases  associated  with  chronic 
phthisis.  In  women  the  disease  extends  commonly  from  the  Fallopian 
tubes.  In  at  least  30  or  40  per  cent  of  the  instances  of  laparotomy  in  this 
affection  reported  by  gyngecologists  the  infection  was  from  them.  The 
prostate  or  the  seminal  vesicles  may  be  the  starting-point.  In  many  cases 
the  peritonseum  is  involved  with  the  pleura  and  pericardium,  particularly 
with  the  former  membrane. 

It  is  interesting  to  note  that  certain  morbid  conditions  of  the  abdominal 
organs  predispose  to  the  development  of  the  disease;  thus  patients  with 
cirrhosis  of  the  liver  very  often  die  of  an  acute  tuberculous  peritonitis. 
The  frequency  with  which  the  condition  is  met  with  in  operations  upon 
ovarian  tumors  has  been  commented  upon  by  gynaecologists.  Many  cases 
have  followed  trauma  of  the  abdomen.  A  very  interesting  feature  is  the 
development  of  tuberculosis  in  hernial  sacs.  The  condition  is  not  very 
uncommon.  In  a  majority  of  the  instances  it  has  been  discovered  acci- 
dentally during  the  operation  for  radical  cure  or  for  strangulation.  In 
7  instances  the  sac  alone  was  involved. 

It  is  generally  stated  that  males  are  attacked  oftener  than  females. 
In  my  own  series  of  21  cases,  15  were  males.  The  recent  laparotomies, 
however,  which  have  been  performed  in  this  disease  have  been  chiefly  in 
females;  so  that  in  the  collected  statistics  T  find  the  cases  to  be  twice  as 
numerous  in  females  as  in  males;  in  the  ratio,  indeed,  of  131  to  60. 


TUBERCULOSIS.  287 

Tuberculous  peritonitis  occurs  at  all  ages.  It  is  common  in  children 
associated  with  intestinal  and  mesenteric  disease.  The  incidence  is  most 
frequent  between  the  ages  of  twenty  and  forty.  It  may  occur  in  advanced 
life.  In  one  of  my  cases  the  patient  was  eighty-two  years  of  age.  Of 
357  cases  collected  from  the  literature,*  there  were  under  ten  years,  27; 
between  ten  and  twenty,  75;  from  twenty  to  thirty,  87;  between  thirty 
and  forty,  71;  from  forty  to  fifty,  61;  from  fifty  to  sixty,  19;  from  sixty 
to  seventy,  4;  above  seventy,  2,  In  America  it  is  more  common  in  the 
negro  than  in  the  white  race. 

Symptoms. — In  certain  special  features  the  tuberculous  varies  con- 
siderably from  other  forms  of  peritonitis.  It  presents  a  symptom-complex 
of  extraordinary  diversity. 

In  the  first  place,  the  process  may  be  latent  and  not  cause  a  single 
symptom.  Such  are  the  cases  met  with  accidentally  in  the  operation  for 
hernia  or  for  ovarian  tumor.  In  direct  contrast  are  the  instances  in 
which  the  onset  is  so  sudden  and  violent  that  the  diagnosis  of  enteritis 
or  hernia  is  made.  The  operation  for  strangulated  hernia  has,  indeed, 
been  performed.  Many  cases  set  in  acutely  with  fever,  abdominal  ten- 
derness, and  the  symptoms  of  ordinary  acute  peritonitis.  Cases  with 
a  slow  onset,  abdominal  tenderness,  tympanites,  and  low  continuous 
fever  resemble  typhoid  fever  very  closely,  and  may  lead  to  error  in  diag- 
nosis. 

Ascites  is  frequent,  but  the  effusion  is  rarely  large.  It  is  sometimes 
hgemorrhagic.  In  this  form  the  diagnosis  may  rest  between  an  acute  miliary 
cancer,  cirrhosis  of  the  liver,  and  a  chronic  simple  peritonitis — conditions 
which  usually  offer  no  special  difficulties  in  differentiation.  A  most  impor- 
tant point  is  the  simultaneous  presence  of  a  pleurisy.  The  tuberculin  test 
may  be  used.  Tympanites  may  be  present  in  the  very  acute  cases,  when 
it  is  due  to  loss  of  tone  in  the  intestines,  owing  to  inflammatory  infiltra- 
tion; or  it  may  occur  in  the  old,  long-standing  cases  when  universal  adhe- 
sion has  taken  place  between  the  parietal  and  visceral  layers.  Fever  is  a 
marked  symptom  in  the  acute  cases,  and  the  temperature  may  reach  103° 
or  104°.  In  many  instances  the  fever  is  slight.  In  the  more  chronic  cases 
subnormal  temperatures  are  common,  and  for  days  the  temperature  may 
not  rise  above  97°,  and  the  morning  record  may  be  as  low  as  95.5°.  An 
occasional  symptom  is  pigmentation  of  the  skin,  which  in  some  cases  has 
led  to  the  diagnosis  of  Addison's  disease.  A  striking  peculiarity  of  tuber- 
culous peritonitis  is  the  frequency  with  which  either  the  condition  simu- 
lates or  is  associated  with  tumor.     These  may  be: 

(n)  Omsntal,  due  to  puckering  and  rolling  of  this  membrane  until  it 
forms  an  elongated  firm  mass,  attached  to  the  transverse  colon  and  lying 
athwart  the  upper  part  of  the  abdomen.  This  cord-like  structure  is  found 
also  with  cancerous  peritonitis,  but  is  much  more  common  in  tuberculosis. 
Gairdner  has  called  special  attention  to  this  form  of  tumor,  and  in  children 
has  seen  it  undergo  gradual  resolution.  A  resonant  percussion  note  may 
sometimes  be  elicited  above  the  mass.     Though  usually  situated  near  the 

*  Johns  Hopkins  Hospital  Reports,  Tol.  ii. 


288  SPECIFIC  IKPECTIOUS  DISEASES. 

umbilicus,  the  omental  mass  may  form  a  prominent  tumor  in  the  right 
iliac  region. 

(b)  Sacculated  exudation,  in  which  the  effusion  is  limited  and  confined 
by  adhesions  between  the  coils,  the  parietal  peritonaeum,  the  mesentery, 
and  the  abdominal  or  pelvic  organs.  This  encysted  exudate  is  most  com- 
mon in  the  middle  zone,  and  has  frequently  been  mistaken  for  ovarian 
tumor.  It  may  occupy  the  entire  anterior  portion  of  the  peritonaeum,  or 
there  may  be  a  more  limited  saccular  exudate  on  one  side  or  the  other. 
It  may  lie  completely  within  the  pelvis  proper,  associated  with  tuberculous 
disease  of  the  Fallopian  tubes. 

(c)  In  rare  cases  the  tumor  formations  may  be  due  to  great  retraction 
or  thickening  of  the  intestinal  coils.  The  small  intestine  is  found  short- 
ened, the  walls  enormously  thickened,  and  the  entire  coil  may  form  a  firm 
knot  close  against  the  spine,  giving  on  examination  the  idea  of  a  solid 
mass.  Not  the  small  intestine  only,  but  the  entire  bowel  from  the  duode- 
num to  the  rectum,  has  been  found  forming  such  a  hard  nodular  tumor. 

(d)  Mesenteric  glands,  which  occasionally  form  very  large,  tumor-like 
masses,  more  commonly  found  in  children  than  in  adults.  This  condition 
may  be  confined  to  the  abdominal  glands.  Ascites  may  coexist.  The  con- 
dition must  be  distinguished  from  that  in  children,  in  which,  with  ascites  or 
tympanites — sometimes  both — there  can  be  felt  irregular  nodular  masses,  due 
to  large  caseous  formations  between  the  intestinal  coils.  Xo  doubt  in  a  con- 
siderable number  of  cases  of  the  so-called  tabes  mesenterica,  particularly  in 
those  with  enlargement  and  hardness  of  the  abdomen — the  condition  which 
the  Trench  call  carreau — there  is  involvement  also  of  the  peritonseum. 

The  diagnosis  of  these  peritoneal  tumors  is  sometimes  very  difficult. 
The  omental  mass  is  a  less  frequent  source  of  error  than  any  other;  but, 
as  already  mentioned,  a  similar  condition  may  occur  in  cancer.  The  most 
important  problem  is  the  diagnosis  of  the  saccular  exudation  from  ovarian 
tumor.  In  fully  one  third  of  the  recorded  cases  of  laparotomy  in  tuber- 
culous peritonitis,  the  diagnosis  of  cystic  ovarian  disease  had  been  made. 
The  most  suggestive  points  for  consideration  are  the  history  of  the  patient 
and  the  evidence  of  old  tuberculous  lesions.  The  physical  condition  is  not 
of  much  help,  as  in  many  instances  the  patients  have  been  robust  and 
well  nourished.  Irregular  febrile  attacks,  gastro-intestinal  disturbance, 
and  pains  are  more  common  in  tuberculous  disease.  Unless  inflamed  there 
is  usually  not  much  fever  with  ovarian  cysts.  The  local  signs  are  very 
deceptive,  and  in  certain  cases  have  conformed  in  every  particular  to  those 
of  cystic  disease.  The  outlines  in  saccular  exudation  are  rarely  so  well 
defined.  The  position  and  form  may  be  variable,  owing  to  alterations  in 
the  size  of  the  coils  of  which  in  parts  the  walls  are  composed.  Modular 
cheesy  masses  may  sometimes  be  felt  at  the  periphery.  Depression  of  the 
vaginal  wall  is  mentioned  as  occurring  in  encysted  peritonitis;  but  it  is 
also  found  in  ovarian  tumor.  Lastly,  the  condition  of  the  Fallopian  tubes, 
of  the  lungs  and  of  the  pleurae,  should  be  thoroughly  examined.  The  asso- 
ciation of  salpingitis  with  an  ill-defined  anomalous  mass  in  the  abdomen 
should  arouse  suspicion,  as  should  also  involvement  of  the  pleura,  the  apex 
of  one  lung,  or  a  testis  in  the  male. 


TUBERCULOSIS.  289 

IV.  Pulmonary  Tubeeculosis  {Phthisis,  Consumption). 

Three  clinical  groups  may  be  conveniently  recognized:  (1)  tuherculo- 
pneumonic  phthisis — acute  phthisis;  (2)  chronic  ulcerative  phthisis;  and  (3) 
fibroid  phthisis. 

According  to  the  mode  of  infection  there  are  two  distinct  types  of 
lesions: 

(a)  When  the  bacilli  reach  the  lungs  through  the  blood-vessels  or  lym- 
phatics the  primary  lesion  is  usually  in  the  tissues  of  the  alveolar  walls,  in 
the  capillary  vessels,  the  epithelium  of  the  air-cells,  and  in  the  connective- 
tissue  framework  of  the  septa.  The  process  of  cell  division  proceeds  as 
already  described  in  the  general  histology  of  tubercle.  The  irritation  of 
the  bacilli  produces,  within  a  few  days,  the  small,  gray  miliary  nodules, 
involving  several  alveoli  and  consisting  largely  of  round,  cuboidal,  uni- 
nuclear epithelioid  cells.  Depending  upon  the  number  of  bacilli  which 
reach  the  lung  in  this  way,  either  a  localized  or  a  general  tuberculosis  is 
excited.  The  tubercles  may  be  uniformly  scattered  through  both  lungs 
and  form  a  part  of  a  general  miliary  tuberculosis,  or  they  may  be  confined 
to  the  lungs,  or  even  in  great  part  to  one  lung.  The  changes  which  the 
tubercles  undergo  have  already  been  referred  to.  The  further  stages 
may  be:  (1)  Arrest  of  the  process  of  cell  division,  gradual  sclerosis  of  the 
tubercle,  and  ultimately  complete  fibroid  transformation.  (2)  Caseation 
of  the  centre  of  the  tubercle,  extension  at  the  periphery  by  proliferation  of 
the  epithelioid  and  lymphoid  cells,  so  that  the  individual  tubercles  or 
small  groups  become  confluent  and  form  diffuse  areas  which  undergo  case- 
ation and  softening.  (3)  Occasionally  as  a  result  of  intense  infection  of  a 
localized  region  through  the  blood-vessels  the  tubercles  are  thickly  set. 
The  intervening  tissue  becomes  acutely  inflamed,  the  air-cells  are  filled 
with  the  products  of  a  desquamative  pneumonia,  and  many  lobules  are 
involved. 

(h)  When  the  bacilli  reach  the  lung  through  the  bronchi — inhalation 
or  aspiration  tuberculosis — the  picture  differs.  The  smaller  bronchi  and 
bronchioles  are  more  extensively  affected;  the  process  is  not  confined  to 
single  groups  of  alveoli,  but  has  a  more  lobular  arrangement,  and  the 
tuberculous  masses  from  the  outset  are  larger,  more  diffuse,  and  may  in 
some  cases  involve  an  entire  lobe  or  the  greater  part  of  a  lung.  It  is  in 
this  mode  of  infection  that  we  see  the  characteristic  peri-bronchial  granu- 
lations and  the  areas  of  the  so-called  nodular  broncho-pneumonia.  These 
broncho-pneumonic  areas,  with  on  the  one  hand  caseation,  ulceration,  and 
cavity  formation,  and  on  the  other  sclerosis  and  limitation,  make  up  the 
essential  elements  in  the  anatomical  picture  of  tuberculous  phthisis. 

1.  Acute  Pneumonic  Tuberculosis  of  the  Lungs. 

This  form,  known  also  by  the  name  of  galloping  consumption,  is  met 
with  both  in  children  and  adults.  In  the  former  many  of  the  cases  are 
mistaken  for  simple  broncho-pneumonia. 

Two  types  may  be  recognized,  the  pneumonic  and  Ironcho-pneumonic. 


290  SPECIFIC  INFECTIOUS  DISEASES. 

(a)  In  the  pneumonic  form  one  lobe  may  be  involved,  or  in  some  in- 
stances an  entire  lung.  The  organ  is  heavy,  the  affected  portion  airless; 
the  pleura  is  usually  covered  with  a  thin  exudate,  and  on  section  the  picture 
resembles  closely  that  of  ordinary  hepatization.  The  following  is  an  extract 
from  the  post-mortem  report  of  a  case  in  which  death  occurred  twenty-nine 
days  after  the  onset  of  the  illness,  having  all  the  characters  of  an  acute 
pneumonia:  "  Left  lung  weighs  1,500  grammes  (double  the  weight  of  the 
other  organ)  and  is  heavy  and  airless,  crepitant  only  at  the  anterior  mar- 
gins. Section  shows  a  small  cavity  the  size  of  a  walnut  at  the  apex,  about 
which  are  scattered  tubercles  in  a  consolidated  tissue.  The  greater  part 
of  the  lung  presents  a  grayish-white  appearance  due  to  the  aggregation 
of  tubercles  which  in  some  places  have  a  continuous,  uniform  appearance, 
in  others  are  surrounded  by  an  injected  and  consolidated  lung-tissue. 
Toward  the  margins  of  the  lower  lobe  strands  of  this  firm  reddish  tissue 
separate  ansemic,  dry  areas.  There  are  in  the  right  lung  three  or  four 
small  groups  of  tubercles  but  no  caseous  masses.  The  bronchial  glands 
are  not  tuberculous."  Here  the  intense  local  infection  was  due  to  the 
small  focus  at  the  apex  of  the  lung,  probably  an  aspiration  process. 

Only  the  most  careful  inspection  may  reveal  the  presence  of  miliary 
tubercles,  or  the  attention  may  be  arrested  by  the  detection  of  tubercles  in 
the  other  lung  or  in  the  bronchial  glands.  The  process  may  involve  only 
one  lobe.  There  may  be  older  areas  which  are  of  a  peculiarly  yellowish- 
white  color  and  distinctly  caseous.  The  most  remarkable  picture  is  pre- 
sented by  cases  of  this  kind  in  which  the  disease  lasts  for  some  months. 
A  lobe  or  an  entire  lung  may  be  enlarged,  firm,  airless  throughout,  and 
converted  into  a  dry,  yellowish-white,  cheesy  substance.  Cases  are  met 
with  in  which  the  entire  lung  from  apex  to  base  is  in  this  condition,  with 
perhaps  only  a  small,  narrow  area  of  air-containing  tissue  on  the  margin. 
More  commonly,  if  the  case  has  lasted  for  two  or  three  months,  rapid 
softening  has  taken  place  at  the  apex  with  extensive  cavity  formation. 

In  a  recent  study  A.  Fraenkel  and  Troje  found  tubercle  bacilli  alone 
in  11  of  12  cases.  They  suggest  that  in  these  cases  of  infection  by  aspira- 
tion the  large  areas  of  exudative  inflammation,  at  some  distance  even  from 
the  seat  of  growth  of  the  bacilli,  are  due  to  the  presence  of  some  diffusible 
poison  produced  by  the  germs. 

Symptoms. — The  attack  sets  in  abruptly  with  a  chill,  usually  in  an 
individual  who  has  enjoyed  good  health,  although  in  many  cases  the  onset 
has  been  preceded  by  exposure  to  cold,  or  there  have  been  debilitating  cir- 
cumstances. The  temperature  rises  rapidly  after  the  chill,  there  are  pain 
in  the  side,  and  cough,  with  at  first  mucoid,  subsequently  rusty-colored 
expectoration  which  may  contain  tubercle  bacilli.  The  dyspnoea  may  be- 
come extreme  and  the  patient  may  have  suffocative  attacks.  The  physical 
examination  shows  involvement  of  one  lobe  or  of  one  lung,  with  signs  of 
consolidation,  dulness,  increased  fremitus,  at  first  feeble  or  suppressed 
vesicular  murmur,  and  subsequently  well-marked  bronchial  breathing.  The 
Tipper  or  lower  lobe  may  be  involved,  or  in  some  cases  the  entire  lung. 

At  this  time,  as  a  rule,  no  suspicion  enters  the  mind  of  the  practitioner 
that  the  case  is  anything  but  one  of  frank  lobar  pneumonia.    Occasionally 


TUBERCULOSIS.  291 

there  may  be  suspicious  circumstances  in  the  history  of  the  patient 
or  in  his  family;  but,  as  a  rule,  no  stress  is  laid  upon  them  in  view  of 
the  intense  and  characteristic  mode  of  onset.  Between  the  eighth  and 
tenth  day,  instead  of  the  expected  crisis,  the  condition  becomes  aggravated, 
the  temperature  is  irregular,  and  the  pulse  more  rapid.  There  may  be 
sweating,  and  the  expectoration  becomes  muco-purulent  and  greenish  in 
color — a  point  of  special  importance,  to  which  Traube  called  attention. 
Even  in  the  second  or  third  week,  with  the  persistence  of  these  symptoms, 
the  physician  tries  to  console  himself  with  the  idea  that  the  case  is  one  of 
unresolved  pneumonia,  and  that  all  will  yet  be  well.  Gradually,  however, 
the  severity  of  the  symptoms,  the  presence  of  physical  signs  indicating 
softening,  the  existence  of  elastic  tissue  and  tubercle  bacilli  in  the  sputa 
present  the  mournful  proofs  that  the  case  is  one  of  acute  pneumonic 
phthisis.  Death  may  occur  before  softening  takes  place,  even  in  the  second 
or  third  week.  In  other  cases  there  is  extensive  destruction  at  the  apex, 
with  rapid  formation  of  cavity,  and  the  case  may  drag  on  for  two  or  three 
months  or  may  become  one  of  chronic  phthisis. 

Diagnosis. — It  is  by  no  means  widely  recognized  in  the  profession 
that  there  is  a  form  of  acute  phthisis  which  may  closely  simulate  ordinary 
pneumonia.  Waters,  of  Liverpool,  gave  an  admirable  description  of  these 
cases,  and  called  attention  to  the  difficulty  in  distinguishing  them  from 
ordinary  pneumonia.  Certainly  the  mode  of  onset  affords  no  criterion 
whatever.  A  healthy,  robust-looking  young  Irishman,  a  cab-driver,  who 
had  been  kept  waiting  on  a  cold,  blustering  night  until  three  in  the  morn- 
ing, was  seized  the  next  afternoon  with  a  violent  chill,  and  the  following 
day  was  admitted  to  my  wards  at  the  University  Hospital,  Philadelphia. 
He  was  made  the  subject  of  a  clinical  lecture  on  the  fifth  day,  when  there 
was  absent  no  single  feature  in  history,  symptoms,  or  physical  signs  of 
acute  lobar  pneumonia  of  the  right  upper  lobe.  It  was  not  until  ten  days 
later,  when  bacilli  were  found  in  his  expectoration,  that  we  were  made 
aware  of  the  true  nature  of  the  case.  I  know  of  no  criterion  by  which 
cases  of  this  kind  can  be  distinguished  in  the  early  stage.  The  tubercle 
bacilli  may  not  be  present  at  first,  but  in  one  of  Fraenkel  and  Troje's  cases 
they  existed  alone  in  the  typical  pneumonic  sputum.  A  point  to  which 
Traube  called  attention,  and  which  is  also  referred  to  as  important  by 
Herard  and  Cornil,  is  the  absence  of  breath-sounds  in  the  consolidated 
region;  but  this,  I  am  sure,  does  not  hold  good  in  all  cases.  The  tubular 
breathing  may  be  intense  and  marked  as  early  as  the  fourth  day;  and 
again,  how  common  it  is  to  have,  as  one  of  the  earliest  and  most  suggestive 
symptoms  of  lobar  pneumonia,  suppression  or  enfeeblement  of  the  vesicular 
murmur!  In  many  cases,  however,  there  are  suspicious  circumstances  in 
the  onset:  the  patient  has  been  in  bad  health,  or  may  have  had  previous 
pulmonary  trouble,  or  there  are  recurring  chills.  Careful  examination 
of  the  sputa  and  a  study  of  the  physical  signs  from  day  to  day  can  alone 
determine  the  true  nature  of  the  case.  A  point  of  some  moment  is  the 
character  of  the  fever,  which  in  true  pneumonia  is  more  continuous,  par- 
ticularly in  severe  cases,  whereas  in  this  form  of  tuberculosis  remissions  of 
1.5°  or  2°  are  not  infrequent. 


292  SPECIFIC  INFECTIOUS  DISEASES. 

(b)  Acute  tuberculous  broncho-pneumonia  is  more  common,  particularly 
in  children,  and  forms  a  majority  of  the  cases  of  pJithisis  florida,  or  "  gal- 
loping consumption/^  It  is  an  acute  caseous  broncho-pneumonia,  starting 
in  the  smaller  tubes,  which  become  blocked  with  a  cheesy  substance,  while 
the  air-cells  of  the  lobule  are  filled  with  the  products  of  a  catarrhal  pneu- 
monia. In  the  early  stages  the  areas  have  a  grayish-red,  later  an  opaque- 
white,  caseous  appearance.  By  the  fusion  of  contiguous  masses  an  entire 
lobe  may  be  rendered  nearly  solid,  but  there  can  usually  be  seen  between 
the  groups  areas  of  crepitant  air  tissue.  This  is  not  an  uncommon  picture 
in  the  acute  phthisis  of  adults,  but  it  is  still  more  frequent  in  children. 
The  following  is  an  extract  from  the  post-mortem  report  of  a  case  on  a  child 
aged  four  months,  which  died  in  the  sixth  week  of  illness:  "  On  section,  the 
right  upper  lobe  is  occupied  with  caseous  masses  from  5  to  12  mm.  in  diame- 
ter, separated  from  each  other  by  an  intervening  tissue  of  a  deep-red  color. 
The  bronchi  are  filled  with  cheesy  substance.  The  middle  and  lower  lobes 
are  studded  with  tubercles,  many  of  which  are  becoming  caseous.  Toward 
the  diaphragmatic  surface  of  the  lower  lobe  there  is  a  small  cavity  the  size 
of  a  marble.  The  left  lung  is  more  crepitant  and  uniformly  studded  with 
tubercles  of  all  sizes,  some  as  large  as  peas.  The  bronchial  glands  are  very 
large,  and  one  contains  a  tuberculous  abscess." 

There  is  a  form  of  tuberculous  aspiration  pneumonia,  to  which  Baum- 
ler  has  called  attention,  developing  as  a  sequence  of  hemoptysis,  and  due 
to  the  aspiration  of  blood  and  the  contents  of  pulmonary  cavities  into  the 
finer  tubes.  Following  the  haemoptysis,  which  may  have  occurred  in  an 
individual  without  suspected  lesion,  there  are  fever,  dyspnoea,  and  signs 
of  a  diffuse  broncho-pneumonia.  Some  of  these  cases  run  a  very  rapid 
course,  and  are  examples  of  galloping  consumption  following  haemoptysis. 
This  accident  may  occur  not  alone  early  in  the  disease,  but  may  follow 
haemorrhage  in  a  well-developed  case  of  pulmonary  tuberculosis. 

In  children  the  enlarged  bronchial  glands  usually  surround  the  root  of 
the  lung,  and  even  pass  deeply  into  the  substance,  and  the  lobules  are  often 
involved  by  direct  contact. 

In  other  cases  the  caseous  broncho-pneumonia  involves  groups  of  alveoli 
or  lobules  in  different  portions  of  the  lungs,  more  commonly  at  both 
apices,  forming  areas  from  1  to  3  cm.  in  diameter.  The  size  of  the  mass 
depends  largely  upon  that  of  the  bronchus  involved.  There  are  cases  which 
probably  should  come  in  this  category,  in  which,  with  a  history  of  an  acute 
illness  of  from  four  to  eight  weeks,  the  lungs  are  extensively  studded  with 
large  gray  tubercles,  ranging  in  size  from  5  to  10  mm.  In  some  instances 
there  are  cheesy  masses  the  size  of  a  cherry.  All  of  these  are  grayish-white 
in  color,  distinctly  cheesy,  and  between  the  adjacent  ones,  particularly  in 
the  lower  lobe,  there  may  be  recent  pneumonia,  or  the  condition  of  lung 
which  has  been  termed  splenization.  •  In  a  case  of  this  kind  at  the  Phila- 
delphia Hospital  death  took  place  about  the  eighth  week  from  the  abrupt 
onset  of  the  illness  with  haemorrhage.  There  were  no  extensive  areas  of 
consolidation,  but  the  cheesy  nodules  were  uniformly  scattered  throughout 
both  lungs.    ISTo  softening  had  taken  place. 

Secondary  infections  are  not  uncommon;    but  Prudden  Avas  able  to 


TUBERCULOSIS.  293 

show  that  the  tubercle  bacillus  could  produce  not  only  distinct  tubercle 
nodules,  but  also  the  various  kinds  of  exudative  phenomena,  the  exudates 
varying  in  appearance  in  different  cases,  which  phenomena  occurred  abso- 
lutely without  the  intervention  of  other  organisms.  The  fact  that  these 
latter  had  not  subsequently  crept  in  was  shown  by  cultures  at  the  autopsy  on 
the  affected  animal. 

Symptoms. — The  symptoms  of  acute  broncho-pneumonic  phthisis 
are  very  variable.  In  adults  the  disease  may  attack  persons  in  good  health, 
but  who  are  overworked  or  "  run  down  "  from  any  cause.  Haemorrhage 
initiates  the  attack  in  a  few  cases.  There  may  be  repeated  chills;  the 
temperature  is  high,  the  pulse  rapid,  and  the  respirations  are  increased. 
The  loss  of  flesh  and  strength  is  very  striking. 

The  physical  signs  may  at  first  be  uncertain  and  indefinite,  but  finally 
there  are  areas  of  impaired  resonance,  usually  at  the  apices;  the  breath- 
sounds  are  harsh  and  tubular,  with  numerous  rales.  The  sputa  may  early 
show  elastic  tissue  and  tubercle  bacilli.  In  the  acute  cases,  within  three 
weeks,  the  patient  may  be  in  a  marked  typhoid  state,  with  delirium,  dry 
tongue,  and  high  fever.  Death  may  occur  within  three  weeks.  In  other 
eases  the  onset  is  severe,  with  high  fever,  rapid  loss  of  flesh  and  strength, 
and  signs  of  extensive  unilateral  or  bilateral  disease.  Softening  takes  place; 
there  are  sweats,  chills,  and  progressive  emaciation,  and  all  the  features  of 
pJitkisis  florida.  Six  or  eight  weeks  later  the  patient  may  begin  to  im- 
prove, the  fever  lessens,  the  general  symptoms  abate,  and  a  case  which 
looks  as  if  it  would  certainly  terminate  fatally  within  a  few  weeks  drags 
on  and  becomes  chronic. 

In  children  the  disease  most  commonly  follows  the  infectious  diseases, 
particularly  measles  and  whooping-cough.*  The  profession  is  gradually 
recognizing  the  fact  that  a  majority  of  all  such  cases  are  tuberculous. 
At  least  three  groups  of  these  tuberculous  broncho-pneumonias  may  be 
recognized.  In  the  first  the  child  is  taken  ill  suddenly  while  teething 
or  during  convalescence  from  fever;  the  temperature  rises  rapidly,  the 
cough  is  severe,  and  there  may  be  signs  of  consolidation  at  one  or  both 
apices  with  rales.  Death  may  occur  within  a  few  days,  and  the  lung  shows 
areas  of  broncho-pneumonia,  with  perhaps  here  and  there  scattered  opaque 
grayish-yellow  nodules.  Macroscopically  the  affection  does  not  look  tuber- 
culous, but  histologically  miliary  granulations  and  bacilli  may  be  found. 
Tubercles  are  usually  present  in  the  bronchial  glands,  but  the  appearance 
of  the  broncho-pneumonia  may  be  exceedingly  deceptive,  and  it  may  re- 
quire careful  microscopical  examination  to  determine  its  tuberculous  char- 
acter. The  second  group  is  represented  by  the  case  of  the  child  previously 
quoted,  which  died  at  the  sixth  week  with  the  ordinary  symptoms  of  severe 
broncho-pneumonia.  And  the  third  group  is  that  in  which,  during  the 
convalescence  from  an  infectious  disease,  the  child  is  taken  ill  with  fever, 
cough,  and  shortness  of  breath.  The  severity  of  the  symptoms  abates 
within  the  first  fortnight;  but  there  is  loss  of  flesh,  the  general  condition 
is  bad,  and  the  physical  examination  shows  the  presence  of  scattered  rales 

*  "  Tussis  conrulsiva  vestibulum  tabis  "  (Willis"), 


294  SPECIFIC  IKPECTIOUS  DISEASES. 

throughout  the  lungs,  and  here  and  there  areas  of  defective  resonance. 
The  child  has  sweats,  the  fever  becomes  hectic  in  character,  and  in  many 
cases  the  clinical  picture  gradually  develops  into  that  of  chronic  phthisis. 

2.  Chronic  Ulcerative  Tuberculosis  of  the  Lungs. 

Under  this  heading  may  be  grouped  the  great  majority  of  cases  of  pul- 
monary tuberculosis,  in  which  the  lesions  proceed  to  ulceration  and  soften- 
ing, and  ultimately  produce  the  well-known  picture  of  chronic  phthisis. 
At  first  a  strictly  tuberculous  affection,  it  ultimately  becomes,  in  a  majority 
of  cases,  a  mixed  disease,  many  of  the  most  prominent  s}Tnptoms  of  which 
^aje  due  to  septic  infection  from  purulent  foci  and  cavities. 

Morbid  Anatomy. — Inspection  of  the  lungs  in  a  case  of  chronic 
phthisis  shows  a  remarkable  variety  of  lesions,  comprising  nodular  tuber- 
cles, diffuse  tuberculous  infiltration,  caseous  masses,  pneumonic  areas,  cavi- 
ties of  various  sizes,  with  changes  in  the  pleura,  bronchi,  and  bronchial 
glands. 

1.  The  Distribution  of  the  Lesions. — For  years  it  has  been  recognized 
that  the  most  advanced  lesions  are  at  the  apices,  and  that  the  disease  pro- 
gresses downward,  usually  more  rapidly  in  one  of  the  lungs.  This  gen- 
eral statement,  which  has  passed  current  in  the  text-books  ever  since  the 
masterly  description  of  Laennec,  has  recently  been  carefully  elaborated 
by  Kingston  Fowler,  who  finds  that  the  disease  in  its  onward  progress 
through  the  lungs  follows,  in  a  majority  of  the  cases,  distinct  routes.  In 
the  upper  lobe  the  primary  lesion  is  not,  as  a  rule,  at  the  extreme  apex, 
but  from  an  inch  to  an  inch  and  a  half  below  the  summit  of  the  lung,  and 
nearer  to  the  posterior  and  external  borders.  The  lesion  here  tends  to 
spread  downward,  probably  from  inhalation  of  the  virus,  and  this  accounts 
for  the  frequent  circumstance  that  examination  behind,  in  the  supra- 
spinous fossa,  will  give  indications  of  disease  before  any  evidences  exist  at 
the  apex  in  front.  Anteriorly  this  initial  focus  corresponds  to  a  spot  just 
below  the  centre  of  the  clavicle,  and  the  direction  of  extension  in  front 
is  along  the  anterior  aspect  of  the  upper  lobe,  along  a  line  running  about 
an  inch  and  a  half  from  the  inner  ends  of  the  first,  second,  and  third  inter- 
spaces. A  second  less  common  site  of  the  primary  lesion  in  the  apex  "  cor- 
responds on  the  chest  wall  with  the  first  and  second  interspaces  below  the 
outer  third  of  the  clavicle."  The  extension  is  downward,  so  that  the  outer 
part  of  the  upper  lobe  is  chiefly  involved. 

In  the  middle  lobe  of  the  right  lung  the  affection  usually  follows  disease 
of  the  upper  lobe  on  the  same  side.  In  the  involvement  of  the  lower  lobe 
the  first  secondary  infiltration  is  about  an  inch  to  an  inch  and  a  half  below 
the  posterior  extremity  of  its  apex,  and  corresponds  on  the  chest  wall  to  a 
spot  opposite  the  fifth  dorsal  spine.  This  involvement  is  of  the  greatest 
importance  clinically,  as  "  in  the  great  majority  of  cases,  when  the  physical 
signs  of  the  disease  at  the  apex  are  sufficiently  definite  to  allow  of  the  diag- 
nosis of  phthisis  being  made,  the  lower  lobe  is  already  affected."  Examina- 
tion, therefore,  should  be  made  carefully  of  this  posterior  apex  in  all  sus- 
picious cases.    In  this  situation  the  lesion  spreads  downward  and  laterally 


TUBERCULOSIS.  295 

along  the  line  of  the  interlobular  sejDta,  a  line  which  is  marked  by  the 
vertebral  border  of  the  scapula,  when  the  hand  is  placed  on  the  opposite 
scapula  and  the  elbow  raised  above  the  level  of  the  shoulder.  Once  pres- 
ent in  an  apex,  the  disease  usually  extends  in  time  to  the  opposite  upper 
lobe;  but  not,  as  a  rule,  until  the  apex  of  the  lower  lobe  of  the  lung  first 
aifected  has  been  attacked. 

Of  427  cases  above  mentioned,  the  right  apex  was  involved  in  172,  the 
left  in  130,  both  in  111. 

Lesions  of  the  base  may  be  primary,  though  this  is  rare.  Percy  Kidd 
makes  the  proportion  of  basic  to  apicic  phthisis  1  to  500,  a  smaller  number 
than  existed  in  my  series.  In  very  chronic  cases  there  may  be  arrested 
lesions  at  the  apex  and  more  recent  lesions  at  the  base. 

2.  Summary  of  the  Lesions  in  Chronic  Ulcerative  Phthisis. — (a)  Mili- 
ary Tubercles. — They  have  one  of  two  distributions:  (1)  A  dissemination 
due  to  aspiration  of  tuberculous  material,  the  tubercles  being  situated  in  the 
air-cells  or  the  walls  of  the  smaller  bronchi;  (2)  the  distribution  due  to 
dissemination  of  tubercle  bacilli  by  the  lymph  current,  the  tubercles  being 
scattered  about  the  old  foci  in  a  radial  manner — the  secondary  crop  of 
Laennec.  Much  more  rarely  there  is  a  scattered  dissemination  from  in- 
fection here  and  there  of  the  smaller  vessels,  the  tubercles  then  being 
situated  in  the  vessel  walls.  Sometimes,  in  cases  with  cavity  formation  at 
the  apex,  the  greater  part  of  the  lower  lobes  presents  many  groups  of  firm, 
sclerotic,  miliary  tubercles,  which  may  indeed  form  the  distinguishing  ana- 
tomical feature — a  chronic  miliary  tuberculosis. 

(&)  Tuberculous  BroncJio-pneumonia. — In  a  large  proportion  of  the  cases 
of  chronic  phthisis  the  terminal  bronchiole  is  the  point  of  origin  of  the 
process,  consequently  we  find  the  smaller  bronchi  and  their  alveolar  terri- 
tories blocked  with  the  accumulated  products  of  inflammation  in  all  stages 
of  caseation.  At  an  early  period  a  cross-section  of  an  area  of  tuberculous 
broncho-pneumonia  gives  the  most  characteristic  appearance.  The  central 
bronchiole  is  seen  as  a  small  orifice,  or  it  is  plugged  with  cheesy  contents, 
while  surrounding  it  is  a  caseous  nodule,  the  so-called  peribronchial  tuber- 
cle. The  longitudinal  section  has  a  somewhat  dendritic  or  foliaceous  ap- 
pearance. The  condition  of  the  picture  depends  much  upon  the  slowness 
or  rapidity  with  which  the  process  has  advanced.  The  following  changes 
may  occur: 

Ulceration. — When  the  caseation  takes  place  rapidly  or  ulceration  occurs 
in  the  bronchial  wall,  the  mass  may  break  down  and  form  a  small  cavity. 

Sclerosis. — In  other  instances  the  process  is  more  chronic.  Fibroid 
changes  gradually  produce  a  sclerosis  of  the  affected  area,  a  condition 
which  is  sometimes  called  cirrhosis  nodosa  tuberculosa.  The  sclerosis  may 
be  confined  to  the  margin  of  the  mass,  forming  a  limiting  capsule,  within 
which  is  a  uniform,  firm,  cheesy  substance,  in  which  lime  salts  are  often 
deposited.  This  represents  the  healing  of  one  of  these  areas  of  caseous 
broncho-pneumonia.  It  is  only,  however,  when  complete  fibroid  trans- 
formation or  calcification  has  occurred  that  we  can  really  speak  of  healing. 
In  many  instances  the  colonies  of  miliary  tubercles  about  these  masses 
show  that  the  virus  is  still  active  in  them.     Subsequently,  in  ulcerative 


296  SPECIFIC  INFECTIOUS  DISEASES. 

processes,  these  calcareous  bodies — lung-stones,  as  they  are  sometimes  called 
— ^may  be  expectorated. 

(c)  Pneumonia. — An  important  though  secondary  place  is  occupied 
by  inflammation  of  the  alveoli  surrounding  the  tubercles,  which  become 
filled  with  epithelioid  cells.  The  consolidation  may  extend  for  some  dis- 
tance about  the  tuberculous  foci  and  unite  them  into  areas  of  uniform  con- 
solidation. Although  in  some  instances  this  inflammatory  process  may  be 
simple,  in  others  it  is  undoubtedly  specific.  It  is  excited  by  the  tubercle 
bacilli  and  is  a  manifestation  of  their  action.  It  may  present  a  very  varied 
appearance;  in  some  instances  resembling  closely  ordinary  red  hepatiza- 
tion, in  others  being  more  homogeneous  and  infiltrated,  the  so-called  infil- 
tration tuberculeuse  of  Laennec.  In  other  cases  the  contents  of  the  alveoli 
undergo  fatty  degeneration,  and  appear  on  the  cut  surface  as  opaque  white 
or  yellowish-white  bodies.  In  early  phthisis  much  of  the  consolidation  is 
due  to  this  pneumonic  infiltration,  which  may  surround  for  some  distance 
the  smaller  tuberculous  foci. 

{d)  Cavities. — A  vomica  is  a  cavity  in  the  lung  tissue,  produced  by 
necrosis  and  ulceration.  It  differs  materially  from  the  bronchiectatic  form. 
The  process  usually  begins  in  the  wall  of  the  bronchus  in  a  tuberculous 
area.  Dilatation  is  produced  by  retained  secretion,  and  necrosis  and  ulcera- 
tion of  the  wall  occur  with  gradual  destruction  of  the  contiguous  tissues. 
By  extension  of  the  necrosis  and  ulceration  the  cavity  increases,  contigu- 
ous ones  unite,  and  in  an  affected  region  there  may  be  a  series  of  small 
excavations  communicating  with  a  bronchus.  In  nearly  all  instances  the 
process  extends  from  the  bronchi,  though  it  is  possible  for  necrosis  and 
softening  to  take  place  in  the  centre  of  a  caseous  area  without  primary 
involvement  of  the  bronchial  wall.  Three  forms  of  cavities  may  be  recog- 
nized. 

The  fresli  ulcerative,  seen  in  acute  phthisis,  in  which  there  is  no  limiting 
membrane,  but  the  walls  are  made  up  of  softened,  necrotic,  and  caseous 
masses.  Small  vomicae  of  this  sort,  situated  just  beneath  the  pleura,  may 
rupture  and  cause  pneumothorax.  In  cases  of  acute  tuberculo-pneumonic 
phthisis  they  may  be  large,  occupying  the  greater  portion  of  the  upper 
lobe.  In  the  chronic  ulcerative  phthisis,  cavities  of  this  sort  are  invariably 
present  in  those  portions  of  the  lung  in  which  the  disease  is  advancing. 
At  the  apex  there  may  be  a  large  old  cavity  with  well-defined  walls,  while 
at  the  anterior  margin  of  the  upper  lobes,  or  in  the  apices  of  the  lower 
lobes,  there  are  recent  ulcerating  cavities  communicating  with  the  bronchi. 

Cavities  with  Well-defined  Walls. — A  majority  of  the  cavities  in  the 
chronic  form  of  phthisis  have  a  well-defined  limiting  membrane,  the  inner 
surface  of  which  constantly  produces  pus.  The  walls  are  crossed  by  trabec- 
ulse  which  represent  remnants  of  bronchi  and  blood-vessels.  Even  the 
vomicae  with  the  well-defined  walls  extend  gradually  by  a  slow  necrosis 
and  destruction  of  the  contiguous  lung  tissue.  The  contents  are  usually 
purulent,  similar  in  character  to  the  grayish  num.mular  sputa  coughed  up 
by  phthisical  patients.  Not  infrequently  the  membrane  is  vascular  or  it 
may  be  haemorrhagic.  Occasionally,  when  gangrene  has  occurred  in  the 
wall,  the  contents  are  horribly  fcetid.    These  cavities  may  occupy  the  greater 


TUBERCULOSIS.  297 

portion  of  the  apex,  forming  an  irregular  series  which  communicate  with 
each  other  and  with  the  bronchi,  or  the  entire  upper  lobe  except  the  an- 
terior margin  may  be  excavated,  forming  a  thin-walled  cavity.  In  rare 
instances  the  process  has  proceeded  to  total  excavation  of  the  lung,  not  a 
remnant  of  which  remains,  except  perhaps  a  narrow  strip  at  the  anterior 
margin.  In  a  case  of  this  kind,  in  a  young  girl,  the  cavity  held  40  fluid 
ounces,  in  another  42  ounces. 

Quiescent  Cavities. — Wlien  quite  small  and  surrounded  by  dense  cica- 
tricial tissue  communicating  with  the  bronchi  they  form  the  cicatrices 
fistuleuses  of  Laennee.  Occasionally  one  apex  may  be  represented  by  a 
series  of  these  small  cavities,  surrounded  by  dense  fibrous  tissue.  The  lin- 
ing membrane  of  these  old  cavities  may  be  quite  smooth,  almost  like  a 
mucous  membrane.    Cavities  of  any  size  do  not  heal  completely. 

Cases  are  often  seen  in  which  it  has  been  supposed  that  a  cavity  has 
healed;  but  the  signs  of  excavation  are  notoriously  uncertain,  and  there 
may  be  pectoriloquy  and  cavernous  sounds  with  gurgling,  resonant  rales 
in  an  area  of  consolidation  close  to  a  large  bronchus. 

In  the  formation  of  vomicse  the  blood-vessels  gradually  become  closed 
by  an  obliterating  inflammation.  They  are  the  last  structures  to  yield 
and  may  be  completely  exposed  in  a  cavity,  even  when  the  circulation  is 
still  going  on  in  them.  Unfortunately,  the  erosion  of  a  large  vessel  which 
has  not  yet  been  obliterated  is  by  no  means  infrequent,  and  causes  profuse 
and  often  fatal  haemorrhage.  Another  common  event  is  the  development 
of  aneurisms  on  the  arteries  running  in  the  walls  of  cavities.  These  may 
be  small,  bunch-like  dilatations,  or  they  may  form  sacs  the  size  of  a  walnut 
or  even  larger.  Easmussen,  Douglas  Powell,  and  others  have  called  atten- 
tion to  their  importance  in  haemoptysis,  under  which  section  they  are  dealt 
with  more  fully. 

And  finally,  about  cavities  of  all  sorts,  the  connective  tissue  develops 
and  tends  to  limit  the  extent.  The  thickening  is  particularly  marked  be- 
neath the  pleura,  and  in  chronic  cases  an  entire  apex  may  be  converted  into 
a  mass  of  fibrous  tissue,  enclosing  a  few  small  cavities. 

'  (e)  Pleura. — Practically,  in  all  cases  of  chronic  phthisis  the  pleura  is 
involved.  Adhesions  take  place  which  may  be  thin  and  readily  torn,  or 
dense  and  firm,  uniting  layers  of  from  2  to  5  mm.  in  thickness.  This 
pleurisy  may  be  simple,  but  in  many  cases  it  is  tuberculous,  and  miliary 
tubercles  or  caseous  masses  are  seen  in  the  thickened  membrane.  Effusion 
is  not  at  all  infrequent,  either  serous,  purulent,  or  hEemorrhagic.  Pneumo- 
thorax is  a  common  accident. 

(f)  Changes  in  the  smaller  hronchi  control  the  situation  in  the  early 
stages  of  tuberculous  phthisis,  and  play  an  important  ivle  throughout  the 
disease.  The  process  very  often  begins  in  the  walls  of  the  smaller  tubes 
and  leads  to  caseation,  distention  with  products  of  inflammation,  and 
broncho-pneumonia  of  the  lobules.  In  many  cases  the  visible  implication 
of  the  bronchus  is  an  extension  upward  of  a  process  which  has  begun  in 
the  smallest  bronchiole.  This  involvement  weakens  the  wall,  leading  to 
bronchiectasis,  not  an  uncommon  event  in  phthisis.  The  mucous  mem- 
brane of  the  larger  bronchi,  which  is  usually  involved  in  a  chronic  catarrh, 


298  SPECIFIC  INFECTIOUS  DISEASES. 

is  more  or  less  swollen,  and  in  some  instances  ulcerated.  Besides  these 
specific  lesions,  they  may  be  the  seat,  especially  in  children,  of  inflamma- 
tion due  to  secondary  invasion,  most  frequently  by  the  micrococcus  lanceo- 
latus,  with  the  production  of  a  broncho-pneumonia. 

(g)  The  hroncJiial  glands,  in  the  more  acute  cases,  are  swollen  and 
cedematous.  Miliary  tubercles  and  caseous  foci  are  usually  present.  In 
cases  of  chronic  phthisis  the  caseous  areas  are  common,  calcification  may 
occur,  and  not  infrequently  purulent  softening. 

(h)  Changes  in  the  other  Organs. — Of  these,  tuberculosis  is  the  most 
common.  In  my  series  of  autopsies  the  brain  presented  tuberculous  lesions 
in  31,  the  spleen  in  33,  the  liver  in  12,  the  kidneys  in  32,  the  intestines 
in  65,  and  the  pericardium  in  7.  Other  groups  of  lymphatic  glands  besides 
the  bronchial  may  be  affected. 

Certain  degenerations  are  common.  Amyloid  change  is  frequent  in 
the  liver,  spleen,  kidneys,  and  mucous  membrane  of  the  intestines.  The 
liver  is  often  the  seat  of  extensive  fatty  infiltration,  which  may  cause 
marked  enlargement.  The  intestinal  tuberculosis  occurs  in  advanced  cases 
and  is  responsible  in  great  part  for  the  troublesome  diarrhoea. 

Endocarditis  is  not  very  uncommon,  and  was  present  in  12  of  my  post 
mortems  and  in  27  of  Percy  Kidd's  500  cases.  Tubercle  bacilli  have  been 
found  in  the  vegetations.  The  subject  has  been  considered  in  an  impor- 
tant monograph  by  Teissier  (Paris,  1894).  Tubercles  may  be  present  on 
the  endocardium,  particularly  of  the  right  ventricle.  As  pointed  out  by 
!N"orman  Chevers,  and  confirmed  by  subsequent  writers,  the  subjects  of 
congenital  stenosis  of  the  pulmonary  orifice  very  frequently  have  phthisis. 

The  larynx  is  frequently  involved,  and  ulceration  of  the  vocal  cords 
and  destruction  of  the  epiglottis  are  not  at  all  uncommon. 

Modes  of  Onset. — We  have  already  seen  that  tuberculosis  of  the 
lungs  may  occur  as  the  chief  part  of  a  general  infection,  or  may  set  in 
with  symptoms  which  closely  simulate  acute  pneumonia.  In  the  ordinary 
type  of  pulmonary  tuberculosis  the  invasion  is  gradual  and  less  striking, 
but  presents  an  extraordinarily  diverse  picture,  so  that  the  practitioner  is 
often  led  into  error.  Among  the  most  characteristic  of  these  types  of  onset 
are  the  following: 

(a)  There  is  a  small  but  important  group  of  cases  in  which  the  disease 
makes  considerable  progress  before  there  are  serious  symptoms  to  arouse 
the  attention  of  the  patient.  This  latent  form  of  the  disease  is  seen  most 
frequently  in  workingmen,  and  the  disease  may  even  advance  to  excava- 
tion of  an  apex  before  they  seek  advice.  In  some  of  these  cases  it  is  not  a 
little  remarkable  how  slight  the  lung  symptoms  have  been. 

A  different  type  of  latent  pulmonary  tuberculosis  is  the  form  in  which 
the  symptoms  are  masked  by  the  existence  of  serious  disease  in  other  organs, 
as  in  the  peritonaeum,  intestines,  or  bones. 

(b)  With  Symptoms  of  Dyspepsia  and  Ancemia. — The  gastric  mode  of 
onset  is  very  common,  and  the  early  manifestations  may  be  great  irritability 
of  the  stomach  with  vomiting  or  a  type  of  acid  dyspepsia  with  eructa- 
tions. In  young  girls  (and  in  children)  with  this  dyspepsia  there  is  very 
frequently  a  pronounced  chloro-ansemia,  and  the  patient  complains  of  pal- 


Tuberculosis.  299 

13itation  bi  the'  lieartj  increasing  weakness,  slight  afternoon  fever,  and 
amenorrhoea. 

(c)  In  a  considerable  number  of  cases  the  onset  of  pulnloiiary  tuber- 
culosis is  with  symptoms  which  suggest  malarial  fever.  The  patient  has 
repeated  paroxysms  of  chills,  fevers,  and  sweats,  which  may  recur  with 
great  regularity.  In  districts  in  which  intermittents  prevail  there  is  no 
more  common  mistake  than  to  confound  the  initial  rigors  of  pulmonary 
tuberculosis  with  malaria. 

(d)  Onset  ivith  Pleurisy. — The  first  symptoms  may  be  a  dry  pleurisy 
over  an  apex,  with  persistent  friction  murmur.  In  other  instances  the 
pulmonary  symptoms  have  followed  an  attack  of  pleurisy  with  effusion. 
The  exudate  gradually  disappears,  but  the  cough  persists  and  the  pa- 
tient becomes  feverish,  and  gradually  signs  of  disease  at  one  apex  become 
manifest.  Of  90  cases  of  pleurisy  with  effusion,  the  history  of  which 
was  followed  by  H.  I.  Bowditch,  one  third  developed  pulmonary  tuber- 
culosis. 

(e)  With  Laryngeal  Symptoms. — The  primary  localization  may  be  in 
the  larynx,  though  in  a  majority  of  the  instances  in  which  huskiness  and 
laryngeal  symptoms  are  the  first  noticeable  features  of  the  disease  there 
are  doubtless  foci  already  existing  in  the  lung.  The  group  of  cases  in 
which  for  many  months  throat  and  larynx  symptoms  precede  the  graver 
manifestations  of  pulmonary  phthisis  is  a  very  important  one. 

(/)  Onset  with  Hcemoptysis. — Frequently  the  very  first  symptom  of 
the  disease  is  a  brisk  hemorrhage  from  the  lungs,  following  which  the  pul- 
monary symptoms  may  develop  with  great  rapidity.  In  other  cases  the 
haemoptysis  recurs,  and  it  may  be  months  before  the  symptoms  become 
well  established.  In  a  majority  of  these  cases  the  local  tuberculous  lesion 
exists  at  the  date  of  the  haemoptysis. 

{g)  With  Tuberculosis  of  the  C ervico-axillary  Glands. — Preceding  the 
onset  of  pulmonary  phthisis  for  months,  or  even  for  years,  the  lymph- 
glands  of  the  neck  or  of  the  neck  and  axilla  of  one  side  may  be  enlarged. 
These  cases  are  by  no  means  infrequent,  and  they  are  of  importance  be- 
cause of  the  latency  of  the  pulmonary  lesions.  Nowadays,  when  operative 
interference  is  so  common,  it  is  well  to  bear  in  mind  that  in  such  patients 
the  corresponding  apex  of  the  lung  may  be  extensively  involved. 

(h)  And,  lastly,  in  by  far  the  largest  number  of  all  cases  the  onset  is 
with  a  Iwonchitis,  or,  as  the  patient  expresses  it,  a  neglected  cold.  There 
has  been,  perhaps,  a  liability  to  catch  cold  easily  or  the  patient  has  been 
subject  to  naso-pharyngeal  catarrh;  then,  following  some  unusual  exposure, 
a  bronchial  cough  develops,  which  may  be  frequent  and  very  irritating. 
The  examination  of  the  lungs  may  reveal  localized  moist  sounds  at  one 
apex  and  perhaps  wheezing  bronchitic  rales  in  other  parts.  In  a  few  cases 
the  early  symptoms  are  often  suggestive  of  asthma  with  marked  wheezing 
and  difTnsc  piping  rales. 

Symptoms. — In  discussing  the  symptoms  it  is  usual  to  divide  the 

disease  into  three  periods:  the  first  embracing  the  time  of  the  growth  and 

development  of  the  tubercles;  the  second,  in  which  they  soften;  and  the 

third,  in  which  there  is  a  formation  of  cavities.    Unfortunately,  these  ana- 

19 


300  SPECIFIC  INFECTIOUS  DISEASES. 

tomical  stages  cannot  be  satisfactorily  correlated  with  corresponding  clini- 
cal periods,  and  we  often  find  that  a  patient  in  the  third  stage  with  a  well- 
marked  cavity  is  in  a  far  better  condition  and  has  greater  prospects  of  re- 
covery than  a  patient  in  the  first  stage  with  diffuse  consolidation.  It  is 
therefore  better  perhaps  to  disregard  them  altogether. 

1.  Local  Symptoms. — Pain  in  the  chest  may  be  early  and  troublesome 
or  absent  throughout.  It  is  usually  associated  with  pleurisy,  and  may  be 
sharp  and  stabbing  in  character,  and  either  constant  or  felt  only  during 
coughing.  Perhaps  the  commonest  situation  is  in  the  lower  thoracic  zone, 
though  in  some  instances  it  is  beneath  the  scapula  or  referred  to  the  apex. 
The  attacks  may  recur  at  long  intervals.  Intercostal  neuralgia  occasionally 
develops  in  the  course  of  ordinary  phthisis. 

Cough  is  one  of  the  earliest  symptoms,  and  is  present  in  the  majority 
of  cases  from  beginning  to  end.  There  is  nothing  peculiar  or  distinctive 
about  it.  At  first  dry  and  hacking,  and  perhaps  scarcely  exciting  the  atten- 
tion of  the  patient,  it  subsequently  becomes  looser,  more  constant,  and 
associated  with  a  glairy,  muco-purulent  expectoration.  In  the  early  stages 
of  the  disease  the  cough  is  bronchial  in  its  origin.  Wlien  cavities  have 
formed  it  becomes  more  paroxysmal,  and  is  most  marked  in  the  morning 
or  after  a  sleep.  Cough  is  not  a  constant  symptom,  however,  and  a  patient 
may  present  himself  with  well-marked  excavation  at  one  apex  who  will 
declare  that  he  has  had  little  or  no  cough.  So,  too,  there  may  be  well- 
marked  physical  signs,  dulness  and  moist  sounds,  without  either  expectora- 
tion or  cough.  In  well-established  cases  the  nocturnal  paroxysms  are  most 
distressing  and  prevent  sleep.  The  cough  may  be  of  such  persistence  and 
severity  as  to  cause  vomiting,  and  the  patient  becomes  rapidly  emaciated 
from  loss  of  food — Morton's  cough  (Phthisiologia,  1689,  p.  101).  The 
laryngeal  complications  give  a  peculiarly  husky  quality  to  the  cough,  and 
when  erosion  and  ulceration  have  proceeded  far  in  the  vocal  cords  the 
efforts  of  coughing  are  much  less  effective. 

Sputum. — This  varies  greatly  in  amount  and  character  at  the  different 
stages  of  ordinary  phthisis.  There  are  cases  with  well-marked  local  signs 
at  one  apex,  with  slight  cough  and  moderately  high  fever,  without  from 
day  to  day  a  trace  of  "expectoration.  So,  also,  there  are  instances  with  the 
most  extensive  consolidation  (caseous  pneumonia),  and  high  fever,  but,  as 
in  a  recent  instance  under  observation  for  several  months,  withoiit  enough 
expectoration  to  enable  an  examination  for  bacilli  to  be  made.  In  the 
early  stage  of  pulmonary  tuberculosis  the  sputum  is  chiefly  catarrhal  and 
has  a  glairy,  sago-like  appearance,  due  to  the  presence  of  alveolar  cells 
which  have  undergone  the  myelin  degeneration.  There  is  nothing  dis- 
tinctive or  peculiar  in  this  form  of  expectoration,  which  may  persist  for 
months  without  indicating  serious  trouble.  The  earliest  trace  of  charac- 
teristic sputum  may  show  the  presence  of  small  grayish  or  greenish-gray 
purulent  masses.  These,  when  coughed  up,  are  always  suggestive  and 
should  be  the  portions  picked  out  for  microscopical  examination.  As 
softening  comes  on,  the  expectoration  becomes  more  profuse  and  puru- 
lent, but  may  still  contain  a  considerable  quantity  of  alveolar  epithelium. 
Finally,  when  cavities  exist,  the  sputa  assume  the  so-called  nummular 


TUBERCULOSIS.  301 

form;  each  mass  is  isolated,  flattened,  greenish-gray  in  color,  quite  airless, 
and  sinks  to  the  bottom  when  spat  into  water. 

By  the  microscopical  examination  of  the  spntum  we  determine  whether 
the  process  is  tuberculous,  and  whether  softening  has  occurred.  For  tubercle 
lacilli  the  Ehrlich-Weigert  method  is  the  best.  Eleven  centimetres  of  a 
saturated  solution  of  fuchsin  in  absolute  alcohol  is  added  to  100  cc.  of 
the  saturated  solution  of  commercial  aniline  oil  (made  by  shaking  up  the 
oil  in  water  and  then  filtering).  This  should  be  made  fresh  every  third 
or  fourth  day.  A  small  bit  of  the  sputum  is  picked  out  on  a  needle  or 
platinum  wire  and  spread  thin  on  the  top-cover  so  as  to  make  a  uniformly 
thin  layer.  The  top-cover  is  slowly  dried  about  a  foot  above  a  Bunsen 
burner.  Sufficient  of  the  staining  fluid  is  then  dropped  upon  the  top- 
cover,  which  is  held  at  a  little  distance  above  the  flame  until  the  fluid 
boils.  The  staining  fluid  is  then  washed  off  in  distilled  water  or  put  under 
the  tap,  decolorized  in  30  per  cent  nitric-acid  fluid,  again  washed  off  in 
water,  and  mounted  on  the  slide.  In  doubtful  cases  the  long  process  is 
used,  the  cover-slips  remaining  twenty-four  hours  in  the  stain.  The  bacilli 
are  seen  as  elongated,  slightly  curved,  red  rods,  sometimes  presenting  a 
beaded  appearance.  They  are  frequently  in  groups  of  three  or  four,  but 
the  number  varies  considerably.  Only  one  or  two  may  be  found  in  a  prep- 
aration, or,  in  some  instances,  they  are  so  abundant  that  the  entire  field  is 
occupied.    Eepeated  examinations  may  be  necessary. 

The  continued  presence  of  tubercle  bacilli  in  the  sputum  is  an  infallible  in- 
dication of  the  existence  of  tuberculosis. 

One  or  two  may  possibly  be  due  to  accidental  inhalation.  A  number 
may  come  from  a  spot  of  softening  3  by  3  cm.  In  the  nummular  sputa  of 
later  stages  the  bacilli  are  very  abundant. 

Elastic  tissue  may  be  derived  from  the  bronchi,  the  alveoli,  or  from 
the  arterial  coats;  and  naturally  the  appearance  of  the  tissue  will  vary  with 
the  locality  from  which  it  comes.  In  the  examination  for  this  it  is  not 
necessary  to  boil  the  sputum  with  caustic  potash.  For  years  I  have  used 
a  simple  plan  which  was  shown  to  me  at  the  London  Hospital  by  Sir 
Andrew  Clark.  This  method  depends  upon  the  fact  that  in  almost  all 
instances  if  the  sputum  is  spread  in  a  sufficiently  thin  layer  the  fragments 
of  elastic  tissue  can  be  seen  with  the  naked  eye.  The  thick,  purulent  por- 
tions are  placed  upon  a  glass  plate  15  X  15  cm.  and  flattened  into  a  thin 
layer  by  a  second  glass  plate  10  X  10  cm.  In  this  compressed  grayish  layer 
between  the  glass  slips  any  fragments  of  elastic  tissue  show  on  a  black 
background  as  grayish-yellow  spots  and  can  either  be  examined  at  once 
under  a  low  power  or  the  uppermost  piece  of  glass  is  slid  along  until  the 
fragment  is  exposed,  when  it  is  picked  out  and  placed  upon  the  ordinary 
microscopic  slide.  Fragments  of  bread  and  collections  of  milk-globules 
may  also  present  an  opaque  white  appearance,  but  with  a  little  practice  they 
can  readily  be  recognized.  Fragments  of  epithelium  from  the  tongue, 
infiltrated  with  micrococci,  are  still  more  deceptive,  but  the  microscope  at 
once  shows  the  difference. 

The  bronchial  elastic  tissue  forms  an  elongated  network,  or  two  or 
three  long,  narrow  fibres  are  found  close  together.    From  the  blood-vessels 


302  SPECIFIC  INFECTIOUS  DISEASES. 

a  somewhat  similar  form  may  be  seen  and  occasionally  a  distinct  sheeting 
is  found  as  if  it  had  come  from  the  intima  of  a  good-sized  artery.  The 
elastic  tissue  of  the  alveolar  wall  is  quite  distinctive;  the  fibres  are  branched 
and  often  show  the  outline  of  the  arrangement  of  the  air-cells.  The  elastic 
tissue  from  bronchus  or  alveoli  indicates  extensive  erosion  of  a  tube  and 
softening  of  the  lung-tissue. 

Another  occasional  constituent  of  the  sputum  is  blood,  which  may  be 
present  as  the  chief  characteristic  of  the  expectoration  in  hsemoptysis  or 
may  simply  tinge  the  sputum.  In  chronic  cases  with  large  cavities,  in 
addition  to  bacteria,  various  forms  of  fungi  may  develop,  of  which  the 
aspergillus  is  the  most  important.     Sarcinse  may  also  occur. 

Calcareous  Fragments. — Formerly  a  good  deal  of  stress  was  laid  upon 
their  presence  in  the  sputum,  and  Morton  described  a  phthisis  a  calculis  in 
pulmonihus  generatis.  Bayle  also  described  a  separate  form  of  phthisie  cal- 
culeuse.  The  size  of  the  fragments  varies  from  a  small  pea  to  a  large  cherry. 
As  a  rule,  a  single  one  is  ejected;  sometimes  large  numbers  are  coughed 
up  in  the  course  of  the  disease.  They  are  formed  in  the  lung  by  the  calci- 
fication of  caseous  masses,  and  it  is~said  also  occasionally  in  obstructed 
bronchi.  They  may  come  from  the  bronchial  glands  by  ulceration  into 
the  bronchi,  and  there  is  a  case  on  record  of  suffocation  in  a  child  from 
this  cause. 

The  daily  amount  of  expectoration  varies.  In  rapidly  advancing  cases, 
with  much  cough,  it  may  reach  as  high  as  500  cc.  in  the  day.  In  cases  with 
large  cavities  the  chief  amount  is  brought  up  in  the  morning.  The  ex- 
pectoration of  tuberculous  patients  usually  has  a  heavy,  sweetish  odor,  and 
occasionally  it  is  fetid,  owing  to  decomposition  in  the  cavities. 

Haemoptysis. — One  of  the  most  famous  of  the  Hippocratic  axioms 
says,  "  From  a  spitting  of  blood  there  is  a  spitting  of  pus."  The  older 
writers  thought  that  the  phthisis  was  directly  due  to  the  inflammatory 
or  putrefactive  changes  caused  by  the  hgemorrhage  into  the  lung.  Morton, 
however,  in  his  interesting  section,  Phthisis  ab  Hasmoptoe,  rather  doubted 
this  sequence.  Laennec  and  Louis,  and  later  in  the  century  Traube,  re- 
garded the  hsemoptysis  as  an  evidence  of  existing  disease  of  the  lung.  From 
the  accurate  views  of  Laennec  and  Louis  the  profession  was  led  away  by 
Graves,  and  particularly  by  Memeyer,  who  held  that  the  blood  in  the  air- 
cells  set  up  an  inflammatory  process,  a  common  termination  of  which  was 
caseation.  Since  Koch's  discovery  we  have  learned  that  many  cases  in 
which  the  physical  examination  is  negative  show,  either  during  the  period 
of  hasmorrhage  or  immediately  after  it,  tubercle  bacilli  in  the  sputa,  so  that 
opinion  has  veered  to  the  older  view,  and  we  now  regard  the  appearance  of 
hgemoptysis  as  an  indication  of  existing  disease.  In  young,  apparently 
healthy  persons,  cases  of  hsemoptysis  may  be  divided  into  three  groups.  In 
the  first  the  bleeding  has  come  on  without  premonition,  without  over- 
exertion or  injury,  and  there  is  no  family  history  of  tuberculosis.  The 
physical  examination  is  negative,  and  the  examination  of  the  expectoration 
at  the  time  of  the  hgemorrhage  and  subsequently  shows  no  tubercle  bacilli. 
Such  instances  are  not  uncommon,  and,  though  one  may  suspect  strongly 
the  presence  of  some  focus  of  tuberculosis,  yet  the  individuals  may  retain 


TUBERCULOSIS.  303 

good  health  for  many  years,  and  have  no  further  trouble.  Of  the  386  cases 
of  haemoptysis  noted  by  Ware  in  private  practice,  62  recovered,  and  pul- 
monary disease  did  not  subsequently  develop. 

In  a  second  group  individuals  in  apparently  perfect  health  are  sud- 
denly attacked,  perhaps  after  a  slight  exertion  or  during  some  athletic 
exercises.  The  physical  examination  is  also  negative,  but  tubercle  bacilli 
are  found  sometimes  in  the  bloody  sputa,  more  frequently  a  few  days  later. 

In  a  third  set  of  cases  the  individuals  have  been  in  failing  health  for 
a  month  or  two,  but  the  symptoms  have  not  been  urgent  and  perhaps  not 
noticed  by  the  patients.  The  physical  examination  shows  the  presence  of 
well-marked  tuberculous  disease,  and  there  are  both  tubercle  bacilli  and 
elastic  tissue  in  the  sputa. 

A  very  interesting  systematic  study  of  the  subject  of  haemoptysis,  par- 
ticularly in  its  relation  to  the  question  of  tuberculosis,  has  been  completed 
in  the  Prussian  army  by  Franz  Strieker.  During  the  five  years  1890-'95 
there  were  900  cases  admitted  to  the  hospitals,  which  is  a  percentage  of 
0.045  of  the  strength  (1,728,505).  Of  the  cases,  in  480  the  haemorrhage 
came  on  without  recognizable  cause.  Of  these  417  cases,  86  per  cent  were 
certainly  or  probably  tuberculous.  In  only  221,  however,  was  the  evidence 
conclusive. 

In  a  second  group  of  213  cases  the  haemorrhage  came  on  during  the 
military  exercise,  and  of  these  75  patients  were  shown  to  be  tuberculous. 

In  118  cases  the  haemorrhage  followed  certain  special  exercises,  as  in 
the  gymnasium  or  in  riding  or  in  consequence  of  swimming.  In  24  cases 
it  developed  during  the  exercise  of  the  voice  in  singing  or  in  giving  com- 
mand or  in  the  use  of  wind  instruments.  A  very  interesting  group  is  re- 
ported of  24  cases  in  which  the  hemorrhage  followed  trauma,  either  a  fall 
or  a  blow  upon  the  thorax.  In  7  of  these  tuberculosis  was  positively  pres- 
ent, and  in  6  other  cases  there  was  a  strong  probability  of  its  existence. 

Among  the  conclusions  which  Strieker  draws  the  following  are  the 
most  important:  namely,  that  soldiers  attacked  with  haemoptysis  without 
special  cause  are  in  at  least  86.8  per  cent  tuberculous.  In  the  cases  in 
which  the  haemoptysis  follows  the  special  exercises,  etc.,  of  military  serv- 
ice, at  least  74.4  per  cent  are  tuberculous.  In  the  cases  which  come  on 
during  swimming  or  as  a  consequence  of  direct  injury  to  the  thorax  about 
one  half  are  not  associated  with  tuberculosis. 

Haemoptysis  occurs  in  from  60  to  80  per  cent  of  all  cases  of  pulmonary 
tuberculosis..  It  is  more  frequent  in  males  than  in  females. 

In  a  majority  of  all  cases  the  bleeding  recurs.  Sometimes  it  is  a  special 
feature  throughout  the  disease,  so  that  a  hsemorrhagic  or  haemoptysical 
form  has  been  recognized.  The  amount  of  blood  brought  up  varies  from 
a  couple  of  drachms  to  a  pint  or  more.  In  69  per  cent  of  4,125  cases  of 
haemoptysis  at  the  Brompton  Hospital  the  amount  brought  up  was  under 
half  an  ounce. 

A  distinction  may  be  drawn  between  the  hsemoptysis  early  in  the  dis- 
ease and  that  which  occurs  in  the  later  periods.  In  tlie  former  the  bleed- 
ing is  usually  slight,  is  apt  to  recur,  and  fatal  hasmorrhage  is  very  rare.  In 
these  instances  the  bleeding  is  usually  from  small  areas  of  softening  or 


304  SPECIFIC  INFECTIOUS  DISEASES. 

from  early  erosions  in  the  bronchial  mucosa.  In  the  later  periods,  after 
cavities  have  formed,  the  bleeding  is,  as  a  rule,  more  profuse  and  is  more 
apt  to  be  fatal.  Single  large  haemorrhages,  proving  quickly  fatal,  are  very 
rare,  except  in  the  advanced  stages  of  the  disease.  In  these  cases  the  bleed- 
ing comes  either  from  an  erosion  of  a  good-sized  vessel  in  the  wall  of  a 
cavity  or  from  the  ruj)ture  of  an  aneurism  of  the  pulmonary  artery. 

The  bleeding,  as  a  rule,  sets  in  suddenly.  Without  any  warning  the 
patient  may  notice  a  warm  salt  taste  and  the  mouth  fills  with  blood.  It 
may  come  up  with  a  slight  cough.  The  total  amount  may  not  be  more 
than  a  few  drachms,  and  for  a  day  or  two  the  patient  may  spit  up  small 
quantities.  When  a  large  vessel  is  eroded  or  an  aneurism  bursts,  the  amount 
of  blood  brought  up  is  large,  and  in  the  course  of  a  short  time  a  pint  or 
two  may  be  expectorated.  Fatal  hsemorrhage  may  occur  into  a  very  large 
cavity  without  any  blood  being  coughed  up.  The  character  of  the  blood  is, 
as  a  rule,  distinctive.  It  is  frothy,  mixed  with  mucus,  generally  bright  red 
in  color,  except  when  large  amounts  are  expectorated,  and  then  it  may  be 
dark.  The  sputa  may  remain  blood-tinged  for  some  days  or  there  are 
brownish-black  streaks  in  the  sputa,  or  "  friable  nodules  consisting  entirely 
of  blood-corpuscles  "  may  be  coughed  up.  Blood  moulds  of  the  smaller 
bronchi  are  sometimes  expectorated. 

The  microscopical  examination  of  the  sputum  in  tuberculous  cases 
is  most  important.  If  carefully  spread  out,  there  may  be  noted,  even  in  an 
apparently  pure  hsemorrhagic  mass,  little  portions  of  mucus  from  which 
bacilli  or  elastic  tissue  may  be  obtained. 

Dyspnoea  is  not  a  common  accompaniment  of  ordinary  phthisis.  The 
greater  part  of  one  lung  may  be  diseased  and  local  trouble  exist  at  the 
other  apex  without  any  shortness  of  breath.  Even  in  the  paroxysms  of 
very  high  fever  the  respirations  may  not  be  much  increased.  Eapid  ad- 
vance of  a  broncho-pneumonia,  or  the  development  of  miliary  tubercles 
throughout  the  lung,  causes  great  increase  in  the  number  of  respirations. 
A  degree  of  dyspnoea  leading  to  cyanosis  is  almost  unknown,  apart  from 
extensive  invasion  of  the  sound  portions  by  miliary  tubercles. 

In  long  standing  cases,  with  contracted  apices  or  great  thickening  of 
the  pleura,  the  right  heart  is  enlarged,  and  the  dyspnoea  may  be  cardiac. 

2.  General  Symptoms. — Fever. — To  get  a  correct  idea  of  the  tempera- 
ture range  in  pulmonary  tuberculosis  it  is  necessary,  as  Einger  pointed 
out,  to  make  tolerably  frequent  observations.  The  usual  8  a.  m.  and  8  p.  m. 
record  is,  in  a  majority  of  the  cases,  very  deceptive,  giving  neither  the 
minimum  nor  maximum.  The  former  usually  occurs  between  2  and  6  a.  m. 
and  the  latter  between  2  and  6  p.  m. 

A  recognition  of  various  forms  of  fever,  viz.,  of  tuberculization,  of 
ulceration,  and  of  absorption,  emphasizes  the  anatomical  stages  of  growth, 
softening  and  cavity  formation;  but  practically  such  a  division  is  of  little 
use,  as  in  a  majority  of  cases  these  processes  are  going  on  together. 

Fever  is  the  most  important  initial  symptom  and  throughout  the  entire 
course  the  thermometer  is  the  most  trustworthy  guide  as  to  the  progress 
of  the  affection.  With  pyrexia  a  patient  loses  in  weight  and  strength, 
and  the  local  disease  usually  progresses.    The  periods  of  apyrexia  are  those 


TUBERCULOSIS. 


305 


of  gain  in  weight  and  strength  and  of  limitation  of  the  local  lesion.  It  by 
no  means  necessarily  follows  that  a  patient  with  tuberculosis  has  pyrexia. 
There  may  be  quite  extensive  disease  without  coexisting  fever.  At  one  time, 
I  have  had  18  instances  of  chronic  phthisis  under  observation,  of  whom 
10  were  practically  free  from  fever.  But  in  the  early  stage,  when  tubercles 
are  developing  and  caseous  areas  are  in  process  of  formation  and  when 
softening  is  in  progress,  fever  is  a  constant  symptom.  It  was  present  in 
100  consecutive  cases  in  my  dispensary  service. 

Two  types  of  fever  are  seen — the  remittent  and  the  intermittent.    These 
may  occur  indifferently  in  the  early  or  in  the  late  stages  of  the  disease 


Chart  XII.    Three  days.     Chronic  tuberculosis. 


or  may  alternate  with  each  other,  a  variability  which  depends  upon  the 
fact  that  phthisis  is  a  progressive  disease  and  that  all  stages  of  lesions  may 
be  found  in  a  single  lung.  Special  stress  should  be  laid  upon  the  fact, 
particularly  in  malarial  regions,  that  tuberculosis  may  set  in  with  a  fever 
typically  intermittent  in  character — a  daily  chill,  with  subsequent  fever 
and  sweat.  In  Montreal,  where  malaria  is  practically  imkuown,  this  was 
always  regarded  as  a  suggestive  symptom;  but  in  Philadelphia  and  Balti- 


306  SPECIFIC  INFECTIOUS  DISEASES. 

more,  where  ague  prevails^  it  is  no  exaggeration  to  say  that  yearly  scores 
of  cases  of  early  tuberculosis  are  treated  for  ague.  These  are  often  cases 
that  pursue  a  rapid  course.  The  fever  of  onset — tuberculization — ^may  be 
almost  continuous,  with  slight  daily  exacerbations;,  and  at  any  time  during 
the  course  of  chronic  phthisis,  if  there  is  rapid  extension,  the  remissions 
become  less  marked. 

A  remittent  fever,  in  which  the  temperature  is  constantly  above  normal 
but  drops  two  or  three  degrees  toward  morning,  is  not  uncommon  in  the 
middle  and  later  stages  and  is  usually  associated  with  softening  or  exten- 
sion of  the  disease.  Here,  too,  a  simple  morning  and  evening  register  may 
give  an  entirely  erroneous  idea  as  to  the  range  of  the  fever.  With  break- 
ing down  of  the  lung-tissue  and  formation  of  cavities,  associated  as  these 
processes  always  are  with  suppuration  and  with  more  or  less  systemic  con- 
tamination, the  fever  assumes  a  characteristically  intermittent  or  hectic^ 
type.  For  a  large  part  of  the  day  the  patient  is  not  only  afebrile,  but  the 
temperature  is  subnormal.  In  the  annexed  two-hourly  chart,  from  a  case 
of  chronic  tuberculosis  of  the  lungs,  it  will  be  seen  that  from  10  p.  m.  to 
8  A.  M.  or  noon,  the  temperature  continuously  fell  and  went  as  low  as  95°. 
A  slow  rise  then  took  place  through  the  late  morning  and  early  afternoon 
hours  and  reached  its  maximum  between  6  and  10  p.  m.  As  shown  in  the 
chart,  there  were  in  the  three  days  about  forty-three  hours  of  pyrexia  and 
twenty-nine  hours  of  apyrexia.  The  rapid  fall  of  the  temperature  in  the 
early  morning  hours  is  usually  associated  with  sweating.  This  hectic,  as 
it  is  called,  which  is  a  typical  fever  of  septic  infection,  is  met  with  when 
the  process  of  cavity  formation  and  softening  is  advanced  and  extending. 

A  continuous  fever  with  remissions  of  not  more  than  a  degree,  develop- 
ing in  the  course  of  pulmonary  tuberculosis,  is  suggestive  of  acute  pneu- 
monia. When  a  two-hourly  chart  is  made,  the  remissions  even  in  acute 
tuberculous  pneumonia  are  usually  well  marked.  A  continued  fever,  such 
as  is  seen  in  the  first  week  of  typhoid,  or  in  some  cases  of  inflammation  of 
the  lung,  is  rare  in  tuberculosis. 

Sweating. — Drenching  perspirations  are  common  in  phthisis  and  con- 
stitute one  of  the  most  distressing  features  of  the  disease.  They  occur  usu- 
ally with  the  drop  in  the  fever  in  the  early  morning  hours,  or  at  any  time 
in  the  day  when  the  patient  sleeps.  They  may  come  on  early  in  the  disease, 
but  are  more  persistent  and  frequent  after  cavities  have  formed.  Some 
patients  escape  altogether. 

The  pulse  is  increased  in  frequency,  especially  when  the  fever  is  high. 
It  is  often  remarkably  full,  though  soft  and  compressible.  Pulsation  may 
sometimes  be  seen  in  the  capillaries  and  in  the  veins  on  the  back  of  the 
hand. 

Emaciation  is  a  pronounced  feature,  from  which  the  two  common  names 
of  the  disease  have  been  derived.  The  loss  of  weight  is  gradual  but,  if  the 
disease  is  extending,  progressive.  The  scales  give  one  of  the  best  indica- 
tions of  the  progress  of  the  case. 

3.  Physical  Signs. — (a)  Inspection. — The  shape  of  the  chest  is  often 
suggestive,  though  it  is  to  be  remembered  that  pulmonary  tuberculosis  may 
be  met  with  in  chests  of  any  build.     Practically,  however,  in  a  consider- 


TUBERCULOSIS.  307 

able  proportion  of  cases  the  thorax  is  long  and  narrow,  with  very  wide 
intercostal  spaces,  the  ribs  more  vertical  in  direction  and  the  costal  angle 
very  narrow.  The  scapiilge  are  "  winged/^  a  point  noted  by  Hippocrates. 
Another  type  of  chest  which  is  very  common  is  that  which  is  flattened  in 
the  antero-posterior  diameter.  The  costal  cartilages  may  be  prominent 
and  the  sternum  depressed.  Occasionally  the  lower  sternum  forms  a  deep 
concavity,  the  so-called  funnel  breast  (Trichter-Brust).  Inspection  gives 
valuable  information  in  all  stages  of  the  disease.  Special  examination 
should  be  made  of  the  clavicular  regions  to  see  if  one  clavicle  stands  out 
more  distinctly  than  the  other,  or  if  the  spaces  above  or  below  it  are  more 
marked.  Defective  expansion  at  one  apex  is  an  early  and  important  sign. 
The  condition  of  expansion  of  the  lower  zone  of  the  thorax  may  be  well 
estimated  by  inspection.  The  condition  of  the  prsecordia  should  also  be 
noted,  as  a  wide  area  of  impulse,  particularly  in  the  second,  third,  and 
fourth  interspaces,  often  results  from  disease  of  the  left  apex.  From  a  point 
behind  the  patient,  looking  over  the  shoulders,  one  can  often  better  esti- 
mate the  relative  expansion  of  the  apices. 

(h)  Palpation. — Deficiency  in  expansion  at  the  apices  or  bases  is  per- 
haps best  gauged  by  placing  the  hands  in  the  subclavicular  spaces  and  then 
in  the  lateral  regions  of  the  chest  and  asking  the  patient  to  draw  slowly  a 
full  breath.  Standing  behind  the  patient  and  placing  the  thumbs  in  the 
supraclavicular  and  the  fingers  in  the  infraclavicular  spaces  one  can  Judge 
accurately  as  to  the  relative  mobility  of  the  two  sides.  Disease  at  an  apex, 
though  early  and  before  dulness  is  at  all  marked,  may  be  indicated  by 
deficient  expansion.  On  asking  the  patient  to  count,  the  tactile  fremitus 
is  increased  wherever  there  is  local  growth  of  tubercle  or  extensive  casea- 
tion. In  comparing  the  apices  it  is  important  to  bear  in  mind  that  normally 
the  fremitus  is  stronger  over  the  right  than  the  left.  So  too  at  the  base, 
when  there  is  consolidation  of  the  lung,  the  fremitus  is  increased;  whereas, 
if  there  is  pleural  effusion,  it  is  diminished  or  absent.  In  the  later  stages, 
when  cavities  form,  the  tactile  fremitus  is  usually  much  exaggerated  over 
them.  When  the  pleura  is  greatly  thickened  the  fremitus  may  be  somewhat 
diminished. 

(c)  Percussion. — Tubercles,  inflammatory  products,  fibroid  changes, 
and  cavities  produce  important  changes  in  the  pulmonary  resonance. 
There  may  be  localized  disease,  even  of  some  extent,  without  inducing 
much  alteration;  as  when  the  tubercles  are  scattered  and  have  air-contain- 
ing tissue  between  them.  One  of  the  earliest  and  most  valuable  signs  is 
defective  resonance  upon  and  above  a  clavicle.  In  a  considerable  propor- 
tion of  all  cases  of  phthisis  the  dulness  is  first  noted  in  these  regions.  The 
comparison  between  the  two  sides  should  be  made  also  when  the  breath 
is  held  after  a  full  inspiration,  as  the  defective  resonance  may  then  be 
more  clearly  marked.  In  the  early  stages  the  percussion  note  is  usually 
higher  in  pitch,  and  it  may  require  an  experienced  ear  to  detect  the  differ- 
ence. In  recent  consolidation  from  caseous  pneumonia  the  percussion  note 
often  has  a  tubular  or  tympanitic  quality.  A  wooden  dulness  is  rarely 
heard  except  in  old  cases  with  extensive  fibroid  change  at  the  apex  or  base. 
Over  large,  thin-walled  cavities  at  the  apex  the  so-called  cracked-pot  sound 


308  SPECIFIC  INFECTIOUS  DISEASES. 

may  be  obtained.  In  thin  subjects  the  percussion  should  be  carefully  prac- 
tised in  the  supraspinous  fossse  and  the  interscapular  space^  as  they  cor- 
respond to  very  important  areas  early  involved  in  the  disease.  In  cases 
with  numerous  isolated  cavities  at  the  apex,  without  much  fibroid  tissue 
or  thickening  of  the  pleura,  the  percussion  note  may  show  little  change, 
and  the  contrast  between  the  signs  obtained  on  auscultation  and  percussion 
is  most  marked.  In  the  direct  percussion  of  the  chest,  particularly  in  thin 
patients  over  the  pectorals,  one  frequently  sees  the  phenomenon  known 
as  myoidema,  a  local  contraction  of  the  muscle  causing  bulging,  which  per- 
sists for  a  variable  period  and  gradually  subsides.  It  has  no  special  signifi- 
cance. 

(d)  Auscultation. — Feeble  breath-sounds  are  among  the  most  charac- 
teristic early  signs,  since  not  as  much  air  enters  the  tubes  and  vesicles  of 
the  affected  area.  It  is  well  at  first  always  to  compare  carefully  the  cor- 
responding points  on  the  two  sides  of  the  chest  without  asking  the  patient 
either  to  draw  a  deep  breath  or  to  cough.  With  early  apical  disease  the 
inspiration  on  quiet  breathing  may  be  scarcely  audible.  Expiration  is 
usually  prolonged.  On  the  other  hand,  there  are  cases  in  which  the  earliest 
sign  is  a  harsh,  rude,  respiratory  murmur.  On  deep  breathing  it  is  fre- 
quently to  be  noted  that  inspiration  is  jerking  or  wavy,  the  so-called  "  cog- 
wheel "  rhythm;  which,  however,  is  by  no  means  confined  to  tuberculosis. 
With  extension  of  the  disease  the  inspiratory  murmur  is  harsh,  and,  when 
consolidation  occurs,  whiffing  and  bronchial.  With  these  changes  in  the 
character  of  the  murmur  there  are  rales,  due  to  the  accompanying  bron- 
chitis. They  may  be  heard  only  on  deep  inspiration  or  on  coughing,  and 
early  in  the  disease  are  often  crackling  in  character.  When  softening 
occurs  they  are  louder  and  have  a  bubbling,  sometimes  a  characteristic 
clicking  quality.  These  "  moist  sounds,"  as  they  are  called,  when  asso- 
ciated with  change  in  the  percussion  resonance  are  extremely  suggestive. 
When  cavities  form,  the  rales  are  louder,  more  gurgling,  and  resonant  in 
quality.  When  there  is  consolidation  of  any  extent  the  breath-sounds  are 
tubular,  and  in  the  large  excavations  loud  and  cavernous,  or  have  an  am- 
phoric quality.  In  the  unaffected  portions  of  the  lobe  and  in  the  opposite 
lung  the  breath-sounds  may  be  harsh  and  even  puerile.  The  vocal  reso- 
nance is  usually  increased  in  all  stages  of  the  process,  and  bronchophony 
and  pectoriloquy  are  met  with  in  the  regions  of  consolidation  and  over 
cavities.  Pleuritic  friction  may  be  present  at  any  stage  and,  as  mentioned 
before,  occurs  very  early.  There  are  cases  in  which  it  is  a  marked  feature 
throughout.  When  the  lappet  of  lung  over  the  heart  is  involved  there 
may  be  a  pleuro-pericardial  friction,  and  when  this  area  is  consolidated 
there  may  be  curious  clicking  rales  synchronous  with  the  heart-beat,  due 
to  the  compression  by  the  heart  of,  and  the  expulsion  of  air  from,  this 
portion.  An  interesting  auscultatory  sign,  met  most  commonly  in  phthisis, 
is  the  so-called  cardio-respiratory  murmur,  a  whiffing  systolic  bruit  due 
to  the  propulsion  of  air  out  of  the  tubes  by  the  impulse  of  the  heart. 
It  is  best  heard  during  inspiration  and  in  the  antero-lateral  regions  of  the 
chest. 

A  systolic  murmur  is  frequently  heard  in  the  subclavian  artery  on  either 


TUBERCULOSIS.  309 

side,  the  pulsation  of  which  may  be  very  visible.  The  murmur  is  in  all 
probability  due  to  pressure  on  the  vessels  by  the  thickened  pleura. 

The  signs  of  cavity  may  be  here  briefly  enumerated. 

(a)  When  there  is  not  much  thickening  of  the  pleura  or  condensation 
of  the  surrounding  lung-tissue,  the  percussion  sound  may  be  full  and  clear, 
resembling  the  normal  note.  More  commonly  there  is  defective  resonance 
or  a  tympanitic  quality  which  may  at  times  be  purely  amphoric.  The  pitch 
of  the  percussion  note  changes  over  a  cavity  when  the  mouth  is  opened  or 
closed  (Wintrich's  sign),  or  it  may  be  brought  out  more  clearly  on  change 
of  position.  The  cracked-pot  sound  is  only  obtainable  over  tolerably  large 
cavities  with  thin  walls.  It  is  best  elicited  by  a  firm,  quick  stroke,  the 
patient  at  the  time  having  the  mouth  open.  In  those  rare  instances  of 
almost  total  excavation  of  one  lung  the  percussion  note  may  be  amphoric 
in  quality,  (h)  On  auscultation  the  so-called  cavernous  sounds  are  heard: 
(1)  Various  grades  of  modified  breathing — blowing  or  tubular,  cavernous 
or  amphoric.  There  may  be  a  curiously  sharp  hissing  sound,  as  if  the  air 
was  passing  from  a  narrow  opening  into  a  wide  space.  In  very  large  cavi- 
ties both  inspiration  and  expiration  may  be  typically  amphoric.  (2)  There 
are  coarse  bubbling  rales  which  have  a  resonant  quality,  and  on  coughing 
may  have  a  metallic  or  ringing  character.  On  coughing  they  are  often  loud 
and  gurgling.  In  very  large  thin-walled  cavities,  and  more  rarely  in 
medium-sized  cavities,  surrounded  by  recent  consolidation,  the  rales  may 
have  a  distinctly  amphoric  echo,  simulating  those  of  pneumothorax.  There 
are  dry  cavities  in  which  no  rales  are  heard.  (3)  The  vocal  resonance  is 
greatly  intensified  and  whispered  pectoriloquy  is  clearly  heard.  In  large 
apical  cavities  the  heart-sounds  are  well  heard,  and  occasionally  there  may 
be  an  intense  systolic  murmur,  probably  always  transmitted  to,  and  not 
produced  as  has  been  supposed,  in  the  cavity  itself.  In  large  excavations 
of  the  left  apex  the  heart  impulse  may  cause  gurgling  sounds  or  clicks 
synchronous  with  the  systole.  They  may  even  be  loud  enough  to  be  heard 
at  a  little  distance  from  the  chest  wall.  A  large  cavity  with  smooth  walls 
and  thin  fluid  contents  may  give  the  succussion  sound  when  the  trunk  is 
abruptly  shaken  (Walshe),  and  even  the  coin  sound  may  be  obtained. 

Pseudo-cavernous  signs  may  be  caused  by  an  area  of  consolidation  near 
a  large  bronchus.  The  condition  may  be  most  deceptive — the  high-pitched 
or  tympanitic  percussion  note,  the  tubular  or  cavernous  breathing,  and  the 
resonant  rales,  simulate  closely  those  of  cavity. 

4.  Complications  of  Pulmonary  Tuberculosis. — (1)  In  the 
Respiratory  System. — The  larynx  is  rarely  spared  in  chronic  pulmonary 
tuberculosis.  The  first  symptom  may  be  huskiness  of  the  voice.  There 
are  pain,  particularly  in  swallowing,  and  a  cough  which  is  often  wheezing, 
and  in  tlie  later  stages  very  inefl^ectual.  Aphonia  and  dysphagia  are  the 
two  most  distressing  symptoms  of  the  laryngeal  involvement.  When  the 
epiglottis  is  seriously  diseased  and  the  ulceration  extends  to  the  lateral 
wall  of  the  pharynx,  the  pain  in  swallowing  may  be  very  intense,  or,  owing 
to  the  imperfect  closure  of  the  glottis,  there  may  be  coughing  spells  and 
regurgitation  of  food  through  the  nostrils.  Bronchitis  and  tracheitis  are 
almost  invariable  accompaniments  of  chronic  pulmonary  tuberculosis. 


310  SPECIFIC  INFECTIOUS  DISEASES. 

Pneumonia  is  a  not  infrequent  terminal  complication  of  chronic 
phthisis.  It  may  run  a  perfectly  normal  course,  while  in  other  instances 
resolution  may  be  delayed,  and  one  is  in  doubt,  in  spite  of  the  abruptness 
of  the  onset,  as  to  the  presence  of  a  simple  or  a  tuberculous  pneumonia. 

Emphysema  of  the  uninvolved  portions  of  the  lung  is  a  common  fea- 
ture, rarely  producing  any  special  symptoms.  There  are,  however,  cases 
of  chronic  tuberculosis  in  which  emphysema  dominates  the  picture,  and 
in  which  the  condition  develops  slowly  during  a  period  of  many  years. 
(General  subcutaneous  emphysema,  which  has  been  met  with  in  a  few 
rare  cases,  is  due  either  to  perforation  of  the  trachea  or  to  the  rupture  of 
a  cavity  closely  adherent  to  the  chest  wall.) 

Gangi'ene  of  the  lung  is  an  occasional  event  in  chronic  pulmonary 
tuberculosis,  due  in  almost  all  instances  to  sphacelus  in  the  walls  of  the 
cavity,  rarely  in  the  lung-tissue  itself. 

Complications  in  the  Pleura. — A  dry  pleurisy  is  a  very  common  accom- 
paniment of  the  early  stages  of  tuberculosis.  It  is  always  a  conservative, 
useful  process.  In  some  cases  it, is  very  extensive,  and  friction  murmurs 
may  be  heard  over  the  sides  and  back.  The  cases  with  dry  pleurisy  and 
adhesions  are  of  course  much  less  liable  to  the  dangers  of  pneumothorax. 
Pleurisy  with  effusion  more  commonly  precedes  than  develops  in  the  course 
of  pulmonary  tuberculosis.  Still,  it  is  common  enough  to  meet  with  cases 
in  which  a  sero-fibrinous  effusion  develops  in  the  course  of  the  chronic 
disease.  There  are  cases  in  which  it  is  a  special  feature,  and  it  often,  I  think, 
favors  chronicity.  A  patient  may  during  a  period  of  four  or  five  years 
have  signs  of  local  disease  at  one  apex  with  recurring  effusion  in  the  same 
side.  Owing  to  adhesions  in  different  parts  of  the  pleura,  the  effusion  may 
be  encapsulated.  Hsemorrhagic  effusions,  which  are  not  uncommon  in 
connection  with  tuberculous  pleurisy,  are  comparatively  rare  in  chronic 
phthisis.  Chyliform  or  milky  exudates  are  sometimes  found.  Purulent 
effusions  are  not  frequent  apart  from  pneumothorax.  An  empyema,  how- 
ever, may  develop  in  the  course  of  the  disease  or  as  a  sequence  of  a  sero- 
fibrinous exudate.  Pneumothorax  is  an  extremely  common  complication 
of  chronic  pulmonary  tuberculosis.  It  may  occur  early  in  the  disease,  but 
more  frequently  is  late.  It  may  prove  fatal  in  twenty-four  hours.  In 
other  instances  a  pyo-pneumothorax  develops  and  the  patient  lingers  for 
weeks  or  months.  In  a  third  group  of  cases  it  seems  to  have  a  beneficial 
effect  on  the  course  of  the  disease. 

(2)  Symptoms  referable  to  other  Organs. — (a)  Cardio-vascular. — The 
retraction  of  the  left  upper  lobe  exposes  a  large  area  of  the  heart.  In  thin- 
chested  subjects  there  may  be  pulsation  in  the  second,  third,  and  fourth 
interspaces  close  to  the  sternum.  Sometimes  with  much  retraction  of  the 
left  upper  lobe  the  heart  is  drawn  up.  A  systolic  murmur  over  the  pul- 
monary area  is  common  in  all  stages  of  phthisis.  Apical  murmurs  are  also 
not  infrequent  and  may  be  extremely  rough  and  harsh  without  necessarily 
indicating  that  endocarditis  is  present.  The  association  of  heart-disease 
with  phthisis  is  not,  however,  very  uncommon.  As  already  mentioned, 
there  were  12  instances  of  endocarditis  in  216  autopsies.  The  arterial 
tension  is  usually  low  in  phthisis  and  the  capillary  resistance  lessened  so 


TUBERCULOSIS.  311 

that  the  pulse  is  often  full  and  soft  even  in  the  later  stages  of  the  disease. 
The  capillary  pulse  is  not  infrequently  met  with,  and  pulsation  of  the 
veins  in  the  back  of  the  hand  is  occasionally  to  he  seen. 

(b)  Blood  Glandular  System. — The  early  anemia  has  already  been  noted. 
It  is  often  more  apparent  than  real,  a  chloro-angemia,  and  the  blood-count 
rarely  sinks  heloAv  two  millions  per  cubic  millimetre. 

The  blood-plates  are,  as  a  rule,  enormously  increased  and  are  seen  in  the 
withdrawn  blood  as  the  so-called  Schultze's  granule  masses.  Without  any 
significance,  they  are  of  interest  chiefly  from  the  fact  that  every  few  years 
some  tyro  announces  their  discovery  as  a  new  diagnostic  sign  of  phthisis. 
The  leucocytes  are  greatly  increased,  particularly  in  the  later  stages. 

{c)  Oastro-intestinal  System. — The  tongue  is  usually  furred,  but  may 
be  clean  and  red.  Small  aphthous  ulcers  are  sometimes  distressing.  A 
red  line  on  the  gums,  a  symptom  to  which  at  one  time  much  attention  was 
paid  as  a  special  feature  of  phthisis,  occurs  in  other  cachectic  states.  Ex- 
tensive tuberculous  disease  of  the  pharynx,  associated  with  a  similar  affec- 
tion of  the  larynx,  may  interfere  seriously  with  deglutition  and  prove  a 
very  distressing  and  intractable  symptom. 

Of  late,  special  attention  has  been  paid  to  the  gastric  symptoms  of  this 
affection.  Tuberculosis  of  the  stomach  is  rare.  Ulceration  may  occur  as  an 
accidental  complication  and  multiple  catarrhal  ulcers  are  not  uncommon. 
Interstitial  and  parenchymatous  changes  in  the  mucosa  are  common  (pos- 
sibly associated  with  the  venous  stasis)  and  lead  to  atrophy,  but  these  can- 
not always  be  connoted  with  the  symptoms,  and  they  may  be  found  when 
not  expected.  On  the  other  hand,  when  the  gastric  symptoms  have  been 
most  persistent  the  mucosa  may  show  very  little  change.  It  is  impossible 
always  to  refer  the  anorexia,  nausea,  and  vomiting  of  consumption  to  local 
conditions.  The  hectic  fever  and  the  neurotic  influences,  upon  which 
Immermann  lays  much  stress,  must  be  taken  into  account,  as  they  play 
an  important  role.  The  organ  is  often  dilated,  and  to  muscular  insuffi- 
ciency alone  may  be  due  some  of  the  cases  of  dyspepsia.  The  condition  of 
the  gastric  secretion  is  not  constant,  and  the  reports  are  discordant.  In 
the  early  stages  there  may  be  superacidity;  later,  a  deficiency  of_acid. 

Anorexia  is  often  a  marked  symptom  at  the  onset;  there  may  be  positive 
loathing  of  food,  and  even  small  quantities  cause  nausea.  Sometimes,  with- 
out any  nausea  or  distress  after  eating,  the  feeding  of  the  patient  is  a  daily 
battle.  When  practicable,  Debove's  forced  alimentation  is  of  great  benefit 
in  such  cases.  Nausea  and  vomiting,  though  occasionally  troublesome  at 
an  early  period,  are  more  marked  in  the  later  stages.  The  latter  may  be 
caused  by  the  severe  attacks  of  coughing.  S.  H.  Habershon  refers  to  four 
different  causes  the  vomiting  in  phthisis:  (1)  central,  as  from  tuberculous 
meningitis;  (2)  pressure  on  the  vagi  by  caseous  glands;  (3)  stimulation 
from  the  peripheral  branches  of  the  vagus,  either  pulmonary,  pharyngeal, 
or  gastric;  and  (4)  mechanical  causes. 

Of  the  iniesiinal  symptoms  diarrhoea  is  the  most  serious.  It  may  come 
on  early,  but  is  more  usually  a  symptom  of  the  later  stages,  and  is  associ- 
ated with  ulceration,  particularly  of  the  largo  bowel.  Extensive  ulceration 
of  the  ileum  may  exist  without  any  diarrhoea.     The  associated  catarrhal 


312  SPECIFIC  INFECTIOUS  DISEASES. 

condition  may  account  in  part  for  it,  and  in  some  instances  the  amyloid  de- 
generation of  the  mucous  membrane. 

(d)  Nervous  System. — (1)  Focal  lesions  due  to  the  development  of 
coarse  tubercles  and  areas  of  tuberculous  meningo-encephalitis.  Aphasia, 
for  instance,  may  result  from  the  growth  of  meningeal  tubercles  in  the 
fissure  of  Sylvius,  or  even  hemijDlegia  may  develop.  The  solitary  tubercles 
are  more  common  in  the  chronic  phthisis  of  children.  (3)  Basilar  menin- 
gitis is  an  occasional  complication.  It  may  be  confined  to  the  brain,  though 
more  commonly  it  is  a  (3)  eerebro-sj5inal  meningitis,  which  may  come  on 
in  persons  without  well-developed  local  signs  in  the  chest.  Twice  have  I 
known  strong,  robust  men  brought  into  hospital  with  signs  of  cerebro- 
spinal meningitis,  in  whom  the  existence  of  pulmonary  disease  was  not 
discovered  until  the  post-mortem.  (4)  Peripheral  neuritis,  which  is  not 
common,  may  cause  an  extensor  paralysis  of  the  arm  or  leg,  more  com- 
monly the  latter,  with  foot-drop.  It  is  usually  a  late  manifestation.  (5) 
Mental  symptoms.  It  was  noted,  even  by  the  older  writers,  that  consump- 
tives had  a  peculiarly  hopeful  temperament,  and  the  spes  pJithisica  forms 
a  curious  characteristic  of  the  disease.  Patients  with  extensive  cavities, 
high  fever,  and  too  weak  to  move  will  often  make  plans  for  the  future  and 
confidently  expect  to  recover. 

Apart  from  tuberculosis  of  the  brain,  there  is  sometimes  in  chronic 
phthisis  a  form  of  insanity  not  unlike  that  which  develops  in  the  con- 
valescence from  acute  affections.  The  whole  question  of  the  mutual  rela- 
tions of  insanity  and  phthisis  is  dealt  with  at  length  in  Mickle's  Goulstonian 
lectures. 

(e)  A  remarkable  hypertrophy  of  the  mammary  gland  may  occur  in  pul- 
monary tuberculosis,*  most  commonly  in  males.  It  may  be  only  on  the 
affected  side.  It  is  a  chronic  interstitial,  non-tuberculous  mammitis  (Allot). 
Mastitis  adolescentium,  not  very  uncommon,  is  not  necessarily  suggestive 
of  pulmonary  tuberculosis. 

(/)  Genito-urinary  System. — The  urine  presents  no  special  peculiari- 
ties in  amount  or  constituents.  Fever,  however,  has  a  marked  influence 
upon  it.  Albumin  is  met  with  frequently  and  may  be  associated  with  the 
fever,  or  is  the  result  of  definite  changes  in  the  kidneys.  In  the  latter  case 
it  is  more  abundant  and  more  curd-like.  Amyloid  disease  of  the  kidneys 
is  not  uncommon.  Its  presence  is  shown  by  albumin  and  tube-casts, 
and  sometimes  by  a  great  increase  in  the  amount  of  urine.  In  other 
instances  there  is  dropsy,  and  the  patients  have  all  the  characteristic  fea- 
tures of  chronic  Bright's  disease. 

Pus  in  the  urine  may  be  due  to  disease  of  the  bladder  or  of  the  pelves 
of  the  kidneys.  In  some  instances  the  entire  urinary  tract  is  involved.  In 
pulmonary  phthisis,  however,  extensive  tuberculous  disease  is  rarely  found 
in  the  urinary  organs.  Bacilli  may  occasionally  be  detected  in  the  pus. 
Hgematuria  is  not  a  very  common  symptom.  It  may  occur  occasionally 
as  a  result  of  congestion  of  the  kidneys,  and  pass  off  leaving  the  urine 
albuminous.     In   other  instances  it   results   from    disease    of   the   pelvis 

*  Allot,  Paris  Thesis,  1887. 


TUBERCULOSIS.  313 

or  of  the  bladder,  and  is  associated  either  with  early  tuberculosis  of  the 
mucous  membranes  or  more  commonly  with  ulceration.  In  any  medical 
clinic  the  routine  inspection  of  the  testes  for  tubercle  will  save  two  or  three 
mistakes  a  year. 

(g)  Cutaneous  System. — The  skin  is  often  dry  and  harsh.  Local  tuber- 
cles occasionally  develop  on  the  hands.  There  may  be  pigmentary  staining, 
the  chloasma  phthisicorum,  which  is  more  common  when  the  peritoneum 
is  involved.  Upon  the  chest  and  back  the  brown  stains  of  pityriasis  versi- 
color are  very  frequent.  The  hair  of  the  head  and  beard  may  become 
dry  and  lanky.  The  terminal  phalanges,  in  chronic  cases,  become  clubbed 
and  the  nails  incurvated — the  Hippoeratic  fingers.  A  remarkable  and  un- 
usual complication  is  general  emphysema,  which  may  result  from  ulcera- 
tion of  an  adherent  lung  or  perforation  of  the  larynx. 

Diagnosis. — When  well  advanced  there  is  rarely  any  doubt  as  to  the 
existence  of  tuberculous  phthisis,  for  the  sputum  gives  positive  informa- 
tion, and  the  physical  signs  of  local  disease  are  well  marked.  The  bacilli 
give  an  infallible  indication  of  the  existence  of  tuberculosis  and  may  be 
found  in  the  sputum  before  the  physical  signs  are  at  all  definite.  On  the 
other  hand,  it  must  be  remembered  that  there  are  cases  in  which,  even 
with  tolerably  well-defined  physical  signs,  the  sputum  is  extremely  scanty 
and  many  examinations  may  be  required  to  detect  tubercle  bacilli.  So 
essential  is  the  examination  of  the  sputum  in  the  early  diagnosis  of  phthisis 
that  I  would  earnestly  insist  upon  the  more  frequent  employment  of  this 
method.  There  is  no  excuse  now  for  its  omission,  since,  if  the  practitioner 
has  not  command  of  the  necessary  technique,  there  are  laboratories  in 
many  parts  of  the  country  at  which  the  examination  can  be  made.  Early 
detection  is  of  vital  importance,  as  successful  treatment  depends  upon  the 
measures  taken  before  the  lungs  are  extensively  involved. 

The  presence  of  elastic  fibres  in  the  sputum  is  an  indication  of  destruc- 
tion of  the  lung-tissue.  In  a  large  proportion  of  cases  it  is  indicative,  too, 
of  tuberculous  disease.  It  also  may  be  found  early,  before  the  physical 
signs  are  well  marked.  Its  detection  is  easy  by  the  above-mentioned  method, 
not  requiring  high  powers  of  the  microscope.  In  cases  of  early  hemoptysis, 
before  there  is  marked  constitutional  disturbance,  or  even  local  signs,  it  is 
very  important  to  make  a  thorough  examination  of  the  sputum,  from 
which  mucoid  and  purulent  portions  may  be  picked  out  for  examination. 
With  localized  and  persistent  signs  in  one  lung,  cough,  fever,  and  loss  of 
flesh,  the  diagnosis  is  rarely  dubious.  It  is  remarkable,  however,  to  what 
an  extent  the  local  process  may  sometimes  proceed  without  disturbance 
of  health  sufficient  to  excite  the  alarm  of  the  physician  or  friends.  There 
are  puzzling  cases  with  localized  physical  signs  at  one  apex,  chiefly  moist 
rales,  rarely  any  percussion  changes,  perhaps  slight  fever,  and  a  glairy 
expectoration  containing  numerous  alveolar  cells.  I  have  seen  several 
cases  of  this  kind  which  have  been  for  a  time  very  obscure,  and  in  which 
repeated  examinations  failed  to  detect  either  bacilli  or  elastic  tissue.  They 
seem  to  be  instances  of  local  catarrhal  trouble  in  the  smaller  tubes,  some 
of  which  clear  in  a  few  weeks. 


314  SPECIFIC  INFECTIOUS  DISEASES. 

3.  Fibroid  Phthisis. 

In  their  monograph  on  Fibroid  Diseases  of  the  Lnng  (1894)  Clark 
Hadley  and  Chaplin  make  the  following  classification:  1.  Pure  fibroid; 
fibroid  phthisis — a  condition  in  which  there  is  no  tubercle.  2.  Tuberculo- 
fibroid  disease — a  condition  primarily  tuberculous,  but  which  has  run  a 
fibroid  course.  3.  Fibro-tuberculous  disease — a  condition  primarily  fibroid, 
but  which  has  become  tuberculous.  The  tuberculo-fibroid  form  may  come- 
on  gradually  as  a  sequence  of  a  chronic  tuberculous  broncho-pneumonia, 
or  follow  a  chronic  tuberculous  pleurisy.  In  other  instances  the  process 
supervenes  upon  an  ordinary  ulcerative  phthisis.  The  disease  becomes 
limited  to  one  apex,  the  cavity  is  surrounded  by  layers  of  dense  fibrous 
tissue,  the  pleura  is  thickened,  and  the  lower  lobe  is  gradually  invaded  by 
the  sclerotic  change.  Ultimately  a  picture,  is  produced  little  if  at  all  differ- 
ent from  the  condition  known  as  cirrhosis  of  the  lungs.  It  may  even  be 
diflficult  to  say  that  the  process  is  tuberculous,  but  in  advanced  cases  the 
bacilli  are  usually  present  in  the  walls  of  the  cavity  at  the  apex,  or  old, 
encapsulated  caseous  areas  exist  in  the  lung,  or  there  may  be  tubercles  at 
the  apex  of  the  other  lung  and  in  the  bronchial  glands.  Dilatation  of  the 
bronchi  is  present;  the  right  ventricle,  sometimes  the  entire  heart,  is  hyper- 
trophied. 

The  disease  is  chronic,  lasting  from  ten  to  twenty  or  more  years,  dur- 
ing which  time  the  patient  may  have  fair  health. 

The  chief  symptoms  are  cough,  which  is  often  paroxysmal  in  character 
and  most  marked  in  the  morning.  The  expectoration  is  purulent,  and 
in  some  instances,  when  the  bronchiectasis  is  extensive,  fetid.  There  is 
dyspnoea  on  exertion,  but  little  or  no  fever. 

The  physical  signs  are  very  characteristic.  The  chest  is  sunken  and 
the  shoulder  lower  on  the  affected  side;  the  heart  is  often  drawn  over  and 
displaced.  If  the  left  lung  is  involved  there  may  be  an  unusually  large 
area  of  cardiac  pulsation  in  the  third,  fourth,  and  fifth  interspaces.  Heart- 
murmurs  are  common.  There  is  dulness  over  the  affected  side  and  defi- 
cient tactile  fremitus.  At  the  apex  there  may  be  well-marked  cavernous 
sounds;  at  the  base,  distant  bronchial  breathing.  The  condition  may  per- 
sist indefinitely.  In  some  cases  the  other  lung  becomes  involved,  or  the 
patient  has  repeated  attacks  of  haemoptysis,  in  one  of  which  he  dies.  As 
a  result  of  the  chronic  suppuration,  amyloid  degeneration  of  the  liver, 
spleen,  and  intestines  may  take  place;  dropsy  frequently  supervenes  from 
failure  of  the  right  heart. 

A  more  detailed  account  is  found  under  Cirrhosis  of  the  Lung,  with 
which  this  form  is  clinically  identical. 

Concurrent  Infections  in  Pulmonary  Tuberculosis.— It  has 
long  been  known  that  in  pulmonary  tuberculosis  organisms  other  than  the 
specific  bacilli  are  present,  particularly  Micrococcus  lanceolatus,  Strepto- 
coccus pyogenes,  and  Staphylococcus  aureus;  less  frequently  Bacillus  pyo- 
cyaneus. 

A  majority  of  all  cases  of  pulmonary  tuberculosis  are  combined  infec- 
tions; streptococci  and  pneumococci  may  be  found  in  the  sputa,  and  the 


TUBERCULOSIS.  315 

former  have  been  isolated  from  the  blood.  Prudden,  who  has  very  care- 
fully studied  this  question,  arrives  at  the  following  conclusions:  The  pul- 
monary lesions  of  tuberculosis  are  subject  to  variations  depending  largely 
on  the  different  modes  of  distribution  of  the  bacilli,  whether  by  the  blood- 
vessels or  through  the  bronchi,  and  also  whether  a  concurrent  infection 
with  other  organisms  has  taken  place.  The  pneumonia  complicating  tuber- 
culosis may  be  the  direct  result  of  the  tubercle  bacillus  or  its  toxines,  or  it 
may  follow  secondary  infection  with  other  germs,  particularly  the  Strepto- 
coccus pyogenes,  the  Micrococcus  lanceolatus,  and  the  Staphylococcus 
pyogenes.  The  frequency  of  this  secondary  infection  and  the  relative  sig- 
nificance of  these  germs  are  not  yet  fully  decided.  The  introduction  of  the 
tubercle  bacilli  into  the  lungs  of  a  rabbit  through  the  trachea  induces  the 
various  phases  of  pulmonary  tuberculosis,  but  cavity  formation  is  rare.  If, 
on  the  other  hand,  into  the  lungs  of  a  rabbit  which  are  the  seat  of  extensive 
consolidation  the  Streptococcus  pyogenes  is  introduced,  then  cavities  form 
rapidly,  and  the  anatomical  picture  is  very  similar  to  that  of  chronic  ulcer- 
ative tuberculosis  in  man.  It  is  very  probable  that  in  man,  too,  the  effect 
of  contamination  with  these  pus  organisms  is  a  very  important  one  in 
hastening  necrosis  and  softening,  and  also  in  the  chronic  cases  they  doubt- 
less produce  in  large  amounts  the  toxines  which  are  responsible  for  many 
of  the  symptoms  of  the  disease. 

Diseases  associated  with  Pulmonary  Tuberculosis.— io&ar 
pneumonia  is  a  not  uncommon  cause  of  death.  It  is  met  with,  most  fre- 
quently indeed,  as  a  terminal  event  in  the  chronic  cases.  It  may,  however, 
occur  early,  and  be  difficult  to  distinguish  from  an  acute  caseous  pneu- 
monia. The  sputa  in  the  latter  are  rarely  rusty,  while  the  fever  in  the 
former  is  more  continuous  and  higher,  but  in  many  cases  it  is  impossible 
to  differentiate  between  the  two  conditions. 

Typhoid  fever  occasionally  occurs  in  persons  the  subjects  of  pulmonary 
tuberculosis.  In  4  cases  of  80  autopsies  in  typhoid  fever  tuberculous  lesions 
were  present.  There  are  cases  on  record  also  of  acute  miliary  tuberculosis 
and  typhoid  fever  present  in  the  same  subject.  There  is  a  widespread 
opinion  that  typhoid  fever  predisposes  to  tuberculosis,  and  Wilson  Fox 
in  his  treatise  on  diseases  of  the  lungs  gives  references  to  a  number  of 
cases.  In  my  experience  it  has  been  very  rare.  I  have  no  recollection  of 
an  instance  in  which  tuberculosis  has  developed  either  during  convalescence, 
or  immediately  after  recovery,  from  typhoid  fever. 

Erysipelas  not  infrequently  attacks  old  poitrinaires  in  hospital  wards 
and  almshouses.  There  are  instances  in  which  the  attack  seems  to  be  bene- 
ficial, as  the  cough  lessens  and  the  symptoms  ameliorate.  It  may,  however, 
prove  fatal. 

The  eruptive  fevers,  particularly  measles,  frequently  precede,  but  rarely 
develop  in  the  course  of  pulmonary  tuberculosis.  In  the  revaccination  of 
a  tuberculous  subject  the  vesicles  run  a  normal  course. 

Fistula  in  ano  is  associated  with  phthisis  in  an  interesting  manner. 
In  a  majority  of  such  cases  it  is  a  tuberculous  process.     The  general  affec- 
tion may  progress  rapidly  after  an  operation.     The  question  is  considered 
in  tuberculosis  of  the  alimentary  canal. 
20 


316  SPECIFIC  INFECTIOUS  DISEASES. 

Heart-disease. — I  have  already  referred  (page  298)  to  the  occurrence  of 
endocarditis  in  tuberculosis.  The  antagonism  between  heart  lesions  and 
phthisis,  upon  which  Eokitansky  laid  stress,  is  not  pronounced.  Stenosis 
of  the  pulmonary  artery  and  aneurism  of  the  aorta  predispose  to  tubercu- 
losis pulmonum,  probably  by  reducing  the  activity  of  the  lesser  circula- 
tion. In  mitral  stenosis  pulmonary  tuberculosis  is  not  infrequent,  in  9  of 
54  cases  (Potain).  A  terminal  acute  tuberculosis  of  one  or  the  other  of 
the  serous  membranes  is  a  very  common  event  in  all  forms  of  cardio-vascu- 
lar  disease. 

In  chronic  and  arrested  phthisis  arteriosclerosis  and  phleho-sderosis 
are  not  uncommon.  Ormerod  noted  30  cases  of  chronic  renal  disease  in 
100  post-mortems. 

The  association  of  tuberculosis  with  chronic  arthritis,  upon  which  cer- 
tain writers  lay  stress,  finds  its  explanation  in  the  lowered  resistance  of 
these  patients,  and  the  greater  liability  to  infection  in  the  institutions  in 
which  so  many  of  them  live. 

Peculiarities  of  Pulmonary  Tuberculosis  at  the  Extremes 
of  Life. — (a)  Old  Age. — It  is  remarkable  how  common  tuberculosis  is  in 
the  aged,  particularly  in  institutions.  McLachlan  noted  145  cases  in  which 
tuberculosis  was  the  cause  of  death  in  old  persons  in  Chelsea  Hospital. 
All  were  over  sixty  years  of  age.  The  experience  at  the  Salpetriere  is  the 
same.    Laennec  met  with  a  case  in  a  person  over  ninety-nine  years  of  age. 

At  the  Philadelphia  Hospital,  in  the  bodies  of  aged  persons  sent  over 
from  the  almshouse  it  was  extremely  common  to  find  either  old  or  recent 
tuberculosis.  A  patient  died  under  my  care  at  the  age  of  eighty-two  with 
extensive  peritoneal  tuberculosis.  Pulmonary  tuberculosis  in  the  aged  is 
usually  latent  and  runs  a  slow  course.  The  physical  signs  are  often  masked 
by  emphysema  and  by  the  coexisting  chronic  bronchitis.  The  diagnosis 
may  depend  entirely  upon  the  discovery  of  the  bacilli  and  elastic  tissue. 
Contrary  to  the  opinion  which  was  held  some  years  ago,  tuberculosis  is  by 
no  means  uncommon  with  senile  emphysema.  Some  of  the  cases  of  tuber- 
culosis in  the  aged  are  instances  of  quiescent  disease  which  may  have  dated 
from  an  early  period. 

(b)  Infants. — The  occurrence  of  acute  tuberculosis  in  children  has  al- 
ready been  mentioned,  and  also  the  fact  that  the  disease  is  occasionally 
congenital.  Eecent  studies,  particularly  of  French  writers,  have  shown 
that  it  is  a  frequent  affection  in  children  under  two  years  of  age.  Leroux 
has  analyzed  the  statistics  of  the  late  Prof.  Parrot,  embracing  219  cases  in 
children  under  three  years.  Of  these  there  were  from  one  day  to  three 
months,  23;  from  three  to  six  months,  35;  from  six  to  twelve  months, 
63  (a  total  of  111  under  one  year);  and  from  one  to  three  years,  108.  Pul- 
monary cavities  were  present  in  57  of  the  cases,  and  in  only  50  was  the 
pulmonary  lesion  the  sole  manifestation.  At  the  St.  Petersburg  Foundling 
Asylum,  in  the  ten  years  ending  1884,  there  were  416  cases  of  tuberculosis 
in  16,581  autopsies.  The  observations  of  Northrup,  at  the  New  York 
Foundling  Hospital,  are  of  special  interest  in  connection  with  the  mode 
of  infection.  Of  125  eases  of  tuberculosis  on  the  records  of  this  institution, 
in  34  the  ravages  were  extensive,  the  seat  of  the  primary  affection  was  not 


TUBERCULOSIS.  317 

clear,  and  the  bronchial  glands  were  large  and  cheesy.  In  20  cases  of 
general  tuberculosis  there  were  cheesy  masses  in  the  bronchial  glands  and 
in  the  lungs.  In  42  cases  of  general  tuberculosis  the  only  cheesy  masses 
were  in  the  bronchial  lymph-glands.  In  9  cases  the  tubercles  were  limited 
to  the  bronchial  nodes  and  the  lungs;  the  latter  containing  only  discrete 
miliary  bodies,  while  the  bronchial  glands  showed  advanced  caseation.  In 
13  cases  there  was  tuberculosis  of  the  bronchial  nodes  only.  In  most  of 
these  cases  the  patients  died  of  infectious  diseases.  These  figures  are  very 
suggestive,  and  point,  as  already  noted,  to  infection  through  the  bronchial 
passages  as  the  most  common  method,  even  in  children.  Of  500  autopsies 
in  children  at  the  Munich  Pathological  Institute,  in  150  (30  per  cent)  tuber- 
culosis was  present  and  in  over  92  per  cent  the  lungs  were  involved 
(Miiller). 

Modes  of  Death  in  Pulmonary  Tuberculosis.  — (a)  By  asthenia, 
a  gradual  failure  of  the  strength.  The  end  is  usually  peaceable  and  quiet, 
occasionally  disturbed  by  paroxysms  of  cough.  Consciousness  is  often  re- 
tained until  near  the  close. 

(b)  By  asphyxia,  as  in  some  cases  of  acute  miliary  tuberculosis  and  in 
acute  pneumonic  phthisis.  In  chronic  phthisis  it  is  rarely  seen,  even  when 
pneumothorax  develops. 

(c)  By  syncope.  This  is  not  common.  I  have  known  it  to  happen  once 
or  twice  in  patients  who  insisted  upon  going  about  when  in  the  advanced 
stages  of  the  disease.  There  may  be,  but  not  necessarily,  fatty  degeneration 
of  the  heart.  A  rapidly  developing  syncope  may  follow  hemorrhage  or 
may  be  due  to  thrombosis  or  embolism  of  the  pulmonary  artery,  or  to  pneu- 
mothorax. 

(d)  From  hcemorrhage.  The  fatal  bleeding  in  chronic  phthisis  is  due 
to  erosion  of  a  large  vessel  or  rupture  of  an  aneurism  in  a  pulmonary 
cavity,  most  commonly  the  latter.  Of  26  cases  analyzed  by  S.  West,  in  11 
the  fatal  haemoptysis  was  due  to  aneurism,  and  of  35  cases  collected  by 
Percy  Kidd,  aneurism  was  present  in  30.  In  a  case  of  Curtin's,  at  the 
Philadelphia  Hospital,  the  bleeding  proved  fatal  before  hemoptysis  oc- 
curred, as  the  eroded  vessel  opened  into  a  capacious  cavity. 

(e)  With  cerebral  symptoms.  Coma  may  be  due  to  meningitis,  less  often 
to  uraemia.  Death  in  convulsions  is  rare.  The  hsemorrhagic  pachy-menin- 
gitis  which  develops  in  some  cases  of  phthisis  occasionally  causes  loss  of 
consciousness,  but  is  rarely  a  direct  cause  of  death.  In  one  of  my  cases, 
death  resulted  from  thrombosis  of  the  cerebral  sinuses  with  symptoms  of 
meningitis. 

V.    TUBEECULOSIS    OF    THE    ALIMENTARY    CaNAL. 

(a)  Lips. — Tuberculosis  of  the  lip  is  very  rare.  It  occurs  occasionally 
in  the  form  of  an  ulcer,  either  alone  or  more  commonly  in  association  witli 
laryngeal  or  pulmonary  disease.  Two  cases  are  reported  and  the  literature 
is  analyzed  in  Verneuil's  Etudes.*  The  ulcer  is  usually  very  sensitive  and 
may  be  mistaken  for  a  chancre  or  an  epithelioma.     The  diagnosis  raay  be 

*  Tome  iii,  Fasc.  I. 


318  SPECIFIC  INFECTIOUS  DISEASES. 

made  in  cases  of  doubt  by  inoculation  or  the  examination  of  a  portion  for 
tubercle  bacilli. 

(&)  Tongue. — The  disease  begins  by  an  aggregation  of  small  granular 
bodies  on  the  edge  or  dorsum.  Ulceration  proceeds,  leaving  an  irregular 
sore  with  a  distinct  but  uneven  margin,  and  a  rough,  often  caseous  base. 
The  disease  extends  slowly  and  may  form  an  ulcer  of  considerable  size. 
I  have  known  it  to  be  mistaken  for  epithelioma  and  the  tongue  to  be  ex- 
cised. It  is  rarely  met  with  except  when  other  organs  are  involved.  The 
glands  of  the  angle  of  the  jaw  are  not  enlarged  and  the  sore  does  not  yield 
to  iodide  of  potassium,  which  are  points  of  distinction  between  the  tuber- 
culous and  the  syphilitic  ulcer.  In  doubtful  cases  the  inoculation  test 
should  be  made,  or  a  portion  excised  for  microscopical  examination. 

(c)  The  salivary  glands  belong  to  that  small  group  of  organs  of  the 
body  which  seem  to  possess  an  immunity  against  tuberculous  infection — 
an  immunity,  however,  which  in  their  case  is  relative,  not  absolute;  a  few 
cases  have  been  reported. 

{d)  Tubercles  of  the  hard  or  soft  palate  nearly  always  follow  extension 
of  the  disease  from  neighboring  parts. 

(e)  Tuberculosis  of  the  Tonsils. — In  7  of  45  consecutive  cases  in  children 
from  three  months  to  fifteen  years  A.  Latham  demonstrated,  by  inoculation, 
the  presence  of  tuberculosis  of  the  tonsils  either  in  organs  removed  by  oper- 
ation or  post,  mortem.  The  observation  is  of  interest  in  connection  with 
the  views  of  Schlenker,  who  claims  that  the  majority  of  the  eases  of  tuber- 
culous cervical  glands  result  from  infection  with  tubercle  bacilli  which 
gain  admission  by  way  of  the  tonsil.  A  large  number  of  his  cases  of  tuber- 
culous cervical  adenitis  were  definitely  of  a  descending  variety  and  asso- 
ciated with  tuberculosis  of  these  glands.  The  majority  also  had  pulmonary 
tuberculosis,  and  he  regards  surface  infection  of  the  tonsil  by  tuberculous 
food  and  sputum  far  more  common  than  infection  by  way  of  the  circula- 
tion. The  disease  may  occur  as  a  superficial  ulceration.  More  commonly 
there  is  an  infiltration  of  the  tonsil  with  miliary  tubercles,  which  produces 
a  greater  or  less  hypertrophy  which  it  is  practically  impossible  to  distin- 
guish from  an  ordinary  enlargement  of  the  tonsil  without  a  microscopical 
examination.     Caseous  foci  occasionally  develop. 

(/)  Pharynx. — In  extensive  laryngeal  tuberculosis  an  eruption  of  mili- 
ary granules  on  the  posterior  wall  of  the  pharynx  is  not  very  uncommon. 
In  chronic  phthisis  an  ulcerative  pharyngitis,  due  to  extension  of  the  dis- 
ease from  the  epiglottis  and  larynx,  is  one  of  the  most  distressing  of  com- 
plications, rendering  deglutition  acutely  painful.  Adenoids  of  the  naso- 
pharynx may  be  tuberculous,  as  shown  by  Lermoyez.  Macroscopically,  they 
do  not  differ  from  the  ordinary  vegetations  found  in  this  situation. 

{g)  A  few  instances  occur  in  the  literature  of  tuberculosis  of  the 
cesophagus.  The  condition  is  a  pathological  curiosity,  except  in  the  slight 
extension  from  the  larynx,  which  is  not  infrequent;  but  in  a  case  in  my 
wards  described  by  Flexner  the  ulcer  perforated  and  caused  purulent  pleu- 
risy. The  condition  has  been  fully  considered  by  Claribel  Cone,  who  has 
described  a  second  case  from  the  Johns  Hopkins  Hospital  (Bulletin,  Novem- 
ber, 1897). 


TUBERCULOSIS.  319 

(h)  Stomach. — Many  cases  are  reiDorted  which  are  doubtful.  Primary 
disease  is  unknown.  Marfan  was  able  to  collect  only  about  a  dozen  authentic 
cases.  Perforation  of  the  stomach  occurred  six  times,  thrice  by  a  tuberculous 
gland.  In  Oppolzer's  case  an  ulcer  of  the  colon  perforated  the  organ.  In 
Musser's  case  there  was  a  large  tuberculous  ulcer  3  X  1^  inches  in  extent. 
Three  cases  have  been  described  from  my  wards  by  Alice  Hamilton  (J.  H^ 
H.  Bulletin,  April,  1897). 

(i)  Intestines. — The  tubercles  may  be  (1)  primary  in  the  mucous  mem- 
brane, or  more  commonly  (3)  secondary  to  disease  of  the  lungs,  or  in  rare 
cases  the  affection  may  (3)  pass  from  the  peritonaeum. 

(1)  Primary  intestinal  tuberculosis  occurs  most  frequently  in  children, 
in  whom  it  may  be  associated  with  enlargement  and  caseation  of  the  mesen^ 
teric  glands,  or  with  peritonitis.  As  stated  on  p.  267,  there  is  great  dis- 
crepancy in  the  statistics  on  this  point — German  4  per  cent,  American  1 
per  cent,  English  18  per  cent — and  the  question  needs  careful  study.  Bie- 
dert  gives  16  cases  in  3,104  instances  of  tuberculosis  in  children.  In  adults 
primary  intestinal  tuberculosis  is  rare,  occurring  in  but  1  instance  in  1,000 
autopsies  upon  tuberculous  adults  at  the  Munich  Pathological  Institute;  but 
now  and  then  cases  occur  in  which  the  disease  sets  in  with  irregular  diar- 
rhoea, moderate  fever,  and  colicky  pains.  In  a  few  cases  hoemorrhage  has 
been  the  initial  symptom.  Eegarded  at  first  as  a  chronic  catarrh,  it  is  not 
until  the  emaciation  becomes  marked  or  the  signs  of  disease  appear  in  the 
lungs  that  the  true  nature  is  apparent.  Still  more  deceptive  are  the  cases  in 
which  the  tuberculosis  begins  in  the  csecum  and  there  are  symptoms  of  ap- 
pendicitis— tenderness  in  the  right  iliac  fossa,  constipation,  or  an  irregular 
diarrhoea  and  fever.  These  signs  may  gradually  disappear,  to  recur  again  in 
a  few  weeks  and  still  further  complicate  the  diagnosis.  Fatal  hajmorrhage 
has  occurred  in  several  of  my  cases.  Perforation  may  occur  with  the  forma- 
tion of  a  pericaecal  abscess,  or  perforation  into  the  peritonceum  may  take 
place,  or  in  very  rare  instances  there  is  partial  healing  with  great,  thicken- 
ing of  the  walls  and  narrowing  of  the  lumen. 

(2)  Secondary  involvement  of  the  bowels  is  very  common  in  chronic 
pulmonary  tuberculosis,  e.  g.,  in  566  of  the  1,000  Munich  autopsies  in  tuber- 
culosis just  referred  to.  In  only  three  of  these  cases  were  the  lungs  not  in- 
volved. The  lesions  are  chiefly  in  the  ileum,  csecum,  and  colon.  The 
affection  begins  in  the  solitary  and  agminated  glands  or  on  the  surface 
of  or  within  the  mucosa.  The  caseation  and  necrosis  lead  to  ulceration, 
which  may  be  very  extensive  and  involve  the  greater  portion  of  the  mucosa 
of  the  large  and  small  bowels.  In  the  ileum  the  Peyer's  patches  are  chiefly 
involved  and  the  ulcers  may  be  ovoid,  but  in  the  jejunum  and  colon  they 
are  usually  round  or  transverse  to  the  long  axis.  The  tuberculous  ulcer 
has  the  following  characters:  (a)  It  is  irregular,  rarely  ovoid  or  in  the 
long  axis,  more  frequently  girdling  the  bowel;  (b)  the  edges  and  base  are 
infiltrated,  often  caseous;  (c)  the  submucosa  and  muscularis  are  usually 
involved;  and  (d)  on  the  serosa  may  be  seen  colonies  of  young  tubercles  or 
a  well-marked  tuberculous  lymphangitis.  Perforation  and  peritonitis  are 
not  uncommon  events  in  the  secondary  ulceration.  Stenosis  of  the  bowel 
from  cicatrization  may  occur;  the  strictures  may  be  multiple. 


320  SPECIFIC  INFECTIOUS  DISEASES. 

Localized  chronic  tuberculosis  of  the  iUo-ccecal  region  is  of  great  im- 
portance. The  cEecum  may  present  a  chronic  hyperplastic  tuberculosis, 
which  not  uncommonly  extends  into  the  appendix.  As  a  consequence 
of  the  changes  produced  a  definite  tumor-like  mass  is  formed  in  the 
right  iliac  fossa.  This  varies  in  size,  is  usually  elongated  in  a  vertical 
direction,  hard,  slightly  movable,  or  bound  down  by  adhesions  and 
very  sensitive  to  pressure.  The  tumor  simulates  more  or  less  closely  a 
true  neoplasm  of  this  region,  particularly  carcinoma.  The  condition  is 
characterized  by  gradual  constriction  of  the  lumen  of  the  bowel,  periodic 
attacks  of  severe  pain,  and  alternating  diarrhoea  and  constipation.  In  a  few 
cases  extirpation  of  the  cgecum  has  been  performed  with  fairly  successful 
results.  In  a  second  form  of  this  disease,  occurring  less  frequently  than 
the  former,  there  is  no  definite  tumor-mass  to  be  felt,  but  a  general  indura- 
tion and  thickening  in  the  right  iliac  fossa  similar  to  the  local  changes 
produced  by  a  recurring  appendicitis.  In  this  variety  a  fistula  discharging 
fecal  matter  occasionally  results.  Both  forms  may  be  distinguished  from 
the  diseases  they  simulate  by  the  finding  of  tubercle  bacilli  in  the  stools 
or  in  the  discharge  from  the  fistula  when  such  exists. 

Tuberculosis  of  the  rectum  has  a  special  interest  in  connection  with 
fistula  in  ano,  which,  according  to  Spillman's  statistics,  occurs  in  about 
3.5,  per  cent  of  cases  of  pulmonary  disease.  In  many  instances  the  lesion 
has  been  shown  to  be  tuberculous.  It  is  very  rarely  primary,  but  if  the 
tissue  on  removal  contains  bacilli  and  is  infective  the  lungs  are  almost 
invariably  found  to  be  involved.  It  is  a  common  opinion  that  the  pul- 
monary symptoms  may  develop  rapidly  after  the  fistula  is  cut.  This  may 
have  some  basis  if  the  operation  consists  in  laying  the  tract  open,  and  not 
in  a  free  excision. 

(3)  Extension  from  the  peritonseum  may  excite  tuberculous  disease  in 
the  bowels.  The  affection  may  be  primary  in  the  peritonaeum  or  extend 
from  the  tubes  in  women  or  the  mesenteric  glands  in  children.  The  coils 
of  intestines  become  matted  together,  caseous  and  suppurating  foci  de- 
velop between  the  folds,  and  perforation  may  take  place  between  the  coils. 

VI.    TUBEECULOSIS    OF   THE    LiVER. 

This  organ  is  very  constantly  involved  in  (a)  general  tuberculosis.  The 
miliary  granulation  may  be  very  small  and  in  acute  cases  scarcely  percepti- 
ble.   The  liver  is  pale  and  often  fatty. 

(h)  A  remarkable  condition  of  the  organ  is  produced  by  the  develop- 
ment of  the  tubercles  in  the  finer  bile-vessels.  They  may  attain  a  con- 
siderable size  and  are  almost  always  softened  in  the  centre,  resembling 
small  abscesses.  The  contents  are  always  bile-stained.  The  organ  may  be 
honeycombed  with  these  tuberculous  abscesses. 

(c)  Large,  coarse  caseous  masses  are  occasionally  found,  sometimes  in 
association  with  perihepatitis  or  tuberculous  peritonitis.  They  may  attain 
the  size  of  an  orange  or  may  even  be  larger. 

(d)  Tuberculous  cirrhosis.  With  the  eruption  of  miliary  tubercles  there 
may  be  slight  increase  in  the  connective  tissue,  which  is  overshadowed  by 


TUBERCULOSIS.  321 

the  fatty  change.  In  all  the  chronic  forms  of  tubercle  in  this  organ  there 
may  be  fibrous  overgrowth.  Hanot,  who  has  described  several  varieties, 
states  that  the  condition  may  be  primary.  Practically  it  is  very  rare,  except 
in  connection  with  chronic  tuberculous  peritonitis  and  perihepatitis,  when 
the  organ  may  be  much  deformed  by  a  sclerosis  involving  the  portal  canals. 
In  this  last  group  there  may  be  symptoms  of  ascites;  as  a  rule,  tuberculosis 
of  the  liver  has  a  purely  anatomical  interest. 

VII.  Tuberculosis  of  the  Brain  and  Cord. 

Tuberculosis  of  the  hrain  occurs  as  (a)  an  acute  miliary  infection  caus- 
ing meningitis  and  acute  hydrocephalus;  (&)  as  a  chronic  meningo-en- 
cephalitis,  usually  localized,  and  containing  small  nodular  tubercles;  and 
(c)  as  the  so-called  solitary  tubercle.  Between  the  last  two  forms  there 
are  all  gradations,  and  it  is  rare  to  see  the  meninges  uninvolved.  The 
acute  variety  has  already  been  considered.  I  shall  here  consider  the  chronic 
form,  which  develops  slowly  and  has  the  clinical  characters  of  a  tumor. 

It  is  most  common  in  the  young.  Of  148  cases  collected  by  Pribram 
118  were  under  fifteen  years  of  age.  Other  organs  are  usually  involved, 
particularly  the  lungs,  the  bronchial  glands,  or  the  bones.  In  rare  in- 
stances no  tubercles  are  found  elsewhere.  They  occur  most  frequently  in 
the  cerebellum;  next  in  the  cerebrum  and  then  in  the  pons.  The  growths 
are  often  multiple,  in  100  out  of  183  cases  (Gowers).  They  range  in  size 
from  a  pea  to  a  walnut;  larger  tumors  occasionally  occur,  and  sometimes 
an  entire  lobe  of  the  cerebellum  is  ajEfected.  On  section  the  tubercle  pre- 
sents a  grayish-yellow,  caseous  appearance,  usually  firm  and  hard,  and  en- 
circled by  a  translucent,  softer  tissue.  The  centre  of  the  growth  may  be 
semi-diffluent.  As  in  other  localities  the  tubercle  may  calcify.  The 
tumors  are  as  a  rule  attached  to  the  meninges,  often  to  the  pia  at  the 
bottom  of  a  sulcus  so  that  they  look  imbedded  in  the  brain-substance. 
About  the  longitudinal  fissure  there  may  be  an  aggregation  of  the  growths, 
with  compression  of  the  sinus,  and  the  formation  of  a  thrombus.  The 
tuberculous  tumor  not  infrequently  excites  acute  meningitis.  In  localized 
meningo-encephalitis  the  pia  is  thickened,  tubercles  are  adherent  to  the 
under  surface  and  grow  about  the  arteries.  It  is  often  combined  with 
cerebral  softening  from  interference  with  the  circulation.  Several  of  the 
most  characteristic  instances  which  I  have  seen  were  on  the  meninges 
covering  the  insula.  This  form  may  develop  in  pulmonary  tuberculosis, 
causing  hemiplegia  or  aphasia  which  may  persist  for  months. 

The  symptoms  of  tuberculous  growths  in  the  brain  are  those  of  tumor, 
and  will  be  considered  in  the  section  on  the  brain. 

In  the  spinal  cord  the  same  forms  are  found.  The  acute  tuberculous 
meningitis  has  been  considered  and  is  almost  always  eerebro-spinal.  The 
solitary  tubercle  of  the  cord  is  rare.  Herter  has  reported  3  cases  and  col- 
lected 24  from  the  literature.  It  was  secondary  in  all  save  one  case.  The 
symptoms  are  those  of  spinal  tumor  or  meningitis. 


322  SPECIFIC  INFECTIOUS  DISEASES. 

VIII.  Tuberculosis  of  the  Genito-urinaet  System. 

The  studies  of  the  past  few  years,  and  particularly  the  work  of  sur- 
geons and  gyngecologists,  have  taught  us  the  great  importance  of  tubercu- 
losis of  this  tract.  Any  part  of  the  genito-urinary  system  may  be  invaded. 
The  successive  involvement  of  the  organs  may  be  so  rapid  that  unless  the 
case  has  been  seen  early  it  may  be  impossible  to  state  with  any  degree  of 
certainty  which  has  been  the  primary  seat  of  infection.  There  may  be 
simultaneous  involvement  of  various  portions  of  the  tract.  In  tuberculosis 
of  the  genito-urinary  system  one  always  has  to  bear  in  mind  the  possibility 
of  latent  disease  elsewhere  in  the  body.  As  Bollinger  says,  tubercle  bacilli 
may  gain  admission  at  some  part  of  the  respiratory  tract  without  produc- 
ing any  lesion  at  the  point  of  entrance,  and  finally  reach  a  bronchial  gland, 
where  they  set  up  a  tuberculous  process  of  extremely  slow  development 
without  producing  any  symptoms.  From  this  point  bacilli  may  enter  the 
blood  stream  and  lodge  in  the  epididymis  or  testicle  proper,  and  produce 
nodules  which  are  readily  discovered,  owing  to  the  ease  with  which  these 
parts  are  examined.  Such  a  case  might  be  quite  easily  mistaken  for  one 
of  primary  genital  tuberculosis,  whereas  the  true  primary  tuberculous  focus 
is  far  distant. 

Infection  of  the  genito-urinary  tract  occurs  in  various  ways: 

1.  By  Hereditary  Transmission. — It  has  been  met  with  in  the  foetus. 
The  comparative  frequency  of  tuberculosis  of  the  testicle  in  very  young 
children  suggests  very  strongly  that  the  uro-genital  organs  may  be  involved 
as  a  result  of  direct  transmission  of  the  disease  from  the  parents. 

2.  By  infection  from  areas  of  tuberculosis  already  existing  in  the  patient, 
(a)  Infection  through  the  Blood. — In  many  cases  uro-genital  tuberculosis 

is  found  at  autopsy  associated  with  disease  of  some  distant  organ,  particu- 
larly the  lungs,  and  it  would  appear  most  probable  that  in  them  infection 
has  been  through  the  blood-vessels.  Jani^s  observations,  which  were  pub- 
lished by  Weigert  after  the  author's  death,  strongly  support  this  theory. 
In  studying  sections  of  the  genital  organs  of  patients  who  died  of  pul- 
monary tuberculosis,  he  found  tubercle  bacilli  in  5  out  of  8  cases  in  the 
testicle,  and  in  4  out  of  6  cases  in  the  prostate,  without  in  any  instance 
finding  microscopical  evidences  of  tubercles  in  these  organs.  The  bacilli 
lay,  in  the  testis,  partly  within  and  partly  close  beside  the  cellular  and 
granular  contents  of  the  seminal  tubiiles,  while  in  the  prostate  they  were 
always  situated  in  the  neighborhood  of  the  glandular  epithelium. 

(h)  Infection  from  the  Peritonceum. — This  source  of  infection,  in  both 
men  and  women,  is  much  more  frequent  than  is  commonly  supposed.  The 
intimate  relationship  between  the  peritongeum  and  bladder  in  both  subjects, 
and  with  the  vesiculse  seminales  and  vasa  deferentia  in  the  male,  allows  of 
a  ready  way  of  invasion  of  these  organs  by  direct  extension  of  the  dis- 
ease. The  peritongeum  is  a  frequent  source  of  genital  tuberculosis  in  the 
female.  No  doubt  many  cases  of  tuberculosis  of  the  Fallopian  tubes  origi- 
nate from  this  source.  The  fact  that  the  fimbriated  extremity  of  the 
tube  is  often  most  seriously  involved  points  rather  strongly  4n  this  direc- 
tion, although  the  fact  might  be  taken  as  a  point  in  favor  of  blood  infection, 


TUBERCULOSIS.  323 

favored  by  its  greater  vascularity.  Various  observations  go  to  show  that  the 
action  of  the  cilia  lining  the  lumina  of  the  Fallopian  tubes  tends  to  at- 
tract particles  introduced  into  the  peritoneal  cavity.  Jani's  observation 
is  very  interesting  in  this  connection,  as  showing  the  possibility  of  tubercle 
bacilli  entering  the  tubes  from  the  peritoneal  cavity  without  there  being 
any  tuberculous  peritonitis.  He  found  typical  tubercle  bacilli  in  the  lumen, 
in  sections  of  a  normal  Fallopian  tube,  in  a  woman  who  died  of  pulmonary 
and  intestinal  tuberculosis.  The  explanation  advanced  was  that  the  bacilli 
made  their  way  through  the  thin  peritoneal  coat  from  one  of  the  intestinal 
ulcers,  thus  reaching  the  peritoneal  cavity,  and  thence  were  attracted  into 
the  Fallopian  tube  by  the  current  produced  by  the  action  of  the  cilia  lining 
the  lumen.  The  intimate  relationship  between  tuberculous  peritonitis  and 
tuberculosis  of  the  Fallopian  tubes  is  shown  in  the  fact  that  the  latter  are 
affected  in  from  30  to  40  per  cent  of  the  cases. 

(c)  Infection  from  other  Organs  ly  Direct  Extension. — The  occurrence 
of  direct  extension  from  the  peritonseum  has  already  been  mentioned.  In 
tuberculous  ulceration  of  the  intestine  or  rectum  adhesions  to  the  bladder 
in  the  male  or  to  the  uterus  and  vagina  in  the  female  may  occur,  with 
resulting  fistulas  and  a  direct  extension  of  the  disease.  Perirectal  tuber- 
culous abscesses  may  lead  to  secondary  involvement  of  some  portion  of  the 
genito-urinary  tract.  It  must  not  be  forgotten  that  tuberculosis  of  the 
vertebrae  may  be  followed  by  tuberculosis  of  the  kidney  as  a  result  of  direct 
extension  of  the  disease. 

3.  By  Infection  from  Without. — Whether  uro-genital  tuberculosis  may 
occur  as  a  result  of  the  entrance  of  tubercle  bacilli  into  the  urethra  or 
vagina  is  still  a  disputed  question.  That  bacilli  gain  admission  to  these 
passages  during  coitus  with  a  person  the  subject  of  uro-genital  tuberculosis, 
or  by  the  use  of  foul  instruments  or  syringes,  seems  quite  probable.  The 
possibility  of  genital  tuberculosis  occurring  in  the  female  as  a  result  of 
coitus  with  a  male  the  subject  of  tuberculosis  in  some  portion  of  the  genito- 
urinary system  was  first  suggested  by  Cohnheim,  who  stated,  however,  that 
it  rarely,  if  ever,  occurred.     Gartner's  experiments  have  been  referred  to. 

In  a  patient  with  intestinal  tuberculosis  the  tubercle  bacilli  might  acci- 
dentally reach  the  urethra  or  vagina  from  the  rectum. 

Uro-genital  tuberculosis  is  commonest  between  the  ages  of  twenty 
and  forty  years — that  is,  during  the  period  of  greatest  sexual  activity. 
Males  are  affected  much  more  frequently  than  females,  the  proportion 
being  3  to  1.  This  great  difference  is  no  doubt  partly  due  to  the  more 
intimate  relationship  between  the  urinary  and  genital  systems  in  the  former 
than  in  the  latter.  In  the  male  the  urethra  forms  the  common  outlet  for 
the  two  systems,  while  in  the  female  there  is  a  separate  outlet  for  each. 

Once  the  uro-genital  tract  has  been  invaded,  the  disease  is  likely  to 
spread  rapidly,  and  the  method  of  extension  is  an  important  one.  Quite 
frequently  there  is  direct  extension,  as  when  the  bladder  is  involved  sec- 
ondarily to  the  kidney  by  passage  of  the  disease  along  the  ureter,  or  where 
the  tuberculous  process  extends  along  the  vas  deferens  to  the  vesiculae 
seminales.  No  doubt  surface  inoculation  occurs  in  some  instances,  and  to 
this  cause  may  be  attributed  a  certain  percentage  of  cases  of  vesical  and 


324  SPECIFIC  INFECTIOUS  DISEASES.^ 

prostatic  disease  following  tuberculosis  of  the  kidney.  Although,  this  prob- 
ability is  acknowledged,  there  is  an  element  of  doubt  as  to  the  possibility 
of  the  kidney  becoming  affected  secondarily  to  the  bladder  or  prostate  by 
the  direct  passage  of  the  bacilli  up  the  lumen  of  one  ureter;  for  in  such  a 
case  we  have  to  suppose  that  a  non-motile  bacillus,  contrary  to  the  laws 
of  gravity,  ascends  against  an  almost  constant  current  of  urine  flowing  in 
the  opposite  direction.  The  lymphatics  may  afford  a  means  for  the  spread- 
ing of  the  disease,  but  in  a  greater  number  of  cases  than  is  generally  sup- 
posed it  takes  place  by  way  of  the  blood-vessels.  Cystoscopic  examina- 
tions of  the  bladder  not  infrequently  show  the  presence  of  tubercles  beneath 
the  mucous  membrane  before  there  is  any  evidence  of  superficial  ulceration 
— a  fact  suggesting  strongly  a  blood  infection. 

The  discovery  of  tubercle  bacilli  in  the  urine  and  the  obtaining  of 
tuberculous  lesions  in  animals  as  a  result  of  inoculation  with  the  urinary 
sediment  afford  us  the  only  positive  evidence  of  genito -urinary  tubercu- 
losis. So  far  there  are  no  authentic  accounts  of  tubercle  bacilli  having 
been  found  in  the  semen  of  men  with  tuberculosis  of  the  testicle  or  vesiculse 
seminales.  Owing  to  the  fact  that  the  smegma  bacillus  has  the  same  stain- 
ing reaction  as  the  tubercle  bacillus,  and,  morphologically,  is  practically 
indistinguishable  from  it,  the  greatest  care  must  be  used  in  obtaining, 
the  specimen  of  urine  for  examination,  to  eliminate,  if  possible,  all  chances 
of  contamination.  Thus  the  urine  examined  must  be  a  catheterized  speci- 
men, and  even  then  one  runs  the  risk  of  carrying  back  into  the  bladder 
on  the  end  of  the  catheter  a  few  bacilli  which  may  be  washed  out  in  the 
stream  of  urine  and  be  mistaken  for  tubercle  bacilli  in  the  sediment. 

(a)  Tuberculosis  of  the  Kidneys  {Phthisis  renum). — In  general  tuber- 
culosis the  kidneys  frequently  present  scattered  miliary  tubercles.  In  pul- 
monary tuberculosis  it  is  common  to  find  a  few  nodules  in  the  substance 
of  the  organ,  or  there  may  be  pyelitis.  Primary  tuberculosis  of  the  kidneys 
is  not  very  rare.  In  a  majority  of  the  cases  the  process  involves  the  pelvis 
and  the  ureter  as  well,  sometimes  the  bladder  and  prostate.  In  only  1  of 
8  cases  was  the  prostate  involved.  It  may  be  difficult  to  say  in  advanced 
cases  whether  the  disease  has  started  in  the  bladder,  prostate,  or  vesicles, 
and  crept  up  the  ureters,  or  whether  it  started  in  the  kidneys  and  pro- 
ceeded downward.  In  a  majority  of  cases,  I  believe,  the  latter  is  true,  and 
the  infection  is  through  the  blood.  One  kidney  alone  may  be  involved,  and 
the  disease  creeps  down  the  ureter  and  may  only  extend  a  few  millimetres 
on  the  vesical  mucosa.  A  man  with  aortic  insufficiency,  who  had  no 
lesions  in  the  lungs,  presented  a  localized  patch  in  the  pelvis  of  the  kidney, 
involving  a  pyramid,  while  the  ureter,  5  em.  from  the  bladder  and  at  its 
orifice,  was  thickened  and  tuberculous.  The  prostate  showed  an  area  of 
caseation.  The  process  is  most  comnlon  in  the  middle  period  of  life,  but  it 
may  occur  at  the  extremes  of  age.  It  is  more  frequent  in  men  than  in 
women.  In  the  earliest  stage,  which  may  be  met  with  accidentally,  the  dis- 
ease is  seen  to  begin  in  the  p}Tamids  and  calyces.  Necrosis  and  caseation 
proceed  rapidly,  and  the  colonies  of  tubercles  start  throughout  the  pyramids 
ancl  extend  upon  the  mucous  membrane  of  the  pelvis.  As  a  rule,  from  the 
outset  it  is  a  tuberculous  pyo-nephrosis.    The  disease  may  be  confined  to  one 


TUBERCULOSIS.  325 

kidney,  or  progress  more  extensively  in  one  than  in  the  other.  At  autopsy 
both  organs  are  usually  found  enlarged.  One  kidney  may  be  completely 
destroyed  and  converted  into  a  series  of  cysts  containing  cheesy  substance — 
a  form  of  kidney  which  the  older  writers  called  scrofulous.  In  the  putty- 
like contents  of  these  cysts  lime  salts  may  be  deposited.  In  other  instances 
the  walls  of  the  pelvis  are  thickened  and  cheesy,  the  pyramids  eroded, 
and  caseous  nodules  are  scattered  through  the  organ,  even  to  the  capsule, 
which  may  be  thickened  and  adherent.  The  other  organ  is  usually  less 
affected,  and  shows  only  pyelitis  or  a  superficial  necrosis  of  one  or  two  pyra- 
mids. The  ureters  are  usually  thickened  and  the  mucous  membrane  ulcer- 
ated and  caseous.  Involvement  of  the  bladder,  vesiculse  seminales,  and 
testes  is  not  uncommon  in  males. 

The  symptoms  are  those  of  pyelitis.  The  urine  may  be  purulent  for 
years,  and  there  may  be  little  or  no  distress.  Even  before  the  bladder  be- 
comes involved  micturition  is  frequent,  and  many  instances  are  mistaken 
for  cystitis.  The  condition  is  for  many  years  compatible  with  fair  health. 
The  curability  is  shown  by  the  accidental  discovery  of  the  so-called  scrofu- 
lous kidney,  converted  into  cysts  containing  a  putty-like  substance.  In 
cases  in  which  the  disease  becomes  advanced  and  both  organs  are  affected, 
constitutional  symptoms  are  more  marked.  There  is  irregular  fever,  with 
chills,  and  loss  of  weight  and  strength.  General  tuberculosis  is  common. 
In  only  one  of  my  cases  were  the  lungs  uninvolved.  In  a  case  at  the 
Montreal  General  Hospital  a  cyst  perforated  and  caused  fatal  peritonitis. 

Physical  examination  may  detect  special  tenderness  on  one  side,  or  the 
kidney  may  be  palpable  in  front  on  deep  pressure;  but  tuberculous  pyelo- 
nephritis seldom  causes  a  large  tumor.  Occasionally  the  pelvis  be- 
comes enormously  distended;  but  this  is  rare  in  comparison  with  its 
frequency  in  calculous  pyelitis.  The  urine  presents  changes  similar  to 
those  of  ordinary  calculous  pyelitis — pus-cells,  epithelium,  and  occasionally 
definite  caseous  masses.  Albumin  is,  of  course,  present.  Tubercle  bacilli 
may  be  demonstrated  by  the  ordinary  methods.  Tube-casts  are  not  often 
seen. 

To  distinguish  the  condition  from  calculous  pyelitis  is  often  difficult. 
Hemorrhage  may  be  present  in  both,  though  not  nearly  so  frequently  in 
the  tuberculous  disease.  The  diagnosis  rests  on  three  points:  (1)  The  de- 
tection of  some  focus  of  tuberculosis,  as  in  the  testes;  (2)  the  presence  of 
tubercle  bacilli  in  the  sediment;  and  (3)  the  use  of  tuberculin.  In  woman 
the  kidney  involved  is  now  easily  determined  by  catheterizing  the  ureters 
after  the  plan  of  my  colleague  Kelly. 

The  incidence  of  renal  implication  in  uro-genital  tuberculosis  may  be 
gathered  from  Orth's  Gottingen  material,  analyzed  by  Oppenheim.  Of  60 
cases  there  were  34  in  which  the  kidneys  were  involved. 

Tuberculosis  of  the  suprarenal  capsules  will  be  considered  under  Ad- 
dison's Disease. 

(b)  Tuberculosis  of  the  Ureter  and  Bladder. — This  rarely  occurs  as 
a  primary  affection,  but  is  nearly  always  secondary  to  involvement  of  other 
parts,  particularly  the  pelvis  of  the  kidney.  In  the  case  of  uro-genital 
tuberculosis,  above  mentioned,  in  a  patient  who  died  of  heart-disease,  the 


326  SPECIFIC  INFECTIOUS  DISEASES. 

ureter,  just  where  it  enters  the  bladder,  showed  a  fresh  patch  of  tuber- 
culosis. 

Protracted  cystitis,  which  has  come  on  without  apparent  cause,  is 
always  suggestive  of  tuberculosis.  The  renal  regions,  the  testes,  and  the 
prostate  should  be  examined  with  care.  It  may  follow  a  pyelo-nephritis, 
or  be  associated  with  primary  disease  of  the  prostate  or  vesiculge  seminales. 
Primary  tuberculosis  of  the  posterior  wall  of  the  bladder  may-  simulate 
stone. 

(c)  Tuberculosis  of  the  Prostate  and  Vesiculse  Seminales. — The  pros- 
tate is  frequently  involved  in  tuberculosis  of  the  uro-genital  tract.  In 
Krzyincki's  cases,  of  15  males  the  prostate  was  involved  in  14  and  the 
vesiculge  seminales  in  11.  In  Orth's  cases  the  prostate  was  involved  in  18 
of  the  37  cases  in  males.  These  parts  are  much  more  frequently  involved 
than  ordinary  post-mortem  statistics  indicate.  Per  rectum  the  prostatic 
lobes  are  felt  to  be  occupied  by  hard  nodules  varying  in  size  fr'om  a  pea  to 
a  bean.  There  is  great  irritability  of  the  bladder,  and  agonizing  pain  in 
catheterization.  An  extremely  rare  lesion  is  primary  urethral  tuberculosis, 
which  may  simulate  stricture. 

{d)  Tuberculosis  of  tie  Testes. — This  somewhat  common  affection 
may  be  primary,  or,  more  frequently,  is  secondary  to  tuberculous  disease 
elsewhere.  Many  cases  occur  before  the  second  year,  and  it  is  stated  to 
have  been  met  with  in  the  foetus.  In  infants  it  is  serious  and  usually  asso- 
ciated with  tuberculous  disease  in  other  parts.  In  9  cases  reported  by 
Hutinel  and  Deschamps,  in  every  one  there  was  a  general  affection.  In 
20  cases  reported  by  JuUien,  6  were  under  one  year,  and  6  between  one 
and  two  years  old.  In  5  of  the  cases  both  testicles  were  affected.  Koplik 
holds  that  most  of  the  instances  of  this  kind  are  congenital,  in  Baumgarten's 
sense.  In  the  adult  the  tubercles  begin  within  the  substance  of  the  gland, 
but  in  children  the  tunica  albuginea  is  first  affected.  The  tubercle  does 
not  always  undergo  caseation,  but  it  may  present  a  number  of  embryonic 
cells,  not  unlike  a  sarcoma. 

Tubercle  of  the  testes  is  most  likely  to  be  confounded  with  syphilis. 
In  the  latter  the  body  of  the  organ  is  most  often  affected,  there  is  less 
pain,  and  the  outlines  of  the  growth  are  more  nodular  and  irregular.  In 
obscure  peritoneal  disease  the  detection  of  tubercle  in  a  testis  has  not  in- 
frequently led  to  a  correct  diagnosis.  The  association  of  the  two  condi- 
tions is  not  uncommon.  The  lesion  in  the  testis  may  heal  completely,  or 
the  disease  may  become  generalized.  General  infection  has  followed  opera- 
tion. Too  much  stress  cannot  be  laid  on  the  importance  of  a  routine 
examination  of  the  testes  in  hospital  patients. 

(e)  Tuberculosis  of  the  FaUopian  Tubes,  Ovaries,  and  Uterus.— The 
Fallopian  tubes  are  by  far  the  most  frequent  seat  of  genital  tuberculosis. 
The  disease  may  be  primary  and  produce  a  most  characteristic  form  of 
salpingitis,  in  which  the  tubes  are  enlarged,  the  walls  thickened  and  infil- 
trated, and  the  contents  cheesy.  Adhesion  takes  place  between  the  fimbria 
and  the  ovaries,  or  the  uterus  may  be  invaded.  The  condition  is  usually 
bilateral.  It  may  occur  in  young  children.  Although,  as  a  rule,  very  evi- 
dent to  the  naked  eye,  there  are  specimens  resembling  ordinary  salpingitis. 


TUBERCULOSIS.  327 

which  show  on  microscopical  examination  numerous  miliary  tubercles 
(Welch  and  Williams).  Tuberculous  salpingitis  may  cause  serious  local 
disease  with  abscess  formation,  and  it  may  be  the  starting-point  of  peri- 
tonitis. 

Tuberculosis  of  the  ovary  is  always  secondary.  There  may  be  an  erup- 
tion of  tubercles  over  the  surface  in  an  extensive  involvement  of  the  stroma 
with  abscess  formation. 

Tuberculosis  of  the  uterus  is  very  rare.  Only  three  examples  have  come 
under  my  observation,  all  in  connection  with  pulmonary  phthisis.  It  may 
be  primary.  The  mucosa  of  the  fundus  is  thickened  and  caseous,  and  tuber- 
cles may  be  seen  in  the  muscular  tissue.  Occasionally  the  process  extends 
to  the  vagina. 

IX.    TUBEKCULOSIS    OF   THE    MaMMAET    GlAND. 

Mandry  (Bruns's  Beitrage,  viii)  has  collected  40  cases,  1  of  which  was 
in  a  male.  The  disease  is  most  common  between  the  fortieth  and  sixtieth 
years.  The  breast  is  frequently  fistulous,  unevenly  indurated,  and  the 
nipple  is  retracted.  The  fistulse  and  ulcers  present  a  characteristic  tuber- 
culous aspect.  There  is  also  a  cold  tuberculous  abscess  of  the  breast.  The 
axillary  glands  are  affected  in  about  two  thirds  of  the  cases.  The  disease 
runs  a  chronic  course  of  months  or  years.  The  diagnosis  can  be  made  by 
the  general  appearance  of  the  fistulse  and  ulcers,  and  by  the  existence  of 
tubercle  bacilli.  The  prognosis  is  not  bad,  if  total  eradication  of  the  dis- 
ease be  possible. 

In  1836  Bedor  described  an  hypertrophy  of  the  breast  in  the  subjects 
of  pulmonary  tuberculosis.  As  a  rule,  if  one  gland  is  involved,  usually  on 
the  side  of  the  affected  lung,  as  already  mentioned,  the  condition  is  one  of 
chronic  interstitial  mammitis,  and  is  not  tuberculous. 

X.    TUBEECULOSIS    OF   THE    CIRCULATORY    StSTEM. 

(fl)  Myocardium. — Scattered  miliary  tubercles  are  sometimes  met  with 
in  the  acute  disease.  Larger  caseous  tubercles  are  excessively  rare.  A. 
Moser  states  that  there  are  only  46  cases  on  record.  There  is  also  a  scle- 
rotic tuberculous  myocarditis. 

(&)  Endocardium. — In  216  autopsies  in  cases  of  chronic  phthisis  I  found 
endocarditis  in  12.  As  a  rule,  it  is  a  secondary  form,  the  result  of  a  mixed 
infection,  so  common  in  pulmonary  tuberculosis.  A  true  tuberculous  en- 
docarditis does,  however,  occur,  directly  dependent  upon  infection  with 
the  bacillus  of  Koch.  As  a  rule,  it  is  a  vegetative  endocarditis,  not  to  be 
distinguished  from  that  caused  by  Streptococcus  or  Staphylococcus.  In 
rare  cases,  however,  caseous  tubercles  develop. 

(c)  Arteries. — Primary  tuberculosis  of  the  larger  blood-vessels  is  un- 
known. The  disease  may,  however,  occur  in  a  large  artery  and  not  result 
from  external  invasion.  In  a  case  of  chronic  tuberculosis  Flexner  found  a 
fresh  tuberculous  growth  in  the  aorta,  which  had  no  connection  with  cheesy 
masses  outside  the  vessel. 


328  SPECIFIC  INFECTIOUS  DISEASES. 

In  the  lungs  and  other  organs  attacked  hy  tuberculosis  the  arteries  are 
involved  in  an  acute  infiltration  which  usually  leads  to  thrombosis,  or  tuber- 
■  eles  may  develop  in  the  walls  and  proceed  to  caseation  and  softening  fre- 
quently with  a  resulting  haemorrhage.  By  extension  into  vessels,  particu- 
larly veins,  the  bacilli  are  widely  distributed  with  the  production  of  miliary 
tuberculosis,  • 

XI.  Diagnosis  op  Tubeeculosis. 

The  recognition  of  the  disease  usually  rests  upon  the  macroscopical 
and  microscopical  appearances  of  the  lesions  and  the  presence  of  the  char- 
acteristic bacilli.  Of  late  an  important  additional  diagnostic  agent  has 
been  introduced  in  the  form  of  Koch's  tuberculin.  For  some  years  Tru- 
deau  has  insisted  upon  the  harmlessness  of  its  use  in  the  diagnosis  of  ob- 
scure cases.  During  the  past  few  years  it  has  been  employed  extensively 
at  the  Johns  Hopkins  Hospital,  both  on  the  medical  and  surgical  sides, 
with  the  most  satisfactory  results,  and,  so  far  as  I  know,  without  any  harm- 
ful efi^ects.  In  obscure  internal  lesions,  in  joint  cases,  and  in  suspected 
tuberculosis  of  the  kidneys  the  use  of  the  tuberculin  gives  most  valuable 
information.  I  may  mention,  for  example,  an  instance  of  Addison's  dis- 
ease in  a  young,  very  muscular  man  without  any  sign  whatever  of  visceral 
tuberculosis.  The  reaction  (as,  indeed,  might  have  been  expected)  was 
very  characteristic.  We  have  used  the  tuberculin  kindly  furnished  from 
the  Saranac  Laboratory,  which  is  made  on  Koch's  original  plan.  In  adults 
a  milligramme  is  employed,  and  if  this  has  no  reaction  a  larger  dose  of  two 
or  three  milligrammes  is  employed  in  two  or  three  days.  There  is  often 
slight  local  irritation  following  the  injection,  and  within  from  ten  to  twelve 
hours  the  febrile  reaction  begins,  the  temperature  rising  to  from  103° 
to  104°. 

XII.  The  Peognosis  in  Tubeeculosis. 

The  parable  of  the  sower  already  referred  to  expresses  better  than  in 
any  other  way  the  question  of  individual  predisposition.  In  a  large  pro- 
portion of  us  the  seed  falls  by  the  wayside.  The  bacilli  which  are  inhaled 
are  picked  up  by  the  phagocj^tes  in  the  air-passages,  and  never  really  enter 
the  body.  In  others  the  seed  falling  upon  a  rock  or  on  stony  ground 
withers  away  as  soon  as  it  springs  up;  and  such  are  the  cases  in  which  the 
bacilli  gain  entrance  to  the  bronchial  glands  and  form  small  foci  which 
rapidly  heal.  The  seed  which  falls  among  thorns  represents  the  germs 
which  gain  entrance  to  the  lungs  and  which  grow  and  cause  the  charac- 
teristic lesions,  but  the  natural  protective  processes  limit  and  control  it, 
and  the  patient  is  cured.  In  the  last  group,  in  which  the  seed  falls  on 
good  ground  and  springs  up  and  bears  fruit  a  hundredfold,  are  the  cases 
in  which  the  disease  progresses  and  the  unfortunate  victim  dies  of  tuber- 
culosis. The  late  Austin  Flint,  facile  princeps  among  American  students 
of  the  disease,  called  attention  to  its  self-limitation  and  intrinsic  tend- 
ency to  recovery  in  tuberculosis.  Of  his  670  cases,  44  recovered,  and 
in  31  the  disease  was  arrested,  spontaneously  in  23  of  the  first  group 


TUBERCULOSIS.  329 

and  in  15  of  the  second.  This  natural  tendency  to  cure  is  still  more  strik- 
ingly shown  in  lymphatic  and  bone  tuberculosis. 

The  following  may  be  considered  favorable  circumstances  in  the  prog- 
nosis of  pulmonary  tuberculosis:  A  good  family  history,  previous  good 
health,  a  strong  digestion,  a  suitable  environment,  and  an  insidious  onset, 
without  high  fever,  and  without  extensive  pneumonic  consolidation.  Cases 
beginning  with  pleurisy  seem  to  run  a  fliore  protracted  and  more  favorable 
course.  Repeated  attacks  of  hsemoptysis  are  unfavorable.  When  well  estab- 
lished the  course  of  tuberculosis  in  any  organ  is  marked  by  intervals  of 
weeks  or  months  in  which  the  fever  lessens,  the  symptoms  subside,  and 
there  is  improvement  in  the  general  health. 

In  pulmonary  cases  the  duration  is  extremely  variable.  Laennec  placed 
the  average  duration  at  two  years,  and  for  the  majority  of  cases  this  is 
perhaps  a  correct  estimate.  Pollock's  large  statistics  of  over  3,500  cases 
shows  a  mean  duration  of  the  disease  of  over  two  years  and  a  half.  Wil- 
liams's analysis  of  1,000  cases  in  private  practice  shows  a  much  more  pro- 
tracted course,  as  the  average  duration  was  over  seven  years. 

Under  the  subject  of  prognosis  comes  the  question  of  the  marriage  of 
persons  who  have  had  tuberculosis,  or  in  whose  family  the  disease  prevails. 
The  following  brief  statements  may  be  made  with  reference  to  it: 

(a)  Subjects  with  healed  lymphatic  or  bone  tuberculosis  marry  with 
personal  impunity  and  may  beget  healthy  children.  It  is  undeniable,  how- 
ever, that  in  such  families,  scrofula,  caries  of  the  bone,  arthritis,  cerebral 
and  pulmonary  tuberculosis  are  more  common.  Which  is  it,  "  heredite 
de  graine  ou  heredite  de  terrain,"  as  the  French  have  it,  the  seed  or  the 
soil,  or  both?  We  cannot  yet  say.  The  risks,  however,  are  such  as  may 
properly  be  taken. 

(6)  The  question  of  marriage  of  a  person  who  has  arrested  or  cured 
lung  tuberculosis  is  more  difficult  to  decide.  In  a  male,  the  personal  risk 
is  not  so  great;  and  when  the  health  and  strength  are  good,  the  external 
environment  favorable,  and  the  family  history  not  extremely  bad  the  ex- 
periment— for  it  is  such — is  often  successful,  and  many  healthy  and  happy 
families  are  begotten  under  these  circumstances.  In  women  the  question 
is  complicated  with  that  of  child-bearing,  which  increases  the  risks  enor- 
mously. With  a  localized  lesion,  absence  of  hereditary  taint,  good  phy- 
sique, and  favorable  environment,  marriage  might  be  permitted.  When 
tuberculosis  has  existed,  however,  in  a  girl  whose  family  history  is  bad, 
whose  chest  expansion  is  slight,  and  whose  physique  is  below  the  standard, 
the  ph)'sician  should,  if  possible,  place  his  veto  upon  marriage. 

(c)  With  existing  disease,  fever,  bacilli,  etc.,  marriage  should  be  pro- 
hibited. Pregnancy  usually  hastens  the  process,  though  it  may  be  held 
in  abeyance.  After  parturition  the  disease  advances  rapidly.  There  is 
much  truth,  indeed,  in  the  remark  of  Dubois:  "  If  a  woman  threatened  with 
phthisis  marries,  she  may  bear  the  first  accouchement  well;  a  second,  with 
difficulty:  a  third,  never."  Conception  may  occur  in  an  advanced  stage 
of  the  disease. 


330  SPECIFIC  INFECTIOUS  DISEASES. 

XIII.  Prophylaxis  in  Tubeeculosis. 

(a)  General. — The  sputa  of  phthisical  patients  should  be  carefully  col- 
lected and  destroyed.  Patients  should  be  urged  not  to  spit  about  care- 
lessly, but  always  to  use"  a  spit-cup  and  never  to  swallow  the  sputa.  Sev- 
eral forms  of  portable  flasks  have  been  devised  and  are  now  on  sale.  The 
destruction  of  the  sputa  of  consumptives  should  be  a  routine  measure  in 
both  hospital  and  private  practice.  Thorough  boiling  or  putting  it  into 
the  fire  is  sufficient.  In  hospitals  it  is  well  to  have  printed  directions  as 
to  the  care  of  the  sputa  and  also  printed  cards  for  out-patients,  giving  the 
most  important  rules.  It  should  be  explained  to  the  patient  that  the  only 
risk,  practically,  is  from  this  source.  The  chances  of  infection  are  greatest 
in  young  children.  The  nursing  and  care  of  consumptives  involve  very 
slight  risks  indeed  if  proper  precautions  are  taken.  The  patient  should 
occupy  a  single  bed. 

A  second  important  general  prophylactic  measure  relates  to  the  inspec- 
tion of  dairies  and  slaughter-houses.  The  possibility  of  the  transmission 
of  tuberculosis  by  infected  milk  has  been  fully  demonstrated  in  the  case 
of  animals,  and  Koch's  statements  should  not  be  allowed  to  interfere  with 
sanitary  measures.  Systematic  veterinary  inspection  of  dairies,  particularly 
in  the  large  cities,  should  be  made,  and  full  power  granted  to  confiscate  and 
kill  suspected  animals.  The  abattoirs  should  be  under  skilled  veterinary 
control,  and  the  carcasses  of  animals  with  advanced  tuberculosis  confis- 
cated. 

Other  important  preventive  measures  are  the  placing  of  pulmonary  tu- 
berculosis on  the  list  of  diseases  to  be  reported  to  the  boards  of  health,  the 
institution  of  civic  and  state  sanitoria  in  which  early  cases  can  be  treated, 
and  lastly,  the  establishment  of  hospitals  for  the  reception  of  chronic 
cases. 

(&)  Individual. — A  mother  with  pulmonary  tuberculosis  should  not 
suckle  her  child.  An  infant  born  of  tuberculous  parents,  or  of  a  family 
in  which  consumption  prevails,  should  be  brought  up  with  the  greatest 
care  and  guarded  most  particularly  against  catarrhal  affections  of  all  kinds. 
Special  attention  should  be  given  to  the  throat  and  nose,  and  on  the  first 
indication  of  mouth-breathing,  or  any  obstruction  of  the  naso-pharynx, 
a  careful  examination  should  be  made  for  adenoid  vegetations.  The,  child 
should  be  clad  in  fiannel  and  live  in  the  open  air  as  much  as  possible,  avoid- 
ing close  rooms.  It  is  a  good  practice  to  sponge  the  throat  and  chest  night 
and  morning  with  cold  water.  Special  attention  should  be  paid  to  diet 
and  to  the  mode  of  feeding.  The  meals  should  be  at  regular  hours  and 
the  food  plain  and  substantial.  From  the  outset  the  child  should  be  en- 
couraged to  drink  freely  of  milk.  Unfortunately,  in  these  cases  there 
seems  to  be  an  uncontrollable  aversion  to  fats  of  all  kinds.  As  the  child 
grows  older,  systematically  regulated  exercise  or  a  course  of  pulmonary 
gymnastics  may  be  taken.  In  the  choice  of  an  occupation  preference 
should  be  given  to  an  out-of-door  life.  Families  with  a  marked  predisposi- 
tion to  tuberculosis  should,  if  possible,  reside  in  an  equable  climate.  It 
would  be  best  for  a  young  man  belonging  to  such  a  family  to  remove  to 


TUBERCULOSIS.  ^''  331 

Colorado  or  Southern  California,  or  to  some  other  suitable  climate,  before 
trouble  begins. 

The  trifling  ailments  of  children  should  be  carefully  watched.  In  the 
convalescence  from  the  fevers,  which  so  frequently  prove  dangerous,  the 
greatest  caution  should  be  exercised  to  prevent  catching  cold.  Cod-liver 
oil,  the  syrup  of  the  iodide  of  iron,  and  arsenic  may  be  given.  As  men- 
tioned, care  of  the  throat  in  these  children  is  very  important.  Enlarged 
tonsils  should  be  removed. 

XIV.  Teeatment  of  Tijbeeculosis. 

I.  The  Natural  or  Spontaneous  Cure. — The  spontaneous  healing  of 
local  tuberculosis  is  an  every-day  affair.  Many  cases  of  adenitis  and  dis- 
ease of  the  bone  or  of  the  joints  terminate  favorably.  The  healing  of  pul- 
monary tuberculosis  is  shown  clinically  by  the  recovery  of  patients  in  whose 
sputa  elastic  tissue  and  bacilli  have  been  found;  anatomically,  by  the  pres- 
ence of  lesions  in  all  stages  of  repair.  In  the  granulation  products  and 
associated  pneumonia  a  scar-tissue  is  formed,  while  the  smaller  caseous  areas 
become  impregnated  with  lime  salts.  To  such  conditions  alone  should 
the  term  healing  be  applied.  When  the  fibroid  change  encapsulates  but 
does  not  involve  the  entire  tuberculous  tissue,  the  tubercle  may  be  termed 
involuted  or  quiescent,  but  is  not  destroyed.  When  cavities  of  any  size 
have  formed,  healing,  in  the  proper  sense  of  the  term,  does  not  occur. 
I  have  yet  to  see  a  specimen  which  would  indicate  that  a  vomica  had  cica- 
trized. Cavities  may  be  greatly  reduced  in  size — indeed,  an  entire  series 
of  them  may  be  so  contracted  by  sclerosis  of  the  tissue  about  them  that 
an  upper  lobe,  in  which  this  process  most  frequently  occurs,  may  be  re- 
duced to  a  third  of  its  ordinary  dimensions.  Laennec  understood  thor- 
oughly this  natural  process  of  cure  in  tuberculosis,  and  recognized  the 
frequency  with  which  old  tuberculous  lesions  occurred  in  the  lungs.  He 
described  cicatrices  completes  and  cicatrices  fistuleuses,  the  latter  being  the 
shrunken  cavities  communicating  with  the  bronchi;  and  remarked  that,  as 
tubercles  growing  in  the  glands,  which  are  called  scrofula,  often  heal,  why 
should  not  the  same  take  place  in  the  lungs? 

There  is  an  old  German  axiom,  "Jedermann  hat  am  Ende  ein  Usclien 
Tuberculose,"  a  statement  partly  borne  out  by  the  statistics  showing  the 
proportion  of  cases  in  persons  dying  of  all  diseases  in  whom  quiescent  or 
tuberculous  lesions  are  found  in  the  lungs.  We  find  at  the  apices  the 
following  conditions,  which  have  been  held  to  signify  healed  tuberculous 
processes:  (1)  Thickening  of  the  pleura,  usually  at  the  posterior  surface 
of  the  apex,  with  subadjacent  induration  for  a  distance  of  a  few  milli- 
metres. This  has,  perhaps,  no  greater  significance  than  the  milky  patch 
on  the  pericardium.  (2)  Puckered  cicatrices  at  the  apex,  depressing  the 
pleura,  and  on  section  showing  a  large  pigmented,  fibrous  scar.  The  bron- 
chioles in  the  neighborhood  may  be  dilated,  but  there  are  neither  tubercles 
nor  cheesy  masses.  This  may  sometimes,  but  not  always,  indicate  a  healed 
tuberculous  lesion.  (3)  Puckered  cicatrices  with  cheesy  or  cretaceous 
nodules,  and  with  scattered  tubercles  in  the  vicinity.     (4)  The  cicatrices 

21 


332  SPECIFIC  INFECTIOUS  DISEASES. 

fistuleuses  of  Laennec^  in  wMch.  the  fibroid  puckering  has  reduced  the  size 
of  one  or  more  cavities  which  communicate  directly  with  the  bronchi. 

In  1,000  autopsies,  excluding  the  216  cases  dead  of  phthisis,  there  were 
59  cases  (7.5  per  cent)  which  presented  undoubted  tuberculous  lesions  in 
the  lungs.  I  excluded  the  simple  fibroid  puckering  and  the  solitary  cheesy 
nodules,  unless,  in  the  latter  case,  there  were  colonies  of  tubercles  in  the 
vicinity.  These  59  cases  died  of  various  diseases  and  at  various  ages.  A 
majority  of  them  were  between  forty  and  sixty.  My  experience  tallies 
closely  with  the  larger  analysis  made  by  Heitler  of  the  Vienna  post-mortem 
records,  in  which,  of  16,562  cases  in  which  the  death  was  not  directly  caused 
by  phthisis,  there  were  780  instances  of  obsolete  tubercle — a  percentage  of 
4.7.  He  excluded,  as  I  have  done,  the  simple  fibroid  induration.  Vari- 
ous observations  have  been  made  of  late  in  which  the  percentage  ranges 
from  27  (Bollinger)  to  39  (Massini).  In  200  autopsies,  in  which  this  point 
was  specially  examined,  Harris  found  38.8  per  cent  in  which  there  were 
relics  of  former  active  tuberculosis.  The  statement  is  made  by  Bouchard 
that,  of  the  post-mortems  at  the  Paris  morgue — generally  upon  persons 
dying  suddenly — the  percentage  found  with  some  evidence  of  tuberculous 
lesion,  active  or  obsolete,  is  as  high  as  75.  Large  as  these  figures  appear, 
they  are  not  probably  incorrect.  If,  as  has  been  done  in  Eibbert^s  labo- 
ratory, a  systematic  inspection  is  made  for  the  purpose,  tuberculous  lesions 
are  found  in  practically  100  per  cent  of  the  bodies  of  adults! 

II.  General  Measures. — The  cure  of  tuberculosis  is  a  question  of  nutri- 
tion; digestion  and  assimilation  control  the  situation;  make  a  patient  grow 
fat  and  the  local  disease  may  be  left  to  take  care  of  itself.  There  are  three 
indications:  First,  to  place  the  patient  in  surroundings  most  favorable  for 
the  maintenance  of  a  maximum  degree  of  nutrition;  second,  to  take  such 
measures  as,  in  a  local  or  general  way,  influence  the  tuberculous  processes; 
third,  to  alleviate  symptoms. 

Open-air  Treatment. — The  value  of  fresh  air  and  out-of-door  life 
is  well  illustrated  by  an  experiment  of  Trudeau.  Inoculated  rabbits  con- 
fined in  a  dark,  damp  place  rapidly  succumbed,  while  others,  allowed  to  run 
wild,  either  recovered  or  showed  slight  lesions.  It  is  the  same  in  human 
tuberculosis.  A  patient  confined  to  the  house — particularly  in  the  close, 
overheated,  stuffy  dwellings  of  the  poor,  or  treated  in  a  hospital  ward — 
is  in  a  position  analogous  to  that  of  the  rabbit  confined  to  a  hutch  in  the 
cellar;  whereas  a  patient  living  in  the  fresh  air  and  sunshine  for  the  greater 
part  of  the  day  has  chances  comparable  to  those  of  the  rabbit  running  wild. 

The  open-air  treatment  of  tuberculosis  may  be  carried  out  at  home, 
by  change  of  residence  to  a  suitable  climate,  or  in  a  sanatorium. 

(a)  At  Home. — In  a  majority  of  all  cases  the  patient  has  to  be  eared  for 
in  his  own  home,  and  if  in  the  city,  under  very  disadvantageous  circum- 
stances. Much,  however,  may  be  done  even  in  cities  to  promote  arrest  by 
insisting  upon  plenty  of  fresh  air.  It  is  often  impossible  to  attempt  any 
systematic  open-air  treatment  in  city  life,  but  there  are  many  cases  in  which 
it  can  be  done  if  the  physician  insists  and  if  he  lays  down  explicit  rules. 
The  patient's  bed  should  be  in  the  room  with  most  sunshine.  While  there 
is  fever  he  should  he  at  rest  in  led,  and  for  the  greater  part  of  each  day. 


TUBERCULOSIS.  333 

unless  the  weather  is  blustering  and  rainy,  the  windows  should  he  open, 
so  that  the  patient  may  be  exposed  freely  to  the  fresh  air.  Low  tempera- 
ture is  not  a  contraindication.  If  there  is  a  balcony  or  a  suitable  yard,  on 
the  brighter  days  the  patient  may  be  wrapped  up  and  put  in  a  reclining 
chair  or  on  a  sofa.  The  important  thing  is  for  the  physician  to  emphasize 
the  fact  that  neither  the  cough,  fever,  night  sweati,  and  not  even  hsemop- 
tysis  contraindicate  a  full  exposure  to  the  fresh  air.  In  country  places 
this  can  be  carried  out  much  more  eifectively.  I  always  advise  to  give 
the  patient  an  almanac,  that  he  can  tick  off  the  number  of  hours  of  sun- 
shine. In  the  summer  he  should  be  out  of  doors  for  at  least  eleven  or 
twelve  hours,  and  in  winter  six  or  eight  hours.  At  night  the  room  should 
be  cool  and  thoroughly  well  ventilated.  In  the  early  stages  of  the  disease 
with  much  fever,  it  nlay  require  several  months  of  this  rest  treatment  in 
the  open  air  before  the  temperature  falls  to  normal. 

(&)  Treatment  in  Sanatoria. — Perhaps  the  most  important  advance  in 
the  treatment  of  tuberculosis  has  been  in  the  establishment  in  favorable 
localities  of  institutions  in  which  patients  are  made  to  live  according  to 
strict  rules.  To  Brehmer,  of  Gobersdorf,  we  owe  the  successful  execution  of 
this  plan,  which  has  been  followed  in  Germany  with  most  gratifying  results. 
In  this  country  the  zeal,  energy,  and  scientific  devotion  of  Edward  L. 
Trudeau  have  demonstrated  its  feasibility,  and  the  Saranac  institution 
has  become  a  model  of  its  kind.  We  need  public  sanatoria  within  easy 
access  of  the  large  cities,  in  which  cases  of  early  tuberculosis  could  be 
treated  at  low  rates  or  at  the  public  cost.  Private  sanatoria  for  the  well- 
to-do  classes  are  urgently  needed.  The  results  at  Gobersdorf,  Falkenstein, 
and  Saranac  demonstrate  the  great  importance  of  system  and  rigid  disci- 
pline in  carrying  out  a  successful  treatment  of  tuberculosis.  Within  the 
past  three  years  much  has  been  done  both  in  the  United  States  and  Great 
Britain  to  promote  the  sanatorium  treatment  of  tuberculosis.  To  Dr. 
Knopf,  of  ISTew  York,  we  are  indebted  for  a  persistent  advocacy  of  its  value. 
The  all-important  matter  is  the  establishment  near  to  the  large  cities  of 
public  sanatoria  for  the  treatment  of  cases  in  the  early  stages.  It  is  all- 
important  that  these  institutions  should  be  placed  in  the  hands  of  men  in 
whose  integrity  and  scientific  ability  the  profession  has  full  confidence. 
There  should  be  established  in  the  large  general  hospital  special  out-patient 
departments  for  tuberculous  patients,  from  which  suitable  cases  could  be 
sent  to  the  civic  sanatoria.  They  could  be  partly  self-supporting,  as  many 
patients  would  pay  a  reasonable  sum  per  month.  An  attempt  is  being  made 
in  Colorado  to  start  an  industrial  sanatorium  on  a  large  scale. 

(c)  Climatic  Treatment. — This,  after  all,  is  only  a  modification  of  the 
open-air  method.  The  first  question  to  be  decided  is  whether  the  patient  is 
fit  to  be  sent  from  home.  In  many  instances  it  is  a  positive  hardship.  A 
patient  with  well-marked  cavities,  hectic  fever,  night  sweats,  and  emacia- 
tion is  much  better  at  home,  and  the  physician  should  not  be  too  much 
influenced  by  the  importunities  of  the  sick  man  or  of  his  friends.  The 
requirements  of  a  suitable  climate  are  a  pure  atmosphere,  an  equable  tem- 
perature not  subject  to  rapid  variations,  and  a  maximum  amount  of  sunshine. 
Given  these  three  factors,  and  it  makes  little  difference  where  a  patient 


334  SPECIFIC  INFECTIOUS  DISEASES. 

goes,  so  long  as  he  lives  an  outdoor  life.  The  purity  of  the  atmosphere  is 
the  first  consideration,  and  it  is  this  requirement  that  is  met  so  well 
in  the  mountains  and  forests.  The  different  climates  may  be  grouped 
into  the  high  altitudes,  the  dry,  warm  climates,  and  the  moist,  warm 
climates. 

In  this  country  ofjiigh  altitudes,  the  Colorado  resorts  are  the  most 
important.  Of  others,  those  in  Arizona  and  New  Mexico  have  been  de- 
veloping rapidly.  The  rarefaction  of  the  air  in  high  altitudes  is  of  benefit 
in  increasing  the  respiratory  movements  in  pulmonary  disease,  but  brings 
about  in  time  a  condition  of  dilatation  of  the  air-vesicles  and  a  permanent 
increase  in  the  size  of  the  chest  which  is  a  marked  disadvantage  when  such 
persons  attempt  subsequently  to  reside  at  the  sea-level.  The  great  advan- 
tage of  these  western  resorts  is  that  they  are  in  progressive,  prosperous 
countries,  in  which  a  man  may  find  means  of  livelihood  and  live  in  com- 
fort. In  Europe  the  chief  resorts  at  high  altitudes  are  at  Davos,  Les  Avants, 
and  St.  Moritz.  Of  resorts  at  a  moderate  altitude,  Asheville  and  the  Adi- 
rondacks  are  the  best  k:nown  in  this  country.  The  Adirondack  cure  has 
become  of  late  years  quite  famous.  Objections  to  it  are  the  expense,  ex- 
cept in  the  case  of  the  sanitorium,  but  for  well-to-do  people  it  is  by  far 
the  most  satisfactory  place.  One  very  decided  advantage  is  that  after 
arrest  of  the  disease  the  patient  can  return  to  the  sea-level  without  any 
special  risk.  The  eases  most  suitable  for  high  altitudes  are  those  in  which 
the  disease  is  limited,  without  much  cavity  formation,  and  without  much 
emaciation.  The  thin,  irritable  patients  with  chronic  tuberculosis  and  a 
good  deal  of  emphysema  are  better  at  the  sea-level.  The  cold  winter  cli- 
mate seems  to  be  of  decided  advantage  in  tuberculosis,  and  in  the  Adiron- 
dacks,  where  the  temperature  falls  sometimes  to  20°  or  even  more  below 
zero,  the  patients  are  able  to  lead  an  out-of-door  life  throughout  the  entire 
winter. 

Of  the  moist,  warm  climates,  in  this  country  Florida  and  the  Bermudas, 
in  Europe  the  Madeira  Islands,  and  in  Great  Britain  Torquay  and  Fal- 
mouth are  the  best  known. 

Of  the  dry,  warm  climates.  Southern  California  in  this  country  is  the 
most  satisfactory.  Many  of  the  health  resorts  in  the  Southern  States,  such 
as  Aiken,  Thomasville,  and  Summerville,  are  delightful  winter  climates 
for  tuberculous  cases.  Egypt,  Algiers,  and  the  Eiviera  are  the  most  satis- 
factory resorts  for  patients  from  Europe.  For  additional  information  on 
the  subject  of  climate,  particularly  in  this  country,  the  reader  is  referred 
to  Solly's  recent  work  on  the  subject. 

Other  considerations  which  should  influence  the  choice  of  a  locality 
are  good  accommodations  and  good  food.  Very  much  is  said  concerning 
the  choice  of  locality  in  the  different  stages  of  pulmonary  tuberculosis, 
but  when  the  disease  is  limited  to  an  apex,  in  a  man  of  fairly  good  personal 
and  family  history,  the  chances  are  that  he  may  fight  a  winning  battle  if 
he  lives  out  of  doors  in  any  climate,  whether  high,  dry  and  cold,  or  low, 
moist  and  warm.  With  bilateral  disease  and  cavity  formation  there  is  but 
little  hope  of  permanent  cure,  and  the  mild  or  warm  climates  are  prefer- 
able. 


TUBERCULOSIS.  335 

III.  Measures  wMch,  by  their  Local  or  General  Action,  influence  the 
Tuberculous  Process. — Under  this  heading  we  may  consider  the  specific, 
the  dietetic,  and  the  general  medicinal  treatment  of  tuberculosis. 

(a)  Specific  Treatment. — The  use  of  Koch's  original  tuberculin  has  been 
in  great  part  abandoned.  Some  observers,  as  Whittaker,  have  had  good 
success  with  it.  In  April,  1897,  Koch  announced  the  discovery  of  new 
tuberculins,  the  most  important  of  which  is  the  so-called  tuberculin  E.  It 
is  still  under  trial.  The  verdict  so  far  has  been  not  at  all  favorable,  ex- 
cept in  lupus. 

A  very  large  number  of  antitoxines  of  various  sorts  have  been  intro- 
duced within  the  past  few  years.  Many  of  them  have  been  submitted  to 
very  searching  tests  in  the  Saranac  Laboratory  by  Trudeau  and  Baldwin, 
whose  careful  work  has  extended  over  a  period  of  four  years.  They  state 
briefly  that,  while  one  or  two  of  the  serums  have  shown  a  slight  degree  of 
antitoxic  power,  in  all  the  others  the  tests  were  negative.  In  none  could 
any  germicidal  or  curative  influence  be  demonstrated. 

(b)  Dietetic  Treatment. — The  outlook  in  tuberculosis  depends  much 
upon  the  digestion.  It  is  rare  to  see  recovery  in  a  case  in  which  there  is 
persistent  gastric  trouble,  and  the  physician  should  ever  bear  in  mind  the 
fact  that  in  this  disease  the  primce  vice  control  the  position.  The  early 
nausea  and  loss  of  appetite  in  many  cases  of  phthisis  are  serious  obstacles. 
Many  patients  loathe  food  of  all  kinds.  A  change  of  air  or  a  sea  voyage 
may  promptly  restore  the  appetite.  When  either  of  these  is  impossible, 
and  if,  as  is  almost  always  the  case,  fever  is  present,  the  patient  should  be 
placed  at  rest,  kept  in  the  open  air  nearly  all  day,  and  fed  at  stated  inter- 
vals with  small  quantities  either  of  milk,  buttermilk,  or  koumyss,  alternat- 
ing if  necessary  with  meat  Juice  and  egg  albumin.  Some  cases  which  are 
disturbed  by  eggs  and  milk  do  well  on  koumyss.  It  may  be  necessary  to 
resort  to  Debove's  method  of  over-alimentation  or  forced  feeding.  The 
stomach  is  first  washed  out  with  cold  water,  and  then,  through  the  tube, 
a  mixture  is  given  containing  a  litre  of  milk,  an  egg,  and  100  grammes  of 
very  finely  powdered  meat.  This  is  given  three  times  a  day.  Sometimes 
the  patients  will  take  this  mixture  without  the  unpleasant  necessity  of  the 
stomach-Jube,  in  which  case  a  smaller  amount  may  be  given.  Eaw  eggs 
are  very  suitable  for  the  purpose  of  over-feeding,  and  may  be  taken  in  the 
intervals  between  the  meals.  Beginning  with  one  three  times  a  day  the 
number  may  be  increased  to  two,  three,  or  even  four  at  a  time.  In  the 
German  sanatoria  a  very  special  feature  is  this  overfeeding,  even  when 
fever  is  present. 

In  many  cases  the  digestion  is  not  at  all  disturbed  and  the  patient  can 
take  an  ordinary  diet.  It  is  remarkable  how  rapidly  the  appetite  and  di- 
gestion improve  on  the  fresh-air  treatment,  even  in  cases  which  have  to 
remain  in  the  city.  Care  should  be  taken  that  the  medicines  do  not  dis- 
turb the  stomach.  Not  infrequently  the  sweet  syrups  used  in  the  cough 
mixtures,  cod-liver  oil,  creasote,  and  the  hypophosphites  produce  irritation, 
and  by  interfering  with  digestion  do  more  harm  than  good.  On  the  other 
hand,  the  bitter  tonics,  with  acids,  and  the  various  malt  preparations  are 
often  in  these  cases  most  satisfactory.    The  indications  for  alcohol  in  tuber- 


336  SPECIFIC  INFECTIOUS  DISEASES. 

culosis  are  enfeebled  digestion  with  fever^  a  weak  heart,  and  rapid  pulse. 
A  routine  administration  is  not  advisable,  and  there  is  no  evidence  that  its 
persistent  use  promotes  fibroid  processes  in  the  tuberculous  areas.  In  the 
advanced  stages,  particularly  when  the  temperature  is  low  between  eight 
and  ten  in  the  morning,  whisky  and  milk,  or  whisky,  egg,  and  milk  may 
be  given  with  great  advantage.  The  red  wines  are  also  beneficial  in  mod- 
erate quantities. 

(c)  General  Medical  Treatment. — No  medicinal  agents  have  any  special 
or  peculiar  action  upon  tuberculous  processes.  The  influence  which  they 
exert  is  upon  the  general  nutrition,  increasing  the  physiological  resistance, 
and  rendering  the  tissues  less  susceptible  to  invasion.  The  following  are 
the  most  important  remedies  which  seem  to  act  in  this  manner: 

Creasote,  which  may  be  administered  in  capsules,  in  increasing  doses, 
beginning  with  1  minim  three  times  a  day  and,  if  well  borne,  increasing 
the  dose  to  8  or  10  minims.  It  may  also  be  given  in  solution  with  tincture 
of  cardamoms  and  alcohol.  It  is  an  old  remedy,  strongly  recommended 
by  Addison,  and  the  reports  of  Jaccoud,  Fraentzel,  and  many  others  show 
that  it  has  a  positive  value  in  the  disease.  Guaiacol  may  be  given  as  a  sub- 
stitute, either  internally  or  hypodermically.  In  101  cases  in  which  it  was 
used  at  my  clinic,  by  Meredith  Eeese,  the  chief  action  was  on  the  cough 
and  expectoration,  which  were  much  lessened,  but  the  remedy  had  no  essen- 
tial influence  on  the  progress  of  the  disease. 

Cod-liver  Oil. — In  glandular  and  bone  tuberculosis,  this  remedy  is  un- 
doubtedly beneficial  in  improving  the  nutrition.  In  pulmonary  tuber- 
culosis its  action  is  less  certain,  and  it  is  scarcely  worthy  of  the  unbounded 
confidence  which  it  enjoyed  for  so  many  years.  It  should  be  given  in  small 
doses,  not  more  than  a  teaspoonful  three  times  a  day  after  meals.  It  seems 
to  act  better  in  children  than  in  adults.  Fever  and  gastric  irritation  are 
eontra-indications  to  its  use.  When  it  is  not  well  borne,  a  dessertspoonful 
of  rich  cream  three  times  a  day  is  an  excellent  substitute.  The  clotted  or 
Devonshire  cream  is  preferable. 

The  Hypopliosphites. — These  in  various  forms  are  useful  tonics,  but  it 
is  doubtful  if  they  have  any  other  action.  They  certainly  exercise  no  spe- 
cific influence  upon  tubercle.  They  may  be  given  in  the  form  of  the  syrup 
of  the  hypophosphites  of  calcium,  sodium,  and  potassium  of  the  IT.  S.  P. 

Arsenic. — There  is  no  general  tonic  more  satisfactory  in  cases  of  tuber- 
culosis of  all  kinds  than  Fowler's  solution.  It  may  be  given  in  5-minim 
doses  three  times  a  day  and  gradually  increased;  stopping  its  use  when- 
ever unpleasant  symptoms  arise,  and  in  any  case  intermitting  it  every 
third  or  four  week. 

One  or  two  special  methods  of  dealing  with  pulmonary  tuberculosis 
may  here  be  mentioned.  The  local  treatment,  by  direct  injection  into  the 
lungs,  has  been  practised  since  its  strong  advocacy  by  Pepper.  It  has, 
however,  not  gained  the  general  support  of  the  profession,  and  is  occa- 
sionally followed  by  serious  results.  As  a  rule,  it  may  be  practised  with 
impunity,  and  the  injections  may  be  made  with  a  long  hypodermic  needle 
into  any  portion  of  the  lung  which  is  diseased.  Iodine,  carbolic  acid, 
creasote  (3-per-cent  solution  in  almond  oil),  and  iodoform  have  been  used 


TUBERCULOSIS.  337 

for  the  purpose.  The  remarkable  results  which  surgeons  have  recently 
obtained  in  the  treatment  of  joint  tuberculosis  by  injections  of  iodoform 
point  to  this  as  a  remedy  which  will  probably  prove  of  service  when  in- 
jected directly  into  the  lungs. 

Treatment  by  compressed  air  is  in  many  cases  beneficial,  and  under 
its  use  the  appetite  improves,  there  is  gain  in  weight,  and  reduction  of  the 
fever.    The  air  may  be  saturated  with  creasote. 

IV.  Treatment  of  Special  Symptoms  in  Pulmonary  Tuberculosis. — (a) 
The  Fever. — There  is  no  more  difficult  problem  in  practical  therapeutics 
than  the  treatment  of  the  pyrexia  of  tuberculosis.  The  patient  should  be 
at  rest,  and  in  the  open  air  for  a  definite  number  of  hours  daily.  Fever  does 
not  contra-indicate  an  out-of-door  life,  but  it  is  well  for  patients  with  a 
temperature  above  100.5°  to  be  at  rest.  For  the  continuous  pyrexia  or  the 
remittent  type  of  the  early  stages,  quinine,  small  doses  of  digitalis,  and 
the  salicylates  may  be  tried;  but  they  are  uncertain  and  rarely  reliable. 
Under  no  circumstances  is  that  priceless  remedy,  quinine,  so  much  abused 
as  in  the  fever  of  tuberculosis.  In  large  doses  it  has  a  moderate  antipyretic 
action,  but  it  is  just  in  these  efficient  doses  that  it  is  so  apt  to  disturb  the 
stomach. 

Antipyrin  and  antifebrin  may  be  used  cautiously;  but  it  is  better, 
when  the  fever  rises  above  103°,  to  rely  upon  cold  sponging  or  the  tepid 
bath,  gradually  cooled.  When  softening  has  taken  place  and  the  fever 
assumes  the  characteristic  septic  type,  the  problem  becomes  still  more  diffi- 
cult. As  shown  by  Chart  XII  (which  is  not  by  any  means  an  exceptional 
one),  the  pyrexia,  at  this  stage,  lasts  only  for  twelve  or  fifteen  hours.  As 
a  rule  it  is  not  more  than  from  eight  to  ten  hours  in  M^hich  the  fever  is 
high  enough  to  demand  antipyretic  treatment.  Sometimes  antifebrin, 
given  in  2-grain  doses  every  hour  for  three  or  four  hours  before  the  rise  in 
temperature  takes  place,  either  prevents  entirely  or  limits  the  paroxysm. 
If  the  temperature  begins  to  rise  between  two  and  three  in  the  afternoon, 
the  antifebrin  may  be  given  at  eleven,  twelve,  one,  and,  if  necessary,  at 
two.  It  answers  better  in  this  way  than  given  in  the  single  doses.  Careful 
sponging  of  the  extremities  for  from  half  an  hour  to  an  hour  during  the 
height  of  the  fever  is  useful.  Quinine  is  of  little  benefit  in  this  type  of 
fever;  the  salicylates  are  of  still  less  use. 

(&)  Sweating. — Atropine,  in  doses  of  gr.  yiir— bV;>  ^^^  the  aromatic  sul- 
phuric acid  in  large  doses,  are  the  best  remedies.  When  there  are  cough 
and  nocturnal  restlessness,  an  eighth  of  a  grain  of  morphia  may  be  given 
with  the  atropine.  Muscarin  (tti,v  of  a  1-per-cent  solution),  tincture  of 
nux  vomica  (ttLxxx),  picrotoxin  (gr.  -gV)  may  be  tried.  The  patient  should 
use  light  flannel  night-dresses,  as  the  cotton  night-shirts,  Avhen  soaked  with 
perspiration,  have  a  very  unpleasant  cold,  clammy  feeling. 

(c)  The  cough  is  a  troublesome,  though  necessary,  feature  in  pulmonary 
tuberculosis.  Unless  very  worrying  and  disturbing  sleep  at  night,  or  so 
severe  as  to  produce  vomiting,  it  is  not  well  to  attempt  to  restrict  it.  When 
irritative  and  bronchial  in  character,  inhalations  are  useful,  particularly  the 
tincture  of  benzoin  or  preparations  of  tar,  creasote,  or  turpentine.  The 
throat  should  be  carefully  examined,  as  some  of  the  most  irritable  and 


338  SPECIFIC  IKFECTIOUS  DISEASES. 

distressing  forms  of  cough  in  phthisis  result  from  laryngeal  erosions.  The 
distressing  nocturnal  cough,  which  begins  just  as  the  patient  gets  into 
bed  and  is  preparing  to  fall  asleep,  requires,  as  a  rule,  preparations  of 
opium.  Codeia,  in  quarter  or  half  grain  doses,  or  the  syrupus  codeia  (5  j) 
may  be  given.  An  excellent  combination  for  the  nocturnal  cough  of 
phthisis  is  morphia  (gr.  ^-i),  dilute  hydrocyanic  acid  (fTlij-iij),  and  syrup 
of  wild  cherry  (3j).  The  spirits  of  chloroform,  B.  P.,  or  the  mistura 
chloroformi,  IJ.  S.  P.,  or  Hoffman's  anodyne,  given  in  whisky  before  going 
to  sleep,  are  efficacious.  Mild  counter-irritation,  or  the  application  of  a 
hot  poultice,  will  sometimes  promptly  relieve  the  cough.  The  morning 
cough  is  often  much  relieved  by  taking  immediately  after  getting  up  a 
glass  of  hot  milk  or  a  cup  of  hot  water,  to  which  15  grains  of  bicarbonate 
of  soda  have  been  added.  In  the  later  stages  of  the  disease,  when  cavities 
have  formed,  the  accumulated  secretion  must  be  expectorated  and  the 
paroxysms  of  coughing  are  now  most  exhausting.  The  sedatives,  such  as 
morphia  and  hydrocyanic  acid,  should  be  given  cautiously.  The  aromatic 
spirit  of  ammonia  in  full  doses  helps  to  allay  the  paroxysm.  Wlien  the 
expectoration  is  profuse,  creasote  internally,  or  inhalations  of  turpentine 
and  iodine,  or  oil  of  eucalyptus,  are  useful.  For  the  troublesome  dysphagia 
a  strong  solution  of  cocaine  (gr.  x)  with  boric  acid  (gr.  v.)  in  glycerine  and 
water  (  i  ]')  may  be  used  locally. 

(d)  For  the  diarrhoea  large  doses  of  bismuth,  combined  with  Dover 
powder,  and  small  starch  enemata,  with  or  without  opium,  may  be  given. 
The  acetate  of  lead  and  opium  pill  often  acts  promptly,  and  the  acid  diar- 
rhoea mixture,  dilute  acetic  acid  (tt],  x-xv),  morphia  (gr.  ^),  and  acetate  of 
lead  (gr.  j-ij),  may  be  tried. 

(e)  The  treatment  of  the  hsemoptysis  will  be  considered  in  the  section 
on  haemorrhage  from  the  lungs.  Dyspnoea  is  rarely  a  prominent  symptom 
except  in  the  advanced  stages,  when  it  may  be  very  troublesome  and  dis- 
tressing.   Ammonia  and  morphia,  cautiously  administered,  may  be  used. 

If  the  pleuritic  pains  are  severe,  the  side  may  be  strapped,  or  painted 
with  tincture  of  iodine.  The  dyspeptic  symptoms  require  careful  treat- 
ment, as  the  outlook  in  individual  cases  depends  much  upon  the  condition 
of  the  stomach.  Small  doses  of  calomel  and  soda  often  allay  the  distress- 
ing nausea  of  the  early  stage. 

XXXV.    LEPROSY. 

Definition. — A  chronic  infectious  disease  caused  by  Bacillus  leprce, 
characterized  by  the  presence  of  tubercular  nodules  in  the  skin  and  mucous 
membranes  (tubercular  leprosy)  or  by  changes  in  the  nerves  (ansesthetic 
leprosy).  At  first  these  forms  may  be  separate,  but  ultimately  both  are 
combined,  and  in  the  characteristic  tubercular  form  there  are  disturbances 
of  sensation. 

History. — The  disease  appears  to  have  prevailed  in  Egypt  even  so 
far  back  as  three  or  four  thousand  years  before  Christ.  The  Hebrew  writers 
make  many  references  to  it,  but,  as  is  evident  from  the  description  in  Leviti- 
cus, many  different  forms  of  skin  diseases  were  embraced  under  the  term 


LEPROSY.  339 

leprosy.  Both  in  India  and  in  China  the  affection  was  also  known  many 
centuries  before  the  Christian  era.  The  old  Greek  and  Eoman  physicians 
were  perfectly  familiar  with  its  manifestations.  As  evidence  of  a  pre- 
Columbian  existence  of  leprosy  in  America^,  Ashmead  refers  to  the  old 
pieces  of"  Peruvian  pottery  representing  deformities  suggestive  of  this  dis- 
ease. Throughout  the  middle  ages  leprosy  prevailed  extensively  in  Europe, 
and  the  number  of  leper  asylums  has  been  estimated  at  at  least  20,000. 
During  the  sixteenth  century  it  gradually  declined. 

The  prize  essays  of  the  National  Leprosy  Committee,  the  Transactions 
of  the  Berlin  Leprosy  Conference,  and  the  new  journal,  Lepra  Bibliotheca 
Internationalis  (1900),  will  be  found  invaluable  to  young  men  going  to 
India,  China,  or  the  Philippines. 

Geographical  Distribution. — In  Europe  leprosy  prevails  in  Ice- 
land, Norway  and  Sweden,  parts  of  Kussia,  particularly  about  Dorpat,  Eiga, 
and  the  Caucasus,  and  in  certain  provinces  of  Spain  and  Portugal.  In 
Great  Britain  the  cases  are  now  all  imported. 

In  the  United  States  there  are  three  important  foci:  Louisiana,  in  which 
the  disease  has  been  known  since  1785,  and  has  of  late  increased.  The 
statement  that  it  was  introduced  by  the  Acadians  does  not  seem  to  me  very 
likely,  since  the  records  of  its  existence  in  Nova  Scotia  and  New  Bruns- 
wick do  not  date  back  to  that  period.  Dr.  Dyer  reports  that  on  January 
12,  1898,  he  knew  of  124  positive  living  cases,  including  25  in  the  Leper 
Home  in  Iberville  Parish.  He  adds  that  it  is  justifiable  to  es'timate  the 
number  of  lepers  in  the  State  of  Louisiana  as  between  300  and  500.  In 
California,  whither  the  disease  has  been  imported  by  the  Chinese,  cases  are 
not  very  infrequent.  I  am  informed  by  D.  W.  Montgomery  that  there 
are  (March  20,  1901)  21  cases  in  the  Twenty-sixth  Street  Hospital,  San 
Francisco.  Of  these,  only  2  are  Americans,  10  are  Chinese.  One  white 
only  is  known  to  have  contracted  the  disease  in  San  Francisco  (Montgom- 
ery). In  Minnesota  with  the  Norwegian  colonists  about  170  lepers  are 
known  to  have  settled.  The  disease  has  steadily  decreased.  Bracken,  in  a 
recent  study  (December,  1900),  states  that  there  are  37  lepers  in  the  North- 
west, 17  of  whom  are  in  Minnesota.  There  is  not  a  single  native-born  leper 
in  the  region.  The  United  States  Leprosy  Commission  has  reported  the 
presence  of  about  500  cases. 

The  few  cases  seen  in  the  large  cities  of  the  Atlantic  coast  are  imported. 

In  the  Dominion  of  Canada  there  are  foci  of  leprosy  in  two  or  three 
counties  of  New  Brunswick,  settled  by  French  Canadians,  and  in  Cape 
Breton,  Nova  Scotia,  The  disease  appears  to  have  been  imported  from 
Normandy  about  the  end  of  the  last  century.  The  number  of  cases  has 
gradually  lessened.  Dr.  A.  C.  Smith,  the  physician  in  charge  of  the  laza- 
retto, at  Tracadie,  New  Brunswick,  reports  under  date  of  January  17,  1898, 
that  there  are  24  lepers  at  present  under  his  care — 18  males  and  6  females. 
Of  these,  3  are  immigrant  Icelanders  from  Manitoba;  1  is  a  negro  from  the 
West  India  Islands.  Dr.  Smith  states  that  segregation  is  gradually  stamp- 
ing out  the  disease  in  New  Brunswick.  The  cases  have  dwindled  from  about 
40  to  half  that  number.  In  Cape  Breton  it  has  almost  disappeared.  A  few 
cases  are  met  with  among  the  Icelandic  settlers  in  Manitoba,  and  with  the 
Chinese  the  affection  has  been  introduced  into  British  Columbia.     Dr.  Han- 


340  SPECIFIC  INFECTIOUS  DISEASES. 

nington,  of  Victoria,  writes,  January  20,  1898,  that  there  are  8  cases  known 
in  this  province.    They  are  segregated  on  Darcy  Island. 

Leprosy  is  endemic  in  the  West  India  Islands.  It  also  occurs  in  Mexico 
and  throughout  the  Southern  States.  In  the  Sandwich  Islands  it  spread 
rapidly  after  1860,  and  strenuous  attempts  have  been  made  to  stamp  it  out 
by  segregating  all  lepers  on  the  island  of  Molokai.  In  1894  there  were  1,153 
lepers  in  the  settlement. 

In  British  India,  according  to  the  Leprosy  Commission,  there  are 
100,000  lepers.  This  is  probably  a  low  estimate.  In  China  leprosy  prevails 
extensively.  In  South  Africa,  it  has  increased  rapidly.  In  Australia, 
New  Zealand,  and  the  Australasian  islands  it  also  prevails,  chiefly  among 
the  Chinese.  The  essays  of  Ashburton  Thompson  and  James  Cantlie  deal 
fully  with  leprosy  in  China,  Australia,  and  the  Pacific  islands. 

Etiology. — Bacillus  leprse,  discovered  by  Hansen,  of  Bergen,  in  1871, 
is  universally  recognized  as  the  cause  of  the  disease.  It  has  many  points 
of  resemblance  to  the  tubercle  bacillus,  but  can  be  readily  differentiated. 
It  is  cultivated  with  extreme  difficulty,  and,  in  fact,  there  is  some  doubt 
as  to  whether  it  is  capable  of  growth  on  artificial  media. 

Modes  of  Infection. — (a)  Inoculation. — While  it  is  highly  probable  that 
leprosy  may  be  contracted  by  accidental  inoculation,  the  experimental  evi- 
dence is  as  yet  inconclusive.  With  one  possible  exception  negative  results 
have  followed  the  attempts  to  reproduce  the  disease  in  man.  The  Ha- 
waiian convict  under  sentence  of  death,  who  was  inoculated  on  September 
30,  1884,  by  Arning,  four  weeks  later  had  rheumatoid  pains  and  gradual 
painful  swelling  of  the  ulnar  and  median  nerves.  The  neuritis  gradually 
subsided,  but  there  developed  a  small  lepra  tubercle  at  the  site  of  the  inocu- 
lation. In  1887  the  disease  was  quite  manifest,  and  the  man  died  of  it  six 
years  after  inoculation.  The  ease  is  not  regarded  as  conclusive,  as  he 
had  leprous  relatives  and  lived  in  a  leprous  country. 

(&)  Heredity. — For  years  it  was  thought  that  the  disease  was  transmitted 
from  parent  to  child,  but  the  general  opinion,  as  expressed  in  the  recent 
Leprosy  Congress  in  Berlin,  was  decidedly  against  this- view.  Of  course, 
the  possibility  of  its  transmission  cannot  be  denied,  and  in  this  respect 
leprosy  and  tuberculosis  occupy  very  much  the  same  position,  though  men 
with  very  wide  experience  have  never  seen  a  new-born  leper.  The  young- 
est cases  are  rarely  under  three  or  four  years  of  age. 

(c)  By  Contagion. — The  bacilli  are  given  off  from  the  open  sores;  they 
are  found  in  the  saliva  and  expectoration  in  the  cases  with  leprous  lesions 
in  the  mouth  and  throat,  and  occur  in  very  large  numbers  in  the  nasal 
secretion.  Sticker  found  in  153  lepers,  subjects  of  both  forms  of  the  dis- 
ease, bacilli  in  the  nasal  secretion  in  138,  and  herein,  he  thinks,  lies  the  chief 
source  of  danger.  SchafPer  was  able  to  collect  lepra  bacilli  on  clean  slides 
placed  on  tables  and  floors  near  to  lepers  whom  he  had  caused  to  read 
aloud.  The  bacilli  have  also  been  isolated  from  the  urine  and  the  milk  of 
patients.  It  seems  probable  that  they  may  enter  the  body  in  many  ways 
through  the  mucous  membranes  and  through  the  skin.  Sticker  believes 
that  the  initial  lesion  is  in  an  ulcer  above  the  cartilaginous  part  of  the  nasal 
septum.     One  of  the  most  striking  examples  of  the  contagiousness  of 


LEPROSY.  341 

leprosy  is  the  following:  "In  1860^  a  girl  who  had  hitherto  lived  at  Holst- 
fershof,  where  no  leprosy  existed,  married  and  went  to  live  at  Tarwast  with 
her  mother-in-law,  who  was  a  leper.  She  remained  healthy,  but  her  three 
children  (1,  2,  3)  became  leprous,  as  also  her  younger  sister  (4),  who  came 
on  a  visit  to  Tarwast  and  slept  with  the  children.  The  younger  sister  de- 
veloped leprosy  after  returning  to  Holstfershof.  At  the  latter  place  a 
man  (5),  fifty-two  years  old,  who  married  one  of  the  '  younger  sister's ' 
children,  acquired  leprosy;  also  a  relative  (6),  thirty-six  years  old,  a  tailor 
by  occupation,  who  frequented  the  house,  and  his  wife  (7),  who  came  from 
a  place  where  no  leprosy  existed.  The  two  men  last  mentioned  are  at 
present  (1897)  inmates  of  the  leper  asylum  at  Dorpat."  There  is  certain 
evidence  to  show  that  the  disease  may  be  spread  through  infected  clothing, 
and  the  high  percentage  of  washerwomen  among  lepers  is  also  suggestive. 

Conditions  influencing  Infection. — The  disease  attacks  persons  of  all 
ages.  We  do  not  yet  understand  all  the  conditions  necessary.  Evidently 
the  closest  and  most  intimate  contact  is  essential.  The  doctors,  nurses, 
and  Sisters  of  Charity  who  care  for  the  patients  are  very  rarely  attacked. 
In  the  lazaretto  at  Tracadie  not  one  of  the  Sisters  who  for  more  than  forty 
years  have  so  faithfully  nursed  the  lepers  has  contracted  the  disease.  Father 
Damian,  in  the  Sandwich  Islands,  and  Father  Boglioli,  in  New  Orleans, 
both  fell  victims  in  the  discharge  of  their  priestly  duties.  There  has  long 
been  an  idea  that  possibly  the  disease  may  be  associated  with  some  special 
kind  of  food,  and  Jonathan  Hutchinson  believes  that  a  fish  diet  is  the 
tertium  quid,  which  either  renders  the  patient  susceptible  or  with  which 
the  poison  may  be  taken. 

Morbid  Anatomy. — The  leprosy  tubercles  consist  of  granuloma- 
tous tissue  made  up  of  cells  of  various  sizes  in  a  connective-tissue  matrix. 
The  bacilli  in  extraordinary  numbers  lie  partly  between  and  partly  in  the 
cells.  The  process  gradually  involves  the  skin,  giving  rise  to  tuberous  out- 
growths with  intervening  areas  of  ulceration  or  cicatrization,  which  in  the 
face  may  gradually  produce  the  so-called  fades  leontina.  The  mucous 
membranes,  particularly  the  conjunctiva,  the  cornea,  and  the  larynx  may 
gradually  be  involved.  In  many  cases  deep  ulcers  form  which  result  in 
extensive  loss  of  substance  or  loss  of  fingers  or  toes,  the  so-called  lepra 
mutilans.  In  anaesthetic  leprosy  there  is  a  peripheral  neuritis  due  to  the 
development  of  the  bacilli  in  the  nerve-fibres.  Indeed,  this  involvement 
of  the  nerves  plays  a  primary  part  in  the  etiology  of  many  of  the  impor- 
tant features,  particularly  the  trophic  changes  in  the  skin  and  the  disturb- 
ances of  sensation. 

Clinical  Forms.— (a)  Tubercular  Leprosy.— Prior  to  the  appear- 
ance of  the  nodules  there  are  areas  of  cutaneous  erythema  which  may  be 
sharply  defined  and  often  hyperassthetic.  This  is  sometimes  known  as 
macular  leprosy.  The  affected  spots  in  time  become  pigmented.  In  some 
instances  this  superficial  change  continues  without  the  development  of 
nodules,  the  areas  become  anfesthetic,  the  pigment  gradually  disappears, 
and  the  skin  gets  perfectly  white — the  lepra  alba.  Among  the  patients 
at  Tracadie  it  was  particularly  interesting  to  see  three  or  four  in  this  early 
stage  presenting  on  the  face  and  forearms  a  patchy  erythema  with  slight 


342  SPECIFIC  INFECTIOUS  DISEASES. 

swelling  of  the  skin.  The  diagnosis  of  the  condition  is  perfectly  clear^ 
though  it  may  be  a  long  time  before  any  other  than  sensory  changes  de- 
velop. The  eyelashes  and  eyebrows  and  the  hairs  on  the  face  fall  out.  The 
mucous  membranes  finally  become  involved,  particularly  of  the  mouthy 
throat,  and  larynx;  the  voice  becomes  harsh  and  fijially  aphonic.  Death 
results  not  infrequently  from  the  laryngeal  complications  and  aspiration 
pneumonia.  The  conjunctiva  are  frequently  attacked,  and  the  sight  is  lost 
by  a  leprous  keratitis. 

(b)  Anaesthetic  Leprosy. — This  remarkable  form  has,  in  characteristic 
cases,  no  external  resemblance  whatever  to  the  other  variety.  It  usually 
begins  with  pains  in  the  limbs  and  areas  of  hypersesthesia  or  of  numbness. 
Very  early  there  may  be  trophic  changes,  seen  in  the  formation  of  small 
bullse  (Hillis).  Maculae  appear  upon  the  trunk  and  extremities,  and  after 
persisting  for  a  variable  time  gradually  disappear,  leaving  areas  of  anges- 
thesia,  but  the  loss  of  sensation  may  come  on  independently  of  the  out- 
break of  maculae.  The  nerve-trunks,  where  superficial,  may  be  felt  to  be 
large  and  nodular.  The  trophic  disturbances  are  usually  marked.  Pem- 
phigus-like bulls  develop  in  the  affected  areas,  which  break  and  leave 
ulcers  which  may  be  very  destructive.  The  fingers  and  toes  are  liable  to 
contractures  and  to  necrosis,  so  that  in  chronic  cases  the  phalanges  are 
lost.  The  course  of  auEesthetie  leprosy  is  extraordinarily  chronic  and  may 
persist  for  years  without  leading  to  much  deformity.  One  of  the  most 
prominent  clerg}Tnen  on  this  continent  had  anaesthetic  leprosy  for  more 
than  thirty  years,  which  did  not  seriously  interfere  with  his  usefulness,  and 
not  in  the  slightest  with  his  career. 

Diagnosis. — ^Even  in  the  early  stage  the  dusky  erythematous  maculae 
with  hyperesthesia  or  areas  of  anaesthesia  are  very  characteristic.  In  an 
advanced  grade  neither  the  tubercular  nor  anjesthetic  forms  could  possibly 
be  mistaken  for  any  other  affection.  In  a  doubtful  case  the  microscopical 
examination  of  an  excised  nodule  is  decisive. 

Treatment. — There  are  no  specific  remedies  in  the  disease.  The 
gurjun  and  chaulmoogra  oils  have  been  recommended,  the  former  in  doses 
of  from  5  to  10  minims,  the  latter  in  2-drachm  doses.  Calmette's  anti- 
venene,  20  to  30  c.  c,  subcutaneously,  has  been  followed  by  remarkable  re- 
sults. Dyer  writes  (March  3,  1901)  that  of  10  cases  treated  with  anti- 
venene,  4  are  to  all  appearances  cured,  2  have  improved.  Segregation 
should  be  compulsory  in  all  cases  except  where  the  friends  can  show  that 
they  have  ample  provision  in  their  own  home  for  the  complete  isolation 
and  proper  care  of  the  patient. 

XXXVI.     INFECTIOUS    DISEASES   OF  DOUBTFUL  NATURE. 

(1)  FEBRICULA— EPHEMERAL  FEVER. 

Definition. — Fever  of  slight  duration,  probably  depending  upon  a 
variety  of  causes.  ^ 

A  febrile  paroxysm  lasting  for  twenty-four  hours  and  disappearing  com- 
pletely is  spoken  of  as  ephemeral  fever.  If  it  persists  for  three,  four,  or 
more  days  without  local  affection  it  is  referred  to  as  f ebricula. 


INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE.  343 

The  cases  may  be  divided  into  several  groups: 

(a)  Those  which  represent  mild  or  abortive  types  of  the  infectious 
diseases.  It  is  not  very  unusual,  during  an  epidemic  of  typhoid,  scarlet 
fever,  or  measles,  to  see  cases  with  some  of  the  prodromal  symptoms  and 
slight  fever,  which  persist  for  two  or  three  days  without  any  distinctive 
features.  I  have  already  spoken  of  these  in  connection  with  the  abortive 
type  of  typhoid  fever.  Possibly,  as  Kahler  suggests,  some  of  the  cases  of 
transient  fever  are  due  to  the  rheumatic  poison. 

(h)  In  a  larger  and  perhaps  more  important  group  of  cases  the  symp- 
toms develop  with  dyspepsia.  In  children  indigestion  and  gastro-intes- 
tinal  catarrh  are  often  accompanied  by  fever.  Possibly  some  instances  of 
longer  duration  may  be  due  to  the  absorption  of  certain  toxic  substances. 
Slight  fever  has  been  known  to  follow  the  eating  of  decomposing  sub- 
stances or  the  drinking  of  stale  beer;  but  the  gastric  juice  has  remarkable 
antiseptic  properties,  and  the  frequency  with  which  persons  take  from 
choice  articles  which  are  "  high,"  shows  that  poisoning  is  not  likely  to 
occur  unless  there  is  existing  gastro-intestinal  disturbance. 

(c)  Cases  which  follow  exposure  to  foul  odors  or  sewer-gas.  That  a 
febrile  paroxysm  may  follow  a  prolonged  exposure  to  noxious  odors  has 
long  been  recognized.  The  cases  which  have  been  described  under  this 
heading  are  of  two  kinds:  an  acute  severe  form  with  nausea,  vomiting, 
colic,  and  fever,  followed  perhaps  by  a  condition  of  collapse  or  coma; 
secondly,  a  form  of  low  fever  with  or  without  chills.  A  good  deal  of  donbt 
still  exists  in  the  minds  of  the  profession  about  these  cases  of  so-called 
sewer-gas  poisoning.  It  is  a  notorious  fact  that  workers  in  sewers  are 
remarkably  free  from  disease,  and  in  many  of  the  cases  which  have 
been  reported  the  illness  may  have  been  only  a  coincidence.  There  are 
instances  in  which  persons  have  been  taken  ill  with  vomiting  and  slight 
fever  after  exposure  to  the  odor  of  a  very  offensive  post  mortem. 
Whether  true  or  not,  the  idea  is  firmly  implanted  in  the  minds  of  the 
laity  that  very  powerful  odors  from  decomposing  matters  may  produce 
sickness. 

(d)  Many  cases  doubtless  depend  upon  slight  unrecognized  lesions,  such 
as  tonsillitis  or  occasionally  an  abortive  or  larval  pneumonia.  Children 
are  much  more  frequently  affected  than  adults. 

The  symptoms  set  in,  as  a  rule,  abruptly,  though  in  some  instances 
there  may  have  been  preliminary  malaise  and  indisposition.  Headache, 
loss  of  appetite,  and  furred  tongue  are  present.  The  urine  is  scanty  and 
high-colored,  the  fever  ranges  from  101°  to  103°,  sometimes  in  children  it 
rises  higher.  The  cheeks  may  be  flushed  and  the  patient  has  the  outward 
manifestations  of  fever.  In  children  there  may  be  bronchial  catarrh  with 
slight  cough.  Herpes  on  the  lips  is  a  common  symptom.  Occasionally 
in  children  the  cerebral  symptoms  are  marked  at  the  outset,  and  there  may 
be  irritation,  restlessness,  and  nocturnal  delirium.  The  fever  terminates 
abruptly  by  crisis  from  the  second  to  the  fourth  day;  in  some  instances 
it  may  continue  for  a  week. 

The  diagnosis  generally  rests  upon  the  absence  of  local  manifestations, 
particularly  the  characteristic  skin  rashes  of  the  eruptive  fevers,  and  most 


344  SPECIFIC  INFECTIOUS  DISEASES. 

important  of  all  the  rapid  disappearance  of  the  pjTexia.     The  cases  most 
readily  recognized  are  those  with  acute  gastro-intestinal  disturbance. 

The  treatment  is  that  of  mild  pyrexia — rest  in  bed,  a  laxative,  and  a 
fever  mixture  containing  nitrate  of  potassium  and  sweet  spirits  of  nitre. 

(2)  WEIL'S  DISEASE. 

Acute  Febrile  Icterus. — In  1886  "Weil  described  an  acute  infectious  dis- 
ease, characterized  by  fever  and  jaundice.  Much  discussion  has  taken  place 
concerning  the  true  nature  of  this  affection,  but  it  has  not  been  definitely 
determined  whether  it  is  a  specific  disease  or  only  a  jaundice  which  may 
be  dueito  various  causes.  The  majority  of  the  cases  have  occurred  during 
the  summer  months.  The  cases  have  occurred  in  groups  in  different  cities. 
A  few  cases  have  been  reported  in  this  country  (Lanphear).  Males  are 
most  frequently  affected.  Many  of  the  cases  have  been  in  butchers.  The 
age  of  the  patients  has  been  from  twenty-five  to  forty. 

The  disease  sets  in  abruptly,  usually  without  prodromes  and  often 
with  a  chill.  There  are  headache,  pains  in  the  back,  and  sometimes  in- 
tense pains  in  the  legs  and  muscles,  particularly  of  the  cheeks.  The  fever 
is  characterized  by  marked  remissions.  Jaundice  appears  early.  The  liver 
and  spleen  are  usually  swollen;  the  former  may  be  tender.  The  jaundice 
may  be  light,  but  in  many  of  the  cases  described  it  has  been  of  the  ob- 
structive form,  and  the  stools  have  been  clay-colored.  Gastro-intestinal 
symptoms  are  rarely  present.  The  fever  lasts  from  ten  to  fourteen  days; 
sometimes  there  are  slight  recurrences,  but  a  definite  relapse  is  rare. 

Albumin  is  usually  present  in  the  urine;  hematuria  has  occurred  in 
some  cases. 

Cerebral  symptoms,  delirium  and  coma,  may  be  present. 

In  the  few  post-mortems  which  have  been  made  nothing  distinctive 
has  been  found.  The  investigations  of  Jaeger  render  it  not  impossible 
that  this  epidemic  form  of  jaundice  depends  upon  infection  with  a  proteus 
— Proteus  fiuorescens. 

■i 

(3)  MILK-SICKNESS. 

This  remarkable  disease  prevails  in  certain  districts  of  the  United 
States,  west  of  the  Alleghany  Mountains,  and  is  connected  with  the  affec- 
tion in  cattle  known  as  the  trembles.  It  prevailed  extensively  in  the  early 
settlements  in  certain  of  the  "Western  States  and  proved  very  fatal.  The 
general  opinion  is  that  it  is  communicated  to  man  only  by  eating  the  flesh 
or  drinking  the  milk  of  diseased  animals.  The  butter  and  cheese  are  also 
poisonous.  In  animals,  cattle  and  the  young  of  horses  and  sheep  are  most 
susceptible.  It  is  stated  that  cows  giving  milk  do  not  themselves  show 
marked  symptoms  unless  driven  rapidly,  and,  according  to  Graff,  the  secre- 
tion may  be  infective  when  the  disease  is  latent.  "When  a  cow  is  very  ill, 
food  is  refused,  the  eyes  are  injected,  the  animal  staggers,  the  entire  mus- 
cular svstem  trembles,  and  death  occurs  in  convulsions,  sometimes  with 
great  suddenness.  Xothing  definite  is  known  as  to  the  cause  of  the  dis- 
ease.   It  is  most  frequent  in  new  settlements. ' 


INFECTIOUS  DISEASES  OP  DOUBTFUL  NATURE.  345 

In  man  the  symptoms  are  those  of  a  more  or  less  acute  intoxication. 
After  a  few  days  of  uneasiness  and  distress  the  patient  is  seized  with  pains 
in  the  stomach,  nausea  and  vomiting,  fever  and  intense  thirst.  There  is 
usually  obstinate  constipation.  The  tongue  is  swollen  and  tremulous,  the 
breath  is  extremely  foul  and,  according  to  Graff,  is  as  characteristic  of  the 
disease  as  is  the  odor  in  small-pox.  Cerebral  s3rmptoms — restlessness,  irri- 
tability, coma,  and  convulsions — are  sometimes  marked,  and  there  may 
gradually  be  produced  a  typhoid  state  in  which  the  patient  dies. 

The  duration  of  the  disease  is  variable.  In  the  most  acute  forms  death 
occurs  within  two  or  three  days.  It  may  last  for  ten  days,  or  even  for 
three  or  four  weeks.  Graff  states  that  insanity  occurred  in  one  case.  The 
poisonous  nature  of  the  flesh  and  of  the  milk  has  been  demonstrated  ex- 
perimentally. An  ounce  of  butter  or  cheese,  or  four  ounces  of  the  beef, 
raw  or  boiled,  given  three  times  a  day,  will  kill  a  dog  within  six  days.  No 
definite  pathological  lesions  are  known.  Fortunately,  the  disease  has  be- 
come rare,  and  the  observation  of  Drake,  Yandell,  and  others,  that  it 
gradually  disappears  with  the  clearing  of  the  forests  and  improved 
tillage,  has  been  amply  substantiated.  It  still  prevails  in  parts  of  North 
Carolina. 

(4)  GLANDULAR  FEVER. 

DeiinitioiL. — An  infectious  disease  of  children,  developing,  as  a  rule, 
without  premonitory  signs,  and  characterized  by  slight  redness  of  the 
throat,  high  fever,  swelling  and  tenderness  of  the  lymph-glands  of  the  neck, 
particularly  those  behind  the  sterno-cleido-mastoid  muscles.  The  fever  is 
of  short  duration,  but  the  enlargement  of  the  glands  persists  for  from 
ten  days  to  three  weeks. 

In  children  acute  adenitis  of  the  cervical  and  other  glands  with  fever 
has  been  noted  by  many  observers,  but  Pfeiffer  in  1889  called  special 
attention  to  it  under  the  name  of  Druesenfieber.  He  described  it  as  an 
infectious  disease  of  young  children  between  the  ages  of  five  and  eight 
years,  characterized  by  the  above-mentioned  symptoms.  Since  Pfeiffer's 
paper  a  good  deal  of  work  has  been  done  in  connection  with  the  subject, 
and  in  this  country  West  and  Hamill,  and  in  England  Dawson  Williams, 
have  more  particularly  emphasized  the  condition. 

Etiology. — It  may  occur  in  epidemic  form.  West,  of  Bellaire,  Ohio,  ^v/ 
describes  an  epidemic  of  96  cases  in  children  between  the  ages  of  seven  /\ 
months  and  thirteen  years.  Bilateral  swelling  of  the  carotid  lymph-glands 
was  a  most  marked  feature.  In  three  fourths  of  the  cases  the  post-cervical, 
inguinal,  and  axillary  glands  were  involved.  The  mesenteric  glands  were 
felt  in  37  cases,  the  spleen  was  enlarged  in  57,  and  the  liver  in  87  cases. 
Coryza  was  not  present,  and  there  were  no  bronchial  or  pulmonary  symp- 
toms. Cases  occurred  between  the  months  of  October  and  June. '  The 
nature  of  the  infection  has  not  been  determined. 

Symptoms. — The  onset  is  sudden  and  the  first  complaint  is  of  pain 
on  moving  the  head  and  neck.  There  mav  be  nausea  arid  vomitinor  and 
abdominal  pain.  The  temperature  ranges  from  101°  to  103°.  The  tonsils 
may  be  a  little  red  and  the  lymphatic  tissues  swollen,  but  the  throat  symp- 


34:6  SPECIFIC  INFECTIOUS  DISEASES. 

toms  are  quite  transient  and  unimportant.  On  the  second  or  third  day 
the  enlarged  glands  aj^pear^  and  during  the  course  they  vary  in  size  from  a 
pea  to  a  goose-egg.  They  are  painful  to  the  touch,  but  there  is  rarely  any 
redness  or  swelling  of  the  skin,  though  at  times  there  is  some  puffin  ess  of 
the  subcutaneous  tissues  of  the  neck,  and  there  may  be  a  little  difficulty  in 
swallowing.  In  some  instances  there  has  been  discomfort  in  the  chest  and 
a  paroxj'smal  cough,  indicating  inYolvement  of  the  tracheal  and  bronchial 
glands.  The  swelling  of  the  glands  persists  for  from  two  to  three  weeks. 
Among  the  serious  features  of  the  disease  are  the  termination  of  the 
adenitis  in  suppuration,  which  seems  rare  (though  Xeumann  has  met  with 
it  in  13  cases),  and  hemorrhagic  nephritis.  Acute  otitis  media  and  retro- 
pharyngeal abscess  have  also  been  reported. 

The  outlook  is  favorable.  West  suggests  the  use  of  small  doses  of  calo- 
mel during  the  height  of  the  trouble. 

(5)  MOTTNTArN"  FEVER— MOUNTAIN  SICKNESS. 

Several  distinct  diseases  have  been  described  as  mountain  fever.  An 
important  group,  the  mountain  ancemia,  is  associated  with  the  ancJiylostoma, 
which  has  not  yet  been  met  with  in  this  countr5^  A  second  group  of  cases 
belongs  to  typhoid  fever;  and  instances  of  this  disease  occurring  in  moun- 
tainous regions  in  the  "Western  States  are  referred  to  as  mountain  fever. 
The  observations  of  Hoff  and  Smart,  and  more  recently  of  Woodruff  and  of 
Raymond,  show  that  the  disease  is  typhoid  fever, 

Becently  C.  E.  Woodruff,  of  the  army,  has  reported  a  group  of  35  cases 
at  Fort  Custer,  which,  as  he  says,  would  certainly  have  been  described  as 
mountain  fever,  but  in  which  the  clinical  features  and  the  Widal  reaction 
showed  there  was  no  question  that  they  were  typhoid.  Eaymond,  too,  re- 
cently called  attention  to  the  existence  of  typhoid  fever  in  Wyoming  among 
the  Indians  in  the  reservation  and  the  soldiers  at  the  post.  It  would  be 
well,  I  think,  for  the  use  of  the  term  mountain  fever  to  be  discontinued. 

Mountain  sicl-ness  comprises  the  remarkable  group  of  phenomena  which 
develop  in  very  high  altitudes.  The  condition  has  been  very  accurately  de- 
scribed by  ]\Ir.  Whymper.  In  the  ascent  of  Chimborazo  they  were  first 
affected  at  a  height  of  16,66-1  feet.  The  s3TQptoms  were  severe  headache, 
gasping  for  breath,  evidently  urgent  lesoin  de  respirer.  The  throat  was 
parched,  and  there  was  intense  thirst,  loss  of  appetite,  and  an  intense 
malaise.  Mr.  Whymper's  temperature  was  100.4°.  The  s}Triptoms  in  his 
case  lasted  for  nearly  three  days.  In  a  less  aggravated  form  such  symp- 
toms may  present  themselves  at  much  lower  levels,  and  in  the  ascent  of  the 
railroad  at  Pike's  Peak  many  persons  suffer  from  distress  in  breathing.  The 
original  cases  described  by  General  Fremont  were  of  this  nature.  A  very 
full  description  is  given  by  Allbutt  in  vol.  iii  of  his  System. 

(6)  MILIARY  FEVER— SWEATING  SICKNESS. 

The  disease  is  characterized  by  fever,  profuse  sweats,  and  an  eruption 
of  miliary  vesicles.  It  prevailed  and  was  very  fatal  in  England  in  the 
fifteenth   and   sixteenth   centuries,   but    of   late   years   it   has   been   con- 


IKPECTIOUS  DISEASES  OP  DOUBTFUL  NATURE.  347 

fined  entirely  to  certain  districts  in  France  (Picardy)  and  Italy.  An  epi- 
demic of  some  extent  occurred  in  France  in  1887.  Hirsch  gives  a  chrono- 
logical account  of  194  epidemics  between  1718  and  1879,  many  of  which 
were  limited  to  a  single  village  or  to  a  few  localities.  Occasionally  the  dis- 
ease has  become  widely  spread.  Slight  epidemics  have  occurred  in  Ger- 
many and  Switzerland.  Within  the  past  few  years  there  have  been  several 
small  outbreaks  in  Austria.  They  are  usually  of  short  duration,  lasting  only 
for  three  or  four  weeks — sometimes  not  more  than  seven  or  eight  days. 
As  in  influenza,  a  very  large  number  of  persons  are  attacked  in  rapid  suc- 
cession. In  the  mild  cases  there  is  only  slight  fever,  with  loss  of  appetite, 
an  erythematous  eruption,  profuse  perspiration,  and  an  outbreak  of  miliary 
vesicles.  The  severe  cases  present  the  symptoms  of  intense  infection — de- 
lirium, high  fever,  profound  prostration,  and  haemorrhage.  The  death- 
rate  at  the  outset  of  the  disease  is  usually  high,  and,  as  is  so  graphically 
described  in  the  account  of  some  of  the  epidemics  of  the  middle  ages,  death 
may  occur  in  a  few  hours.  The  most  recent  and  the  fullest  account  of  the 
disease  is  given  in  Nothnagel's  Handbuch  by  Immermann. 

(7)  FOOT  AND  MOUTH  DISEASE— EPIDEMIC  STOMATITIS— 
APHTHOUS  FEVER. 

Foot  and  mouth  disease  is  an  acute  infectious  disorder  met  with  chiefly 
in  cattle,  sheep,  and  pigs,  but  attacking  other  domestic  animals.  It  is  of 
extraordinary  activity,  and  spreads  with  "  lightning  rapidity "  over  vast 
territories,  causing  very  serious  losses.  In  cattle,  after  a  period  of  incuba- 
tion of  three  or  five  days,  the  animal  gets  feverish,  the  mucous  membrane 
of  the  mouth  swells,  and  little  grayish  vesicles  the  size  of  a  hemp  seed 
begin  to  develop  on  the  edges  and  lower  portion  of  the  tongue,  on  the 
gums,  and  on  the  mucous  membrane  of  the  lips.  They  contain  at  first  a 
clear  fluid,  which  becomes  turbid,  and  then  they  enlarge  and  gradually 
become  converted  into  superficial  ulcers.  There  is  ptyalism,  and  the  ani- 
mals lose  flesh  rapidly.  In  the  cow  the  disease  is  also  frequently  seen 
abouf  the  udder  and  teats,  and  the  milk  becomes  yellowish-white  in  color 
and  of  a  mucoid  consistency. 

The  transmission  to  man  is  by  no  means  uncommon,  and  of  late  sev- 
eral important  epidemics  have  been  studied  in  the  neighborhood  of  Berlin. 
Dr.  Salmon  informs  me  that  in  the  United  States  foot  and  mouth  dis- 
ease has  very  rarely  occurred,  but  in  1870,  as  well  as  in  1841,  it  was 
communicated  in  a  few  instances  to  man.  In  Zuill's  translation  of  Fried- 
berger  and  Frohner's  Pathology  and  Therapeutics  of  Domestic  Animals 
(Philadelphia,  1895)  the  disease  is  thus  described:  "Transmission  of 
aphthous  fever  to  man  is  not  rare.  The  veterinarian  has  oftener  occasion 
to  observe  it  than  the  physician.  The  use  of  milk  from  aphthous  cows 
contaminates  children  quite  frequently  and  is  fatal  to  them.  This  may 
also  happen  through  ingestion  of  butter  or  cheese  made  of  milk  coming 
from  aphthous  animals,  or  also  directly  through  wounds  of  the  arms,  hands, 
or  by  intermcfliary  agents.  In  man  the  symptoms  are:  fever,  digestive 
troubles,  and  vesicular  eruption  upon  the  lips,  the  buccal  and  pharyngeal 

122 


348  SPECIFIC  INFECTIOUS  DISEASES. 

mucous  membranes  (angina).  The  disease  does  not  seem  to  be  trans- 
missible through  the  meat  of  diseased  animals.  Perhaps  the  serious  affec- 
tions of  the  skin  which  were  observed  to  develop  in  children  after  vaccina- 
tion (especially  in  1883-'84)  may  have  been  determined  by  mistaking  the 
mammary  eruption  of  aphthous  fever  for  cow-pox." 

In  widespread  epidemics  there  has  been  sometimes  a  marked  tendency 
to  haemorrhages.  The  disease  runs,  as  a  rule,  a  favorable  course,  but  in 
SiegeFs  report  of  a  recent  epidemic  the  mortality  was  8  per  cent. 

Of  great  biological  interest  is  Loffler's  demonstration  that  the  lymph 
from  the  vesicles  of  foot-and-mouth  disease  retains  its  full  virulence  after 
filtration  through  unglazed  porcelain,  the  pores  of  which  are  so  minute  as 
to  prevent  the  passage  of  the  smallest  known  bacteria.  He  concludes  that 
the  micro-organism  is  beyond  the  existing  powers  of  microscopic  vision. 
Loffler  has  devised  a  method  of  vaccinating  animals  against  this  disease. 

Wlien  epidemics  are  prevailing  in  cattle  the  milk  should  be  boiled, 
and  the  proper  prophylactic  measures  taken  to  isolate  both  the  cattle  and 
the  individuals  who  come  in  contact  with  them. 


SECTION  II. 
DISEASES  DUE  TO  AI^IMAL  PARASITES. 


I.    PSOROSPERMIASIS. 

Under  this  term  are  embraced  several  affections  produced  by  the  spo- 
rozoa.  These  parasites,  belonging  to  the  protozoa,  are  also  known  as  psoro- 
sperms  and  gregarinidae.  They  are  extraordinarily  abundant  in  the  in- 
vertebrates, and  are  not  uncommon  in  the  higher  mammals.  The  entire 
group  of  blood  parasites,  hsematozoa,  which  live  within  the  corpuscles,  are 
closely  related  to  them.  Psorosperms  are,  as  a  rule,  parasites  of  the  cells 
— Cytozoa.  The  commonest  and  most  suitable  variety  for  study  is  the 
Coccidium  oviforme  of  the  rabbit,  which  produces  a  disease  of  the  liver  in 
which  the  organ  is  studded  throughout  with  whitish  nodules,  ranging  in 
size  from  a  pin's  head  to  a  split  pea.  On  section  each  nodule  is  seen  to  be 
a  dilated  portion  of  a  bile-duct;  the  walls  are  lined  with  epithelium  in  the 
interior  of  which  are  multitudes  of  ovoid  bodies — the  coccidia.  Another 
very  common  form  occurs  in  the  muscles  of  the  pig,  the  so-called  Eainey's 
tube,  which  is  an  ovoid  body  within  the  sarcolemma  containing  a  number 
of  small,  sickle-shaped,  unicellular  organisms,  the  Sarcocystis  miescheri.  An- 
other species,  the  S.  Jiominis,  has  been  described  in  man. 

These  bodies  probably  play  a  more  important  role  in  human  pathology 
than  has  hitherto  been  thought.  The  cases  reported  may  be  grouped  under 
the  following  divisions:  internal  and  external. 

(1)  Internal  Psorospermiasis. — In  a  majority  of  the  cases  of  this  group 
the  psorosperms  have  been  found  in  the  liver,  producing  a  disease  similar 
to  that  which  occurs  in  rabbits.  In  Guebler's  case  there  were  tumors 
which  could  be  felt  in  the  liver  during  life,  and  they  were  determined  by 
Leuckart  to  be  due  to  coccidia.  In  W.  B.  Haddon's  case  the  patient  was 
admitted  to  St.  Thomas's  Hospital  with  slight  fever  and  drowsiness;  he 
gradually  became  unconscious;  death  occurred  on  the  fourteenth  day  of 
observation.  Whitish  neoplasms  were  found  upon  the  peritoneum,  omen- 
tum, and  on  the  layers  of  the  pericardium;  and  a  few  were  found  in  the 
liver,  spleen,  and  kidneys.  A  somewhat  similar  case,  though  more  remark- 
able, as  it  ran  a  very  acute  course,  is  reported  by  Silcott.  A  woman,  aged 
fifty-three,  admitted  to  St.  Mary's  Hospital,  was  thought  to  be  suffering  from 
typhoid  fever.    She  had  had  a  chill  six  weeks  before  admission.    There  were 

349 


350  DISEASES  DUE  TO  ANIMAL  PARASITES. 

fever  of  an  intermittent  type,  slight  diarrhcEa,  nausea,  tenderness  over  the 
liver  and  spleen,  and  a  dry  tongue;  death  occurred  from  heart-failure.  The 
liver  was  enlarged,  weighed  83  ounces,  and  in  its  substance  there  were  case- 
ous foci,  around  each  of  which  was  a  ring  of  congestion.  The  spleen 
weighed  16  ounces  and  contained  similar  bodies.  The  ileum  presented  six 
papule-like  elevations.  The  masses  resembled  tubercles,  but  on  examina- 
tion coccidia  were  found. 

The  parasites  are  also  found  in  the  kidneys  and  ureters.  Cases  of  this 
kind  have  been  recorded  by  Bland  Sutton  and  Paul  Eve.  In  Eve's  case 
the  symptoms  were  haematuria  and  frequent  micturition,  and  death  took 
place  on  the  seventeenth  day.  The  nodules  throughout  the  pelvis  and 
ureters  have  been  regarded  as  mucous  cysts.  In  a  case  reported  by  Joseph 
Griffiths  the  tumors  in  the  ureter  caused  hydronephrosis. 

(2)  Cutaneous  Psorospermiasis. — The  parasitic  nature  of  the  keratosis 
follicularis  of  White,  and  of  Paget's  disease  of  the  nipple,  which  seemed 
to  have  been  established,  has  been  called  in  question,  and  the  bodies  de- 
scribed as  psorosperms  are  believed  to  be  the  result  of  epithelial  degenera- 
tion. So,  too,  in  molluscum  contagiosum  and  in  epithelioma,  the  nature 
of  the  structures  which  lie  in  and  between  the  epithelial  cells,  and  which 
have  some  resemblance  to  psorosperms,  is  still  unsettled;  some  claiming 
that  they  are  truly  parasitic,  others  affirming  that  they  are  nothing  but 
altered  protoplasm  of  the  epithelial  cells. 

There  are  several  undoubted  instances,  however,  of  parasitic  sporozoa 
producing  extensive  disease  of  the  skin.  In  Wernicke's  case  (from  Buenos 
Ayres)  the  lesions  were  scattered  over  the  face,  trunk,  and  left  thigh.  The 
sporozoa  were  found  in  numbers  in  the  pus  of  the  skin  lesions,  and  also 
in  the  inguinal  glands,  which  were  excised. 

Eixford  and  Gilchrist  describe  two  cases  (Johns  Hopkins  Hospital  Ee- 
ports,  vol.  i).  In  the  first  case,  which  was  regarded  as  tuberculosis  of  the 
skin,  the  lesion  remained  local  for  nearly  eight  years.  The  lymphatic  glands 
then  became  involved.  The  affection  gradually  attacked  the  nose,  cheeks, 
and  other  parts  of  the  head,  the  left  hand,  the  leg,  and  the  left  testicle. 
For  seven  or  eight  years  the  patient  had  no  constitutional  symptoms,  but 
after  the  glands  became  involved  an  intermittent  fever  developed.  In  the 
later  stages  he  had  a  cough  with,  purulent  expectoration.  The  autopsy 
revealed  what  appeared  to  be  tuberculosis  of  the  lungs,  adrenals,  and  testis. 
There  were  numerous  tuberculous-looking  nodules  in  the  spleen,  on  the 
surface  of  the  liver,  and  the  pleurae.  In  all  of  the  lesions  enormous  numbers 
of  sporozoa  were  found,  especially  in  the  caseous  masses.  Successful  inocu- 
lations were  made  into  rabbits  and  dogs.  The  second  case  was  similar,  but 
much  more  acute.  There  were  thirty  skin  lesions  distributed  over  the 
body.  The  patient  died  within  three  months  after  the  appearance  of  the 
initial  lesion.  In  an  excised  lymph-gland  enormous  numbers  of  sporozoa 
were  found.  The  cycle  of  development  was  readily  followed.  These  bodies 
differ  in  all  points  from  those  described  as  protozoa  in  cancer  and  in  mol- 
luscum contagiosum. 

Two  of  the  most  important  protozoon  diseases — namely,  amoebic  dys- 
entery and  malaria — have  been  described. 


DISTOMIASIS.  351 


II.    PARASITIC    INFUSORIA. 


Several  flagellates  have  been  found  parasitic  in  man.  Among  the  most 
common  are  the  Tricliomonas  vaginalis,  which  measures  15  to  35  /*  in 
length,  and  has  four  flagella,  which  are  as  long  as  or  longer  than  the  body. 
It  is  by  no  means  an  uncommon  parasite  in  the  acid  vaginal  mucus. 

The  Tricliomonas  or  Cercomonas  hominis  lives  in  the  intestines,  and 
is  met  with  in  the  stools  under  all  sorts  of  conditions.  It  is  probably  not 
imthogenic.  I  have  seen  it  also  in  the  vomit  in  a  case  of  chronic  gastric 
catarrh.  Trichomonads  have  been  niet  with  also  in  the  urine  in  several 
cases,  and  may  be  truly  pathogenic.  In  Dock's  *  case  the  parasites  were 
associated  with  a  hsemorrhagic  cystitis  without  bacteria. 

The  Lamblia  intestinalis  is  another  intestinal  monad,  larger  than  the 
common  Trichomonas.  Flagellates  have  also  been  found  in  the  expec- 
toration in  cases  of  gangrene  of  the  lung  and  of  bronchiectasis,  and  in 
pleurisy. 

Among  the  parasitic  Ciliata  may  be  mentioned  the  Balantidium  coli, 
which  has  been  found  occasionally  in  the  large  intestine  in  forms  of  dys- 
entery. The  parasite  is  oval  in  form,  70  to  100  jx  long  and  50  to  70  /a  broad. 
It  is  doubtful  whether  it  is  pathogenic. 

III.    DISTOMIASIS. 

Several  forms  of  trematodes  or  flukes  are  parasitic  in  man,  and  when 
in  numbers  may  cause  serious  disease. 

(1)  Liver  Flukes. — The  following  species  of  flukes  have  been  found: 
The  Fasciola  liepatica,  a  very  common  parasite  in  ruminants,  which  has  a 
length  of  from  28  to  32  mm.  The  Distonium  lanceolatum,  a  much  smaller 
forfn,  from  8  to  10  mm.  in  length,  which  is  also  very  common  in  sheep  and 
cattle.  The  Distoma  husJd,  the  largest  form,  measuring  from  4  to  8  cm. 
in  length.  One  or  two  other  less  important  forms  have  occasionally  been 
met  with.  The  studies  of  the  Japanese  physicians  have  brought  to  light 
the  interesting  fact  that  there  is  a  distoma  widely  endemic  in  certain  prov- 
inces in  that  country.  The  two  forms  described  as  Distoma  endeniicum  and 
Distoma  perniciosum  are  identical,  and  are  known  now  as  Distoma  sinense. 
According  to  Baelz,  fully  20  per  cent  of  the  inhabitants  of  certain  provinces 
are  aff'ected.  The  Distoma  felineum,  which  has  been  found  recently  in  this 
country  by  Ward,  of  Nebraska,  in  cats,  is  a  common  human  parasite  in 
Siberia. 

The  flukes  occupy  the  bile-passages  and  the  upper  portion  of  the  small 
intestine.  When  in  large  numbers  they  may  cause  serious  and  fatal  dis- 
ease of  the  liver,  usually  with  ascites  and  jaundice.  The  liver  may  be  enor- 
mously enlarged;  in  Kichner's  case  it  weighed  11  pounds.  The  flukes  may 
cause  a  chronic  cholangitis,  leading  to  great  thickening  or  even  calcifica- 
tion of  the  walls  of  the  bile-duct.  The  ova  have  been  found  in  the  stools. 
Occasionally  the  distomcs  arc  found  under  the  skin. 


•  American  Journal  of  the  Medical  Sciences,  January,  1896. 


352  DISEASES  DUE  TO  ANIMAL  PARASITES. 

The  endemic  fluke  disease  of  Japan  is  characterized  by  enlargement  of 
the  liver,  emaciation,  diarrhoea,  and  frequently  ascites. 

(2)  The  Blood  Fluke;  Schistosoma  hcematohium  {Bilharzia  hcematohia). 
— This  trematode  is  found  in  Egypt,  southern  Africa,  and  Arabia,  and  is 
the  cause  in  these  countries  of  the  endemic  hsematuria.  The  female  is 
about  2  cm.  in  length,  cylindrical,  filiform,  and  about  0.07  mm.  in  diame- 
ter. The  parasite  lives  in  the  venous  system,  particularly  in  the  portal 
vein,  and  in  the  veins  of  the  spleen,  bladder,  kidneys,  and  mesentery.  Ac- 
cording to  Bilharz,  at  least  50  per  cent  of  the  lower  classes  in  Egypt  are 
infected  with  it.  It  is  not  yet  known  how  the  parasite  gains  entrance  to 
the  body.  In  all  probability  it  is  by  drinking  impure  water  containing  the 
embryos. 

The  symptoms  are  due  to  changes  in  the  mucous  membrane  of  the 
urinary  organs  caused  by  the  presence  of  the  ova  in  the  blood-vessels  of 
these  parts.  Hsematuria  is  the  first  and  most  constant  symptom,  leading 
gradually  to  angemia.  There  is  generally  pain  during  micturition.  The 
blood  is  not  constant  in  the  urine.  The  ova  of  the  Bilharzia  are  readily 
seen  under  a  microscope  with  a  low  power.  They  are  ovoid  in  shape, 
translucent,  with  a  small  spike  at  one  end.  They  may  be  widely  distributed 
in  the  body — in  the  submucosa  of  the  bowel,  in  polypoid  excrescences  in 
the  rectum,  in  the  lungs  and  elsewhere. 

The  disease  is  rarely  fatal;  a  great  majority  of  the  cases  recover.  Chil- 
dren are  more  commonly  attacked  than  grown  persons,  and  the  disease 
often  disappears  by  the  time  of  puberty. 

(3)  Bronchial  Fluke;  Distomum  Westermanni;  Parasitic  Hcemoptysis. — 
In  parts  of  China,  Japan,  and  Formosa  there  is  an  epidemic  disease,  de- 
scribed by  Einger  and  Manson,  characterized  by  attacks  of  cough  and 
haemoptysis  associated  with  the  presence  of  a  small  fluke  in  the  bronchial 
tubes. 

IV.    DISEASES    CAUSED    BY  NEMATODES. 

I.    ASCAHIASIS. 

(a)  Ascaris  lumbricoides,  the  most  common  human  parasite,  is  found 
chiefly  in  children.  The  female  is  from  7  to  12  inches  in  length,  the  male 
from  4  to  8  inches.  In  form  it  is  cylindrical,  being  pointed  at  both  ends;  it 
has  a  yellowish-brown,  sometimes  a  slightly  reddish  color.  Four  longitudinal 
bands  can  be  seen,  and  it  is  striated  transversely.  The  ova,  which  are 
sometimes  found  in  large  numbers  in  the  fseces,  are  small,  brownish-red 
in  color,  elliptical,  and  have  a  very  thick  covering.  They  measure  0.075 
mm.  in  length  and  0.058  mm.  in  width.  The  life  history  has  been  demon- 
strated to  be  "  direct " — i.  e.,  without  intermediate  host.  The  parasite 
occupies  the  upper  portion  of  the  small  intestine.  Usually  not  more  than 
one  or  two  are  present,  but  occasionally  they  occur  in  enormous  numbers. 
The  migrations  are  peculiar.  They  may  pass  into  the  stomach,  whence 
they  may  be  ejected  by  vomiting,  or  they  may  crawl  up  the  oesophagus 
and  enter  the  pharynx,  from  which  they  may  be  withdrawn.  A  child  under 
my  care  in  the  small-pox  department  of  the  General  Hospital,  during  con- 


DISEASES  CAUSED  BY  NEMATODES.  353 

valescence,  withdrew  in  this  way  more  than  thirty  round  worms  within  a 
few  weeks.  In  other  instances  the  worm  reaches  the  larynx,  and  has  been 
known  to  produce  fatal  asphyxia,  or,  passing  into  the  trachea,  to  cause 
gangrene  of  the  lung.  They  may  go  through  the  Eustachian  tube  and  appear 
at  the  external  meatus.  The  most  serious  migration  is  into  the  bile-duct. 
There  is  a  specimen  in  the  Wistar-Horner  Museum  of  the  University  of 
Pennsylvania  in  which  not  only  the  common  duct,  but  also  the  main 
branches  throughout  the  liver,  are  enormously  distended  and  packed  with 
numerous  round  worms.  The  bowel  may  be  blocked,  or  in  rare  instances  an 
ulcer  may  be  perforated.  Even  the  healthy  bowel  wall  may  be  penetrated 
(Apostolides). 

A  peculiarly  irritating  substance,  often  evident  to  the  sense  of  smell  in 
handling  specimens,  is  formed  by  the  round  worms.  Peiper  and  others 
suggest  that  the  nervous  symptoms,  sometimes  resembling  those  of  menin- 
gitis, are  due  to  this  poison.  Chauffard,  Marie,  and  Tauchon  have  gone  still 
further,  and  report  a  remarkable  condition  of  fever,  intestinal  symptoms, 
foul  breath,  and  intermittent  diarrhoea  in  connection  with  the  presence  of 
lumbricoides.  They  call  it  typho-lumbricosis.  The  febrile  condition  may 
continue  for  a  month  or  more.  The  symptoms  are  supposed  to  be  excited 
reflexly,  or  to  be  due  to  the  virulence  of  the  ascarides  themselves.  It  does 
not  seem  to  me  a  very  clearly  defined  condition,  and  when  one  considers 
the  extraordinary  frequency  of  lumbricoid  worms  and  the  remarkable  num- 
ber which  may  be  harbored  without  causing  any  special  trouble,  I  think  we 
require  more  evidence  before  we  accept  the  conclusions  of  these  authors. 

The  symptoms  are  not  definite.  When  a  few  parasites  are  present  they 
may  be  passed  without  causing  disturbance.  In  children  there  are  irritative 
symptoms  usually  attributed  to  worms,  such  as  restlessness,  irritability, 
picking  at  the  nose,  grinding  of  the  teeth,  twitchings,  or  convulsions.  These 
symptoms  may  be  marked  in  very  nervous  children. 

Treatment. — Santonin  can  be  given,  mixed  with  sugar,  in  doses  of 
from  one  half  to  one  grain  for  a  child  and  two  to  three  grains  for  an  adult, 
followed  by  a  calomel  or  a  saline  purge.  The  dose  may  be  given  for  three 
or  four  days.  An  unpleasant  consequence  which  sometimes  follows  the 
administration  of  this  drug  is  xanthopsia  or  yellow  vision. 

(h)  Oxyuris  vermicularis  (Thread-worm;  Pin-worm). — This  common 
parasite  occupies  the  rectum  and  colon.  The  male  measures  about  4  mm. 
in  length,  the  female  about  10  mm.  They  produce  great  irritation  and 
itching,  particularly  at  night,  symptoms  which  become  intensely  aggravated 
by  the  nocturnal  migration  of  the  parasites.  Occasionally  peri-rectal  ab- 
scesses are  formed,  containing  numbers  of  the  worms. 

The  patients  become  extremely  restless  and  irritable,  the  sleep  is  often 
disturbed,  and  there  may  be  loss  of  appetite  and  ansemia.  Though  most 
common  in  children,  the  parasite  occurs  at  all  ages. 

The  worm  is  readily  detected  in  the  fasces.  Infection  probably  takes 
place  through  the  water  or  possibly  through  salads,  such  as  lettuce  and 
cresses.  A  person  the  subject  of  the  worms  passes  ova  in  large  numbers 
in  the  fjeces,  and  the  possibility  of  reinfection  must  be  scrupulously 
guarded  against. 


354:  DISEASES  DUE  TO  ANIMAL  PAEASITES. 

The  treatment  is  simple,  though  occasionally  there  are  instances  in 
which  all  forms  of  medication  are  resisted.  A  case  is  mentioned  of  a  gen- 
~  tleman,  aged  forty,  who  had  suffered  from  childhood  and  had  failed  to 
obtain  any  benefit  from  prolonged  treatment  by  many  helminthologists. 
I  have  reported  a  case  of  several  years^  duration.  Santonin  may  be  used 
in  small  doses,  and  mild  purgatives,  particularly  rhubarb.  Large  injec- 
tions containing  carbolic  acid,  vinegar,  quassia,  aloes,  or  turpentine  may 
be  employed.  In  children  the  use  of  cold  injections  of  strong  salt  and 
water  is  usually  efficacious.  They  should  be  repeated  for  at  least  ten  days. 
In  giving  the  injection  care  should  be  taken  to  have  the  hips  well  elevated, 
so  that  the  fluid  can  be  retained  as  long  as  possible.  For  the  intense  itch- 
ing and  irritation  at  night  vaseline  may  be  freely  used,  or  belladonna  oint- 
ment. 

II.  Teichiniasis. 

The  Trichina  spiralis  in  its  adult  condition  lives  in  the  small  intes- 
tine. The  disease  is  produced  by  the  embryos,  which  pass  from  the  intes- 
tines and  reach  the  voluntary  muscles,  where  they  finally  become  encap- 
sulated larvae — muscle  trichinae.  It  is  in  the  migration  of  the  embryos 
(possibly  from  poisons  produced  by  them)  that  the  group  of  symptoms 
known  as  trichinasis  is  produced. 

Description  of  the  Parasites. — (a)  Adult  or  intestinal  form.  The  female 
measures  from  3  to  4  mm.;  the  male,  1.5  mm.,  and  has  two  little  projections 
from  the  hinder  end. 

(h)  The  larva  or  muscle  trichina  is  from  0.6  to  1  mm.  in  length  and  lies^ 
coiled  in  an  ovoid  capsule,  which  is  at  first  translucent,  but  subsequently 
opaque  and  infiltrated  with  lime  salts.  The  worm  presents  a  pointed  head 
and  a  somewhat  rounded  tail. 

When  flesh  containing  the  trichinae  is  eaten  by  man  or  by  any  ani- 
mal in  which  the  development  can  take  place,  the  capsules  are  digested 
and  the  trichinae  set  free.  They  pass  into  the  small  intestine,  and  about 
the  third  day  attain  their  full  growth  and  become  sexually  mature.  Vir- 
chow's  experiments  have  shown  that  on  the  sixth  or  seventh  day  the  em- 
bryos are  fully  developed.  The  young  produced  by  each  female  trichina 
have  been  estimated  at  several  hundred.  Leuckart  thinks  that  various 
broods  are  developed  in  succession,  and  that  as  many  as  a  thousand  em- 
bryos may  be  produced  by  a  single  worm.  The  time  from  the  ingestion 
of  the  flesh  containing  the  muscle  trichinae  to  the  development  of  the 
brood  of  embryos  in  the  intestines  is  from  seven  to  nine  days.  The 
female  worm  penetrates  the  intestinal  wall  and  the  embryos  are  probably 
discharged  directly  into  the  lymph  spaces  (Askanazy),  thence  into  the 
venous  system,  and  by  the  blood  stream  to  the  muscles,  which  constitute 
their  seat  of  election.  Dr.  J.  Y.  Graham,  of  the  University  of  Alabama, 
has  recently  reviewed  the  question  of  the  mode  of  transmission  in  an  ex- 
haustive monograph,  and  he  gives  strong  arguments  in  favor  of  the  trans- 
mission through  the  blood  stream.  After  a  preliminary  migration  in  the 
intermuscular  connective  tissue  they  penetrate  the  primitive  muscle-fibres, 
and  in  about  two  weeks  develop  into  the  full-grown  muscle  form.    In  this 


DISEASES  CAUSED  BY  NEMATODES.  355 

process  an  interstitial  myositis  is  excited  and  gradually  an  ovoid  capsule 
develops  about  the  parasite.  Two,  occasionally  three  or  four,  worms  may 
be  seen  within  a  single  capsule.  This  process  of  encapsulation  has  been 
estimated  to  take  about  six  weeks.  Within  the  muscles  the  parasites  do 
not  undergo  further  development.  Gradually  the  capsule  becomes  thicker, 
and  ultimately  lime  salts  are  deposited  within  it.  This  change  may  take 
place  in  man  within  four  or  five  months.  In  the  hog  it  may  be  deferred 
for  many  years.  The  calcification  renders  the  cyst  visible,  and  since  first 
seen  by  Tiedemann,  in  1822,  and  Hilton,  in  1832,  these  small,  opaque,  oat- 
shaped  bodies  have  been  familiar  objects  to  demonstrators  of  normal  and 
morbid  anatomy.  The  trichinge  may  live  within  the  muscles  for  an  indefi- 
nite period.  They  have  been  found  alive  and  capable  of  developing  as  late 
as  twenty  or  even  twenty-five  years  after  their  entrance  into  the  system. 
In  many  instances,  however,  the  worms  are  completely  calcified.  The 
trichina  has  been  found  or  "  raised  "  in  twenty-six  different  species  of  ani- 
mals (Stiles).  Medical  literature  abounds  in  references  to  its  presence  in 
fish,  earthworms,  etc.,  but  these  parasites  belong  to  other  genera.  In 
faecal  examinations  for  the  parasite  it  is  well  to  remember  that  the  "  cell 
body''  of  the  anterior  portion  of  the  intestine  is  a  diagnostic  criterion  of 
the  T.  spiralis.  It  was  first  found  in  the  hog  by  the  late  Joseph  Leidy. 
Experimentally,  guinea-pigs  and  rabbits  are  readily  infected  by  feeding 
them  with  muscle  containing  the  larval  form.  Dogs  are  infected  with 
difficulty;  cats  more  readily.  Experimentally,  animals  sometimes  die  of 
the  disease  if  large  numbers  of  the  parasites  have  been  eaten.  In  the  hog 
the  trichinge,  like  the  cysticerci,  cause  few  if  any  symptoms.  An  animal 
the  muscles  of  which  are  swarming  with  living  trichinae  may  be  well  nour- 
ished and  healthy-looking.  An  important  point  also  is  the  fact  that  in 
the  hog  the  capsule  does  not  readily  become  calcified,  so  that  the  parasites 
are  not  visible  as  in  the  human  muscles.  For  a  long  time  the  trichina  was 
looked  upon  as  a  pathological  curiosity,  but  in  1860  Zenker  discovered  in 
a  girl  in  the  Dresden  Hospital,  who  had  symptoms  of  typhoid  fever,  both 
the  intestinal  and  the  muscle  forms  of  the  trichinae,  since  which  time  the 
disease  has  been  thoroughly  studied. 

Man  is  infected  by  eating  the  flesh  of  trichinous  hogs.  The  incidence 
of  the  disease  in  swine  varies  much  in  different  countries.  In  Germany, 
where  a  thorough  and  systematic  microscopic  examination  of  all  swine 
flesh  is  made,  the  proportion  of  trichinous  hogs  is  about  1  in  1,852.  At 
the  Berlin  abattoir,  where  the  microscopic  examination  is  conducted  by  a 
staff  of  over  eighty  men  and  women,  two  portions  are  taken  from  the  ab- 
dominal muscles,  from  the  diaphragm,  and  from  the  intercostal  muscles, 
and  one  piece  from  the  muscles  of  the  larynx  and  tongue.  A  special  com- 
pressor is  used  to  flatten  the  fragments  of  the  muscle,  and  the  examination 
is  made  with  a  magnifying  power  of  from  70  to  100  diameters.  During 
the  three  years  ending  in  1885  there  were  603  trichinous  hogs  detected,  a 
ratio  of  1  to  1,292.  Statistics  are  not  available  in  England.  In  the  United 
States  systematic  inspection  is  unknown,  and  the  statistics  are  by  no  means 
extensive  enough.  "  Taking  all  the  examinations  of  American  pork  thus 
far  made,  both  at  home  and  abroad,  and  we  have  a  total  of  298,782,  in  which 


356  DISEASES  DUE  TO  ANIMAL  PARASITES. 

trichinse  were  found  6,380  times,  being  2-.1  per  cent,  or  1  to  48  "  (Salmon, 
1884). 

In  1883,  in  conjunction  with  A.  W.  Clement,  I  examined  1,000  hogs 
at  the  Montreal  abattoir,  and  found  only  4  infected. 

Modes  of  Infection. — The  danger  of  infection  depends  entirely  upon 
the  mode  of  preparation  of  the  flesh.  Thorough  cooking,  so  that  all  parts 
of  the  meat  reach  the  boiling  point,  destroys  the  parasites;  but  in  large 
joints  the  central  portions  are  often  not  raised  to  this  temperature.  The 
frequency  of  the  disease  in  different  countries  depends  largely  upon  the 
habits  of  the  people  in  the  preparation  of  pork.  In  North  Germany^  where 
raw  ham  and  wurst  are  freely  eaten,  the  greatest  number  of  instances  have 
occurred.  In  South  Germany,  France,  and  England  cases  are  rare.  In 
this  country  the  greatest  number  of  persons  attacked  have  been  Germans. 
Salting  and  smoking  the  flesh  are  not  always  sufficient,  and  the  Havre 
experiments  showed  that  animals  are  readily  infected  when  fed  with  por- 
tions of  the  pickled  or  the  smoked  meat  as  prepared  in  this  country.  Carl 
Fraenkel,  however,  states  that  the  experiments  on  this  point  have  been 
negative,  and  that  it  is  very  doubtful  if  any  cases  of  trichiniasis  in  Germany 
have  been  caused  by  American  pork.  Germany  has  yet  to  show  a  single 
case  of  trichiniasis  due  to  pork  of  unquestioned  American  origin. 

Frequency  of  Infection. — H.  U.  Williams,  of  Buffalo,  made  a  thorough 
study  of  the  muscle  from  505  unselected  autopsies,  and  found  37  cases  of 
trichiniasis,  5.3  per  cent.  The  subjects  had  all  died  of  causes  other  than 
trichiniasis.  This  important  study  shows  how  widespread  is  the  disease, 
and  that  in  reality  we  frequently  overlook  the  sporadic  form,  a  mistake 
which  is  now  less  often  made,  owing  to  T.  E.  Brown's  discovery  of  the  asso- 
ciated eosinophilia. 

The  disease  often  occurs  in  epidemics,  a  large  number  of  persons  being 
infected  from  a  single  source.  Among  the  best  known  of  these,  one  occurred 
at  Hedersleben,  in  which  there  were  337  persons  affected,  and  another  at 
Emersleben,  in  which  there  were  350  persons  attacked.  The  extensive  out- 
breaks of  this  sort  have  been,  with  few  exceptions,  in  North  German}^,  and 
they  are  a  comment  on  the  inefficiency  of  the  inspection.  The  statistics  on 
the  subject  in  this  country  have  been  collected  for  me  by  Alfred  Mann, 
by  F.  A.  Packard,  of  Philadelphia,  and  more  exhaustively  by  C.  W.  Stiles, 
who  states  that  up  to  1893  there  was  a  total  of  709  cases;  since  then  he 
says,  in  a  letter  of  February  7,  1898,  there  have  been  40  or  50  cases  re- 
ported. He  thinks  that  900  would  cover  the  total  number  thus  far  re- 
ported for  this  country.  According  to  States,  New  York  heads  the  list 
with  139  cases;  Illinois  shows  119;  Massachusetts,  115;  Iowa,  108.  No 
doubt  many  cases  escape  detection,  and  the  disease  is  not  very  uncommon. 
I  have  had  7  cases  within  four  years  in  my  wards. 

Symptoms. — The  ingestion  of  trichinous  flesh  is  not  necessarily  fol- 
lowed by  the  disease.  When  a  limited  number  are  eaten  only  a  few  em- 
bryos pass  to  the  muscles  and  may  cause  no  symptoms.  Well-characterized 
cases  present  a  gastro-intestinal  period  and  a  period  of  general  infection. 

In  the  course  of  a  few  days  after  eating  the  infected  meat  there  are 
signs  of  gastro-intestinal  disturbance — pain  in  the  abdomen,  loss  of  appe- 


DISEASES  CAUSED  BY  NEMATODES.  357 

tite,  vomiting,  and  sometimes  diarrhoea.  The  preliminary  symptoms,  how- 
ever, are  by  no  means  constant,  and  in  some  of  the  large  epidemics  cases 
have  been  observed  in  which  they  have  been  absent.  In  other  instances 
the  gastro-intestinal  features  have  been  marked  from  the  outset,  and  the 
attack  has  resembled  cholera  nostras.  Pain  in  different  parts  of  the 
body,  general  debility,  and  weakness  have  been  noted  in  some  of  the 
epidemics. 

The  invasion  symptoms  develop  between  the  seventh  and  the  tenth  day, 
sometimes  not  until  the  end  of  the  second  week.  There  is  fever,  except  in 
very  mild  cases.  Chills  are  not  common.  The  thermometer  may  register 
102°  or  104°,  and  the  fever  is  usually  remittent  or  intermittent.  The  mi- 
gration of  the  parasites  into  the  muscles  excites  a  more  or  less  intense  myo- 
sitis, which  is  characterized  by  pain  on  pressure  and  movement,  and  by 
swelling  and  tension  of  the  muscles,  over  which  the  skin  may  be  oedema- 
tous.  The  limbs  are  placed  in  the  positions  in  which  the  muscles  are  in 
least  tension.  The  involvement  of  the  muscles  of  mastication  and  of  the 
larynx  may  cause  difficulty  in  chewing  and  swallowing.  In  severe  cases 
the  involvement  of  the  diaphragm  and  intercostal  muscles  may  lead  to 
intense  dyspnoea,  which  sometimes  proves  fatal.  CEdema,  a  feature  of  great 
importance,  may  be  early  in  the  face,  particularly  about  the  eyes.  Later 
it  develops  in  the  extremities  when  the  swelling  and  stiffness  of  the  mus- 
cles are  at  their  height.  Profuse  sweats,  tingling  and  itching  of  the  skin, 
and  in  some  instances  urticaria,  have  been  described. 

Blood. — A  marked  leucocytosis,  which  may  reach  above  30,000,  is  pres- 
ent. A  special  feature  is  the  extraordinary  increase  in  the  number  of 
eosinophilic  cells,  which  may  comprise  more  than  50  per  cent  of  all  the 
leucocytes.  There  have  been  in  my  wards  within  the  past  four  years  7 
cases  in  which  this  eosinophilia  was  most  pronounced.  In  4  of  the  cases 
the  diagnosis  was  actually  suggested  by  the  great  increase  in  the  eosino- 
philes;  in  1  case  they  reached  68  per  cent  of  the  total  number  of  leuco- 
cytes. 

The  general  nutrition  is  much  disturbed  and  the  patient  becomes 
emaciated  and  often  anaemic,  particularly  in  the  protracted  cases.  The 
patellar  tendon  reflex  may  be  absent.  The  patients  are  usually  conscious, 
except  in  cases  of  very  intense  infection,  in  which  the  delirium,  dry  tongue, 
and  tremor  give  a  picture  suggesting  typhoid  fever.  In  addition  to  the 
dyspnoea,  present  in  the  severer  infections,  there  may  be  bronchitis,  and  in 
the  fatal  cases  pneumonia  or  pleurisy.  In  some  epidemics  polyuria  has  been 
a  common  symptom.    Albuminuria  is  frequent. 

The  intensity  and  duration  of  the  symptoms  depend  entirely  upon  the 
grade  of  infection.  In  the  mild  cases  recovery  is  complete  in  from  ten  to 
fourteen  days.  In  the  severe  forms  convalescence  is  not  established  for 
six  or  eight  weeks,  and  it  may  be  months  before  the  patient  recovers  the 
muscular  strength.  One  case  in  the  Hedersleben  epidemic  was  weak  eight 
years  after  the  attack. 

Of  72  fatal  cases  in  the  Hedersleben  epidemic,  the  greatest  mortality 
occurred  in  the  fourth  and  fifth  and  sixth  weeks;  namely,  52  cases.  Two 
died  in  the  second  week  with  severe  choleraic  symptoms. 


358  DISEASES  DUE  TO  ANIMAL  PARASITES. 

The  mortality  has  ranged  in  different  outbreaks  from  1  or  2  per  cent 
to  30  per  cent.  In  the  Hedersleben  epidemic  101  persons  died.  Among 
456  cases  reported  in  this  country  there  were  122  deaths. 

The  anatomical  changes  are  chiefly  in  the  yoluntary  muscles.  The 
trichinae  enter  the  primitive  muscle  bundles,  which  undergo  granular  de- 
generation with  marked  nuclear  proliferation.  There  is  a  local  myositis, 
and  gradually  about  the  parasite  a  cyst  wall  is  formed.  These  changes,  as 
well  as  the  remarkable  alterations  in  the  blood,  have  been  described  in  full 
by  Thomas  R.  Brown.*  Cohnheim  has  described  a  fatty  degeneration  of 
the  liver  and  enlargement  of  the  mesenteric  glands.  At  the  time  of  death 
in  the  fourth  or  fifth  week  or  later  the  adult  trichinae  are  still  found  in  the 
intestines. 

The  prognosis  depends  much  upon  the  quantity  of  infected  meat  which 
has  been  eaten  and  the  number  of  trichinae  which  mature  in  the  intestines. 
In  children  the  outlook  is  more  favorable.  Early  diarrhoea  and  moder- 
ately intense  gastro-intestinal  symptoms  are,  as  a  rule,  more  favorable  than 
constipation. 

Diagnosis. — The  disease  should  always  be  suspected  when  a  large 
birthday  party  or  Fest  among  Germans  is  followed  by  cases  of  apparent 
typhoid  fever.  The  parasites  may  be  found  in  the  remnants  of  the  ham 
or  sausages  used  on  the  occasion.  The  worms  may  be  discovered  in  the 
stools.  "The  stools  should  be  spread  on  a  glass  plate  or  black  background 
and  examined  with  a  low-power  lens,  when  the  trichinae  are  seen  as  small, 
glistening,  silvery  threads.  In  doubtful  cases  the  diagnosis  may  be  made 
by  the  removal  of  a  small  fragment  of  muscle.  A  special  harpoon  has 
been  devised  for  this  purpose  by  means  of  which  a  small  portion  of  the 
biceps  or  of  the  pectoral  muscle  may  be  readily  removed.  Under  cocaine 
anaesthesia  an  incision  may  be  made  and  a  small  fragment  removed.  The 
disease  may  be  mistaken  for  acute  rheumatism,  particularly  as  the  pains 
are  so  severe  on  movement,  but  there  is  no  special  swelling  of  the  joints. 
The  great  increase  in  the  eosinophiles  in  the  blood  is,  as  mentioned  above, 
a  most  suggestive  point  in  diagnosis.  The  tenderness  is  in  the  muscles 
both  on  pressure  and  on  movement.  The  intensity  of  the  gastro-intestinal 
symptoms  in  some  cases  has  led  to  the  diagnosis  of  cholera.  Many  of  the 
former  epidemics  were  doubtless  described  as  typhoid  fever,  which  the 
severer  cases,  owing  to  the  prolonged  fever,  the  sweats,  the  delirium,  dry 
tongue,  and  gastro-intestinal  symptoms,  somewhat  resemble.  The  pains 
in  the  muscles,  with  tension  and  swelling,  oedema,  particularly  about  the 
eyes,  and  shortness  of  breath  are  the  most  important  diagnostic  points. 
Under  acute  myositis  reference  has  already  been  made  to  the  cases  which 
closely  resemble  trichiniasis.  The  epidemic  in  1879  on  board  the  training 
ship  Cornwall  presented  symptoms  similar  to  those  of  trichiniasis.  One 
patient  died.  Two  months  after  burial  the  body  was  examined,  and  living 
and  dead  nematode  worms  were  found  which,  as  Bastian  showed,  were  not 
the  trichina,  but  a  rhabditis.  They  were  probably  not  parasitic,  but  en- 
tered the  body  of  the  cadet  after  burial. 

♦  Journal  of  Experimental  Medicine,  vol.  iii. 


DISEASES  CAUSED  BY  NEMATODES.  359 

Prophylaxis.— It  is  not  definitely  known  how  swine  become  dis- 
eased. It  lias  been  thought  that  they  are  infected  from  rats  about  slaugh- 
ter-houses, but  it  is  just  as  reasonable  to  believe  that  the  rats  are  infected 
by  eating  portions  of  the  trichinous  flesh  of  swine.  The  swine  should,  as 
far  as  possible,  be  grain-fed,  and  not,  as  is  so  common,  allowed  to  eat  offal. 
The  most  satisfactory  prophylaxis  is  the  complete  cooking  of  pork  and 
sausages,  and  to  this  custom  in  England,  France,  South  Germany,  and 
particularly  in  this  country,  immunity  is  largely  due. 

Treatment. — If  it  has  been  discovered  within  twenty-four  or  thirty- 
six  hours  that  a  large  number  of  persons  have  eaten  infected  meat,  the 
indications  are  to  thoroughly  evacuate  the  gastro-intestinal  canal.  Purga- 
tives of  rhubarb  and  senna  may  be  given,  or  an  occasional  dose  of  calomel. 
Glycerin  has  been  recommended  in  large  doses  in  order  that  by  passing 
into  the  intestines  it  may  by  its  hygroscopic  properties  destroy  the  worm. 
Male-fern,  kamala,  santonin,  and  thymol  have  all  been  recommended  in 
this  stage.  Turpentine  may  be  tried  in  full  doses.  There  is  no  doubt  that 
diarrhoea  in  the  first  week  or  ten  days  of  the  infection  is  distinctly  favor- 
able. The  indications  in  the  stage  of  invasion  are  to  relieve  the  pains, 
to  secure  sleep,  and  to  support  the  patient's  strength.  There  are  no  medi- 
cines which  have  any  influence  upon  the  embryos  in  their  migration 
through  the  muscles. 

III.  Anchylostomiasis. 

The  Uncinaria  (DocJimius,  StrongyJus)  duodenalis,  also  known  as  the 
8derostomum  or  AncJiylostoma  duodenah,  is  the  only  strongjde  harmful  to 
man.  It  belongs  to  the  same  family  as  the  Sclerostomum  equinum,  which 
causes  the  verminous  aneurism  in  the  horse.  The  parasites  live  in  the 
upper  portion  of  the  small  intestine,  chiefly  in  the  jejunum.  They  are 
easily  seen,  the  male  being  from  6  to  10  mm.  long,  and  the  female  from 
10  to  18  mm.  The  mouth  is  provided  with  a  series  of  tooth-like  hooks, 
by  means  of  which  the  parasite  attaches  itself  to  the  mucous  membrane. 
The  male  has  a  prominent  expansion  or  bursa  at  the  tail  end.  Stiles  has 
shown  that  the  American  form  differs  from  the  European  species.  Griesin- 
ger  demonstrated  its  association  with  the  Egyptian  chlorosis.  It  has  also 
been  shown  to  be  the  cause  of  the  anemia  to  which  miners  and  brick- 
makers  are  subject.  Throughout  Europe  the  disease  has  been  widely  spread 
by  the  employment  of  Italian  and  Polish  laborers.  In  certain  Italian  prov- 
inces it  is  extremely  prevalent  and  serious.  It  occurs  in  the  Indies,  in 
Brazil,  and  the  "West  Indies,  and  has  been  described  in  Jamaica  (Strachan). 
Dobson  has  shown  that  there  is  an  extraordinary  prevalence  of  the  worm 
even  among  healthy  coolies  in  India  and  Assam,  amounting  to  80  per  cent. 
Stiles  has  shown  that  the  disease  prevails  widely  throughout  the  Southern 
States,  and  is  the  chief  cause  of  the  anaemia  and  poor  health  so  common 
in  many  districts.  It  is  very  fatal  in  Porto  Eico,  causing  more  than  one- 
fourth  of  the  deaths. 

Symptoras. — The  parasites  withdraw  blood  by  suction,  and  the  symp- 
toms result  from  this  slow  depletion.  That  the  parasites  produce  a  toxic 
substance  has  also  been  suggested.  In  the  early  stage  there  may  only  be 
gastric  or  gastro-intestinal  disturbance,  but  if  the  parasites  are  present  in 


360  DISEASES  DUE  TO  ANIMAL  PARASITES. 

large  numbers  ansemia  is  gradually  produced  and  constitutes  tlie  charac- 
teristic feature  of  the  disease.  The  Egyptian  chlorosis,  brick-maker's  anae- 
mia, tunnel  ansemia,  miner's  cachexia,  and  mountain  anaemia  are  due  to 
this  cause.  The  clinical  course  is  variable.  In  some  instances  the  ansemia 
develops  acutely  and  reaches  a  high  grade  within  a  short  time,  causing  great 
shortness  of  breath  and  oedema.  There  is  serious  disturbance  of  nutrition, 
sometimes  diarrhoea  and  colicky  pains;  but  the  most  pronounced  symptom 
is  the  pallor  and  the  associated  phenomena  of  chronic  ansemia,  with  debility 
and  wasting.  The  lesions  of  the  intestines  are  those  of  chronic  catarrh, 
and  small  haemorrhages  occur  in  the  mucosa.  The  worms  are  found  within 
2  metres  of  the  pylorus,  often  with  their  heads  buried  in  the  mucosa.  Dila- 
tation and  hypertrophy  of  the  heart  have  been  found  in  many  cases.  Sand- 
with  states  that  in  Egypt  the  disease  is  most  common  in  peasants  who  work 
in  the  damp  earth,  many  of  whom  are  earth-eaters. 

The  diagnosis  is  not  difficult.  The  eggs,  which  are  abundant  in  the 
stools,  are  oval,  about  53  ^  long  by  32  /x  broad,  and  possess  a  thin,  trans- 
parent shell.  There  is  no  operculum,  as  in  the  ovum  of  the  oxyuris,  and 
eggs  found  in  the  faeces  are  in  various  stages  of  segmentation.  The  larvae 
develop  in  moist  earth  and  readily  get  into  the  drinking-water,  through 
which  infection  occurs. 

The  systematic  employment  of  latrines  and  the  boiling  of  all  water 
used  for  drinking  purposes  are  the  important  prophylactic  measures. 
Thymol,  recommended  by  Bozzolo,  is  a  specific,  and  should  be  given  in 
large  doses,  2  grammes  (in  wafers)  at  8  a.  m.  and  2  grammes  at  10  a.  m. 
(Sandwith).  The  diet  should  be  milk  and  soup.  Two  hours  after  the 
second  dose  of  thymol  a  purge  of  castor  oil  or  magnesia  is  given.  If  neces- 
sary, the  treatment  may  be  repeated  in  a  week. 

IV.    FlLAEIASIS. 

Zoologically  the  Filaria  sanguinis  hominis  is  as  yet  sub  judice.  Man- 
son's  views  are  as  follows: 

Under  the  general  term  Filaria  sanguinis  hominis  three  species  of 
nematodes  are  included: 

1.  Filaria  hancrofti,  Cobold,  1877.  This  is  the  ordinary  blood  filaria. 
The  embryos  are  found  in  the  peripheral  circulation  only  during  sleep  or 
at  night.  The  mosquito  is  the  intermediate  host.  The  embryos  measure 
270  to  340  /x  long  by  7  to  11  /x  broad;  tail  pointed.  The  adult  male  meas- 
ures 83  mm.  long  by  0.407  mm.  broad;  the  tail  forms  two  turns  of  a  spiral. 
The  adult  female  measures  155  mm.  long  by  0.715  mm.  broad;  vulva  2.56 
mm.  from  anterior  extremity;  eggs  38  fi  by  14  /a.  This  is  the  species  to 
which  the  hsematochyluria  and  elephantiasis  are  attributed. 

2.  Filaria  diurna,  Manson,  1891.  The  larvas  agree  with  the  preceding, 
except  that  Manson  indicates  the  absence  of  granules  in  the  axis  of  the 
body.  The  worms  occur  in  the  peripheral  circulation  only  during  the 
day,  or  when  the  patient  stays  awake.  Manson  suspects  that  the  Filaria  ha 
represents  the  adult  stage. 

3.  Filaria  perstaiw,  Manson,  1891.   Only  the  embryos  are  known.  These 


DISEASES  CAUSED  BY  NEMATODES.  361 

are  nmch  smaller  than  the  preceding — 200  yx  long,  posterior  extremity  ob- 
tuse, anterior  extremity  with  a  sort  of  retractile  rostellum. 

This  is  the  species  to  which  Manson  would  attribute  the  sleeping- 
sickness  of  the  negroes.  He  is  also  inclined  to  regard  the  Filaria  perstans 
as  the  cause  of  craw-craw,  a  papillo-pustular  skin  eruption  of  the  west 
coast  of  Africa,  which  is  probably  the  same  as  Nielly's  dermatose  parasitaire, 
the  parasite  of  which  was  called  by  Blanehard  RhaMitis  niellyi.  Manson 
has  shown  that  in  the  blood  of  the  aboriginal  Indians  in  British  Guiana 
there  are  two  forms  of  filarial  embryos,  which  differ  somewhat  from  the 
ordinary  types.  Daniels  and  Ozzard  have  shown  the  extraordinary  preva- 
lence of  these  parasites  in  the  aborigines — fully  58  per  cent.  Recently 
Daniels  has  found  the  mature  filarige  in  two  subjects  in  the  upper  part  of 
the  mesentery,  near  the  pancreas  and  in  the  subpericardial  fat. 

The  most  important  of  these  is  the  Filaria  Bancrofti,  which  produces 
the  haematochyluria  and  the  lymph-scrotum. 

The  female  produces  an  extraordinary  number  of  embryos,  which  enter 
the  blood  current  through  the  lymphatics.  Each  embryo  is  within  its 
shell,  which  is  elongated,  scarcely  perceptible,  and  in  no  way  impedes  the 
movements.  They  are  about  the  ninetieth  part  of  an  inch  in  length  and 
the  diameter  of  a  red  blood-corpuscle  in  thickness,  so  that  they  readily 
pass  through  the  capillaries.  They  move  with  the  greatest  activity,  and 
form  very  striking  and  readily  recognized  objects  in  a  blood-drop  under 
the  microscope.  A  remarkable  feature  is  the  periodicity  in  the  occurrence 
of  the  embryos  in  the  blood.  In  the  daytime  they  are  almost  or  entirely 
absent,  whereas  at  night,  in  typical  cases,  they  are  present  in  large  num- 
bers. If,  however,  as  Stephen  Mackenzie  has  shown,  the  patient,  reversing 
his  habits,  sleeps  during  the  day,  the  periodicity  is  reversed.  The  further 
development  of  the  embryos  appears  to  be  associated  with  the  mosquito, 
which  at  night  sucks  the  blood  and  in  this  way  frees  them  from  the  body. 
After  developing  a  little  it  was  thought  that  they  were  set  free  in  the 
water  by  the  death  of  the  host.  S.  P.  James  has  found  them  in  the  tissues 
of  the  proboscis  of  the  mosquito,  and  the  infection  is  probably  direct,  as  in 
malaria.  The  filariee  may  be  present  in  the  body  without  causing  any 
symptoms.  In  the  blood  of  animals  filariae  are  very  common  and  rarely 
cause  inconvenience.  It  is  only  when  the  adult  worms  or  the  ova  block 
the  lymph  channels  that  certain  definite  symptoms  occur.  Manson  sug- 
gests that  it  is  the  ova  (prematurely  discharged),  which  are  considerably 
shorter  and  thicker  than  the  full-grown  embryos,  which  block  the  lymph 
channels  and  produce  the  conditions  of  hsematochyluria,  elephantiasis,  and 
lymph-scrotum. 

The  parasite  is  widely  distributed,  particularly  in  tropical  and  sub- 
tropical countries.  Guiteras  has  shown  that  the  disease  prevails  exten- 
sively in  the  Southern  States,  and  since  his  paper  appeared  contributions 
have  been  made  by  Matas,  of  New  Orleans,  Mastin,  of  Mobile,  and  De  Saus- 
sure,  of  Charleston,  and  Opie. 

The  effects  produced  may  be  described  under  the  following  conditions: 

(a)  Hmmatocliyluria. — Without  any  external  manifestations,  and  in 
many  cases  without  special  disturbance  of  health,  the  subject  from  time 


362  DISEASES  DUE  TO  ANIMAL  PARASITES. 

to  time  passes  urine  of  an  opaque  white,  milky  appearance,  or  Moody,  or 
a  chylous  fluid  which  on  settling  shows  a  slightly  reddish  clot.  The  urine 
may  be  normal  in  quantity  or  increased.  The  condition  is  usually  inter- 
mittent, and  the  patient  may  pass  normal  urine  for  weeks  or  months  at  a 
time.  Microscopically,  the  chylous  urine  contains  minute  molecular  fat 
granules,  usually  red  blood-corpuscles  in  various  amounts.  The  embryos 
were  first  discovered  by  Demarquay,  at  Paris  (1863),  and  in  the  urine  by 
Wucherer,  at  Bahia,  in  1866.  It  is  remarkable  for  how  long  the  condition 
may  persist  without  serious  impairment  of  the  health.  A  patient,  sent  to 
me  by  Dawson,  of  Charleston,  has  had  hsematochyluria  intermittently  for 
eighteen  years.  The  only  inconvenience  has  been  in  the  passage  of  the 
blood-clots  which  collect  in  the  bladder.  At  times  he  has  also  uneasy  sensa- 
tions in  the  lumbar  region.  The  embryos  are  present  in  his  blood  at  night 
in  large  numbers.  Chyluria  is  not  always  due  to  the  filaria.  The  non- 
parasitic form  of  the  disease  is  considered  on  page  859. 

Opportunities  for  studying  the  anatomical  condition  of  these  cases 
rarely  occur.  In  the  case  described  by  Stephen  Mackenzie  the  renal  and 
peritoneal  lymph  plexuses  were  enormously  enlarged,  extending  from  the 
diaphragm  to  the  pelvis.  The  thoracic  duct  above  the  diaphragm  was  im- 
pervious. 

(h)  Lymph-scrotum  and  certain  forms  of  elephantiasis  are  also  caused 
by  the  filaria.  In  the  former  the  tissues  of  the  scrotum  are  enormously 
thickened  and  the  distended  lymph-vessels  may  be  plainly  seen.  A  clear, 
sometimes  a  turbid,  fluid  follows  puncture  of  the  skin.  The  parasites  are 
not  always  to  be  found.  I  have  examined  two  typical  cases  without  finding 
filarias  in  the  exuded  fluids  or  in  the  blood  at  night.  So  also  the  majority 
of  cases  of  elephantiasis  which  occur  in  this  country  are  non-parasitic. 
In  China  it  is  stated  that  the  parasites  occur  in  all  these  cases.* 

Treatment. — So  far  as  I  know,  no  drug  destroys  the  embryos  in  the 
blood.  In  infected  districts  the  drinking-water  should  be  boiled  or  filtered. 
In  cases  of  chyluria  the  patients  should  use  a  dry  diet  and  avoid  all  excess 
of  fat.  The  chyle  may  disappear  quite  rapidly  from  the  urine  under  these 
measures,  but  it  does  not  necessarily  indicate  that  the  case  is  cured.  So 
long  as  clots  and  albumin  are  present  the  leak  in  the  lymphoid  varix  is  not 
healed,  although  the  fat,  not  being  supplied  to  the  chyle,  may  not  be  pres- 
ent. A  single  tumblerful  of  milk  will  at  once  give  ocular  proof  of  the 
patency  or  otherwise  of  the  rupture  in  the  varix  (Manson). 

The  surgical  treatment  of  some  of  these  cases  is  most  successful,  par- 
ticularly in  the  removal  of  the  adult  filarise  from  the  enlarged  lymph-glands, 
especially  in  the  groin.  Maitland  states  that  during  the  past  seven  years 
25  operations  of  this  kind  have  been  performed  without  serious  symptoms. 

V.  Dracontiasis  {Guinea-worm  Disease). 

The  Filaria  or  Dracunculus  medinensis  is  a  widely  spread  parasite  in 
parts  of  Africa  and  the  East  Indies.    In  the  United  States  instances  oeca- 

*  For  full  consideration  of  the  subject  of  congenital  occlusion  and  dilatation  of  lymph 
channels,  see  the  work  on  this  subject  by  Samuel  C.  Busey,  New  York,  1878. 


DISEASES  CAUSED  BY  NEMATODES.  363 

sionally  occur.  Jarvis  reports  a  case  in  a  post  chaplain  who  had  lived  at 
Fortress  Monroe,  Va.,  for  thirty  years.  Van  Harlingen's  patient,  a  man 
aged  forty-seven,  had  never  lived  out  of  Philadelphia,  so  that  the  worm 
must  be  included  among  the  parasites  of  this  country.  A  majority  of  the 
cases  reported  in  American  Journals  have  been  imported. 

Only  the  female  is  known.  It  develops  in  the  subcutaneous  and  inter- 
muscular connective  tissues  and  produces  vesicles  and  abscesses.  In  the 
large  majority  of  the  cases  the  parasite  is  found  in  the  leg.  Of  181  cases, 
in  124  the  worm  was  found  in  the  feet,  33  times  in  the  leg,  and  11  times  in 
the  thigh.  It  is  usually  solitary,  though  there  are  cases  on  record  in  which 
six  or  more  have  been  present.  It  is  cylindrical  in  form,  about  2  mm.  in 
diameter,  and  from  50  to  80  cm.  in  length. 

The  worm  gains  entrance  to  the  system  through  the  stomach,  not 
through  the  skin,  as  was  formerly  supposed.  It  is  probable  that  both  male 
and  female  are  ingested;  but  the  former  dies  and  is  discharged,  while  the 
latter  after  impregnation  penetrates  the  intestine  and  attains  its  full  de- 
velopment in  the  subcutaneous  tissues,  where  it  may  remain  quiescent  for 
a  long  time  and  can  be  felt  beneath  the  skin  like  a  bundle  of  string.  The 
worm  contains  an  enormous  number  of  living  embryos,  and  to  enable  them 
to  escape  she  travels  slowly  downward  head  first,  and,  as  mentioned,  usually 
reaches  the  foot  or  ankle.  The  head  then  penetrates  the  skin  and  the  epi- 
dermis forms  a  little  vesicle,  which  ruptures,  and  a  small  ulcer  is  left,  at  the 
bottom  of  which  the  head  often  protrudes.  The  distended  uterus  ruptures 
and  the  embryos  are  discharged  in  a  whitish  fluid.  After  getting  rid  of 
them  the  worm  will  spontaneously  leave  her  host.  In  the  water  the  em- 
bryos develop  in  the  cyclops — a  small  crustacean — and  it  seems  likely  that 
man  is  infected  by  drinking  the  water  containing  these  developed  larvae. 

When  the  worm  first  appears  it  should  not  be  disturbed,  as  after  par- 
turition she  may  leave  spontaneously.  When  the  worm  begins  to  come 
out  a  common  procedure  is  to  roll  it  round  a  portion  of  smooth  wood  and 
in  this  way  prevent  the  retraction,  and  each  day  wind  a  little  more  until 
the  entire  worm  is  withdrawn.  It  is  stated  that  special  care  must  be  taken 
to  prevent  tearing  of  the  worm,  as  disastrous  consequences  sometimes  fol- 
low, probably  from  the  irritation  caused  by  the  migration  of  the  embryos. 

The  parasite  may  be  excised  entire,  or  killed  by  injections  of  bichloride 
of  mercury  (1  to  1,000).  It  is  stated  that  the  leaves  of  the  plant  called 
amarpattee  are  almost  a  specific  in  the  disease.  Asafoetida  in  full  doses  is 
said  to  kill  the  worm. 

In  East  Africa  Kolb  states  that  he  found  in  the  abdominal  cavity  of 
a  recently  killed  native  Massai  several  large  nematode  worms  believed  to 
be  allied  to  the  filaria  medinensis.  He  thinks  this  parasite  is  possibly  asso- 
ciated with  what  is  known  as  the  Massai  disease,  characterized  by  attacks  of 
fever  lasting  some  three  days,  with  tenderness  of  the  abdomen  and  vomit- 
ing. Kolb  thinks  that  in  these  cases  the  filarige  which  have  become  en- 
cysted about  the  liver  "  as  a  normal  event  in  their  life  history  burst  their 
cysts,  the  contents  escaping  into  the  peritoneal  cavity,  thereby  giving  rise 
to  the  symptoms."  The  subject  is  one  which  requires  further  investiga- 
tion. 

23 


364  DISEASES  DUE  TO  ANIMAL  PAUASITES. 

VI.  Otheb  Nematodes. 

(a)  Among  less  important  filarian  worms  parasitic  in  man  the  follow- 
ing may  be  mentioned:  Filaria  loa,  which  is  a  cylindrical  worm  of  about 

3  cm.  in  length  and  whose  habitat  is  beneath  the  conjunctiva.  It  has 
been  found  on  the  West  African  coast,  in  Brazil,  and  in  the  West  Indies. 
Filaria  lentis,  which  has  been  found  in  a  cataract.  Three  specimens  have 
been  found  together.  Filaria  ladialis,  which  has  been  found  in  a  pustule 
in  the  upper  lip.  Filaria  hominis  oris,  which  was  described  by  Leidy, 
from  the  mouth  of  a  child.  Filaria  hronchialis,  which  has  been  found 
occasionally  in  the  trachea  and  bronchi.  This  parasite  has  been  seen  in  a 
few  cases  in  the  bronchioles  and  in  the  lungs.  There  is  no  evidence  that 
it  ever  produces  an  extensive  verminous  bronchitis  similar  to  that  which 
I  have  described  in  dogs.  Filaria  immitis — the  common  Filaria  sanguinis 
of  the  dog — of  which  Bowlby  has  described  two  cases  in  man.  In  one  case 
with  hsematuria  female  worms  were  found  in  the  portal  vein,  and  the  ova 
were  present  in  the  thickened  bladder  wall  and  in  the  ureters. 

(h)  TricliocepJialus  dispar  (Whip-worm). — This  parasite  is  not  infre- 
quently found  in  the  caecum  and  large  intestine  of  man.    It  measures  from 

4  to  5  em.  in  length,  the  male  being  somewhat  shorter  than  the  female. 
The  worm  is  readily  recognized  by  the  remarkable  difference  between  the 
anterior  and  posterior  portions.  The  former,  which  forms  at  least  three 
fifths  of  the  body,  is  extremely  thin  and  hair-like  in  contrast  to  the  thick 
hinder  portion  of  the  body,  which  in  the  female  is  conical  and  pointed,  and 
in  the  male  more  obtuse  and  usually  rolled  like  a  spring.  The  eggs  are 
oval,  lemon-shaped,  0.05  mm.  in  length,  and  each  is  provided  with  a  button- 
like projection. 

The  number  of  the  worms  found  is  variable,  as  many  as  a  thousand 
having  been  counted.  It  is  a  widely  spread  parasite.  In  parts  of  Europe 
it  occurs  in  from  10  to  30  per  cent  of  all  bodies  examined,  but  in  this  coun- 
try it  is  not  so  common.  The  trichocephalus  rarely  causes  symptoms. 
It  has  been  thought  by  certain  physicians  in  the  East  to  be  the  cause  of 
beri-beri.  Several  cases  have  been  reported  recently  in  which  profound 
anaemia  has  occurred  in  connection  with  this  parasite,  usually  with  diar- 
rhoea. Enormous  numbers  may  be  present,  as  in  Eudolphi's  case,  without 
producing  any  symptoms. 

The  diagnosis  is  readily  made  by  the  examination  of  the  faeces,  which 
contain,  sometimes  in  great  abundance,  the  characteristic  lemon-shaped, 
hard,  dark-brown  eggs. 

(c)  Diodophyme  gig  as  {Eustrongylus  gig  as). — This  enormous  nematode, 
the  male  of  which  measures  about  a  foot  in  length  and  the  female  about 
three  feet,  occurs  in  very  many  animals  and  has  occasionally  been  met  with 
in  man.  It  is  usually  found  in  the  renal  region  and  may  entirely  destroy 
the  kidney. 

(d)  Strongyloides  intestinalis. — Under  this  name  are  now  included  the 
small  nematode  worms  found  in  the  faeces  and  formerly  described  as 
Anguillula  stercoralis,  AnguiUula  intestinalis,  and  RTidbdonema  intestinale. 
This  parasite  occurs  abundantly  in  the  stools  of  the  endemic  diarrhoea  of 


DISEASES  CAUSED  BY  CESTODES.  365 

hot  countries,  and  has  been  specially  described  by  the  French  in  the  diar- 
rhoea of  Cochin-China.  It  has  been  found  in  Manila  by  Strong,  and  two 
cases  have  been  reported  from  my  clinic  by  W.  S.  Thayer.  It  is  stated 
that  the  worms  occupy  all  parts  of  the  intestines,  and  have  even  been 
found  in  the  biliary  and  pancreatic  ducts.  It  is  only  when  they  are  in 
very  large  numbers  that  they  produce  severe  diarrhoea  and  aneemia. 

AcANTHOCEPHALA  (Thom-Jieaded  Worms). 

The  Gigantorliynchus  or  Ecliinorhynchus  gigas  is  a  common  parasite  in 
the  intestine  of  the  hog  and  attains  a  large  size.  The  larvse  develop  in 
cockchafer  grubs.  The  American  intermediate  host  is  the  June  bug 
(Stiles).  Lambl  found  a  small  EchinorJiynchus  in  the  intestine  of  a  boy. 
Welch's  specimen,  which  was  found  encysted  in  the  intestine  of  a  soldier 
at  Netley,  is  stated  by  Cobbold  probably  not  to  have  been  an  EchinorJiyn- 
chus. Recently  a  case  of  Echinorhynchus  moniliformis  has  been  described 
in  Italy  by  Grassi  and  Calandruccio. 


V.    DISEASES   CAUSED    BY  CESTODES 

(Tape-worms;  Hydatid  Disease). 

Man  harbors  the  adult  parasites  in  the  small  intestine,  the  larval  forms 
in  the  muscles  and  solid  organs. 

I.  Intestinal  Cestodes;  Tape-woems. 

(a)  Taenia  solium,  or  pork  tape-worm.  This  is  not  a  common  form  in 
this  country.  It  is  much  more  frequent  in  parts  of  Europe  and  Asia. 
When  mature  it  is  from  6  to  12  feet  in  length.  The  head  is  small,  round, 
not  so  large  as  the  head  of  a  pin,  and  provided  with  four  sucking  disks  and 
a  double  row  of  booklets;  hence  it  is  called,  in  contradistinction  to  the 
other  form  in  man,  the  armed  tape-worm.  To  the  head  succeeds  a  narrow, 
thread-like  neck,  then  the  segments,  or  proglottides,  as  they  are  called. 
The  segments  possess  both  male  and  female  generative  organs,  and  about 
every  four  hundred  and  fiftieth  becomes  mature  and  contains  ripe  ova.  The 
worm  attains  its  full  growth  in  from  three  to  three  and  a  half  months, 
after  which  time  the  segments  are  continuously  shed  and  appear  in  the 
stools.  The  segments  are  about  1  cm.  in  length  and  from  7  to  8  mm.  in 
breadth.  Pressed  between  glass  plates  the  uterus  is  seen  as  a  median  stem 
with  about  eight  to  fourteen  lateral  branches.  There  are  many  thousands  of 
ova  in  each  ripe  segment,  and  each  ovum  consists  of  a  firm  shell,  inside  of 
which  is  a  little  embryo,  provided  with  six  booklets.  The  segments  are 
continuously  passed,  and  if  the  ova  are  to  attain  furtJier  development  they 
must  be  taken  into  the  stomach,  either  of  a  pig,  or  of  man  himself.  The 
egg-shells  are  digested,  the  six-hooked  embryos  become  free,  and  passing 
from  the  stomach  reach  various  parts  of  the  body  (the  liver,  muscles,  brain, 
or  eye),  where  they  develop  into  the  larvae  or  cysticerci.    A  hog  under  these 


366  DISEASES  DUE  TO  ANIMAL  PARASITES. 

circumstances  is  said  to  be  measled,  and  the  cysticerci  are  spoken  of  as 
measles  or  bladder  worms. 

The  tcenia  solium  received  its  name  because  it  was  thought  to  exist  as 
a  solitary  parasite  in  the  bowel,  but  two  or  three  or  even  more  worms  may 
occur. 

(b)  Tcenia  saginata  or  mediocanellata — ^the  unarmed  or  beef  tape- worm. 
This  is  a  longer  and  larger  parasite  than  the  Tcenia  solium.  It  is  certainly 
the  common  tape-worm  of  this  country.  Of  scores  of  specimens  which  I 
have  examined  almost  all  were  of  this  variety.  According  to  Berenger- 
Ferand  it  has  spread  rapidly  in  western  Europe,  owing  probably  to  the 
importation  of  beef  and  live-stock  from  the  Mediterranean  basin.  It  may 
attain  a  length  of  15  or  20  feet,  or  more.  The  head  is  large  in  comparison 
with  that  of  the  Tcenia  solium,  and  measures  over  2  mm.  in  breadth.  It  is 
square-shaped  and  provided  with  four  large  sucking  disks,  but  there  are  no 
booklets.  The  ripe  segments  are  from  17  to  18  mm.  in  length,  and  from 
8  to  10  mm.  in  breadth.  The  uterus  consists  of  a  median  stem  with  from 
fifteen  to  thirty-five  lateral  branches,  which  are  given  off  more  dichoto- 
mdusly  than  in  the  Tcenia  solium.  The  ova  are  somewhat  larger,  and  the 
shell  is  thicker,  but  the  two  forms  can  scarcely  be  distinguished  by  their  ova. 
The  ripe  segments  are  passed  as  in  the  tcenia  solium,  and  are  ingested  by 
cattle,  in  the  flesh  or  organs  of  which  the  eggs  develop  into  the  bladder 
worms  or  cysticerci. 

Of  other  forms  of  tape-worm  may  be  mentioned: 

(c)  Dipylidium  caninum  {Tcenia  elliptica,  Tcenia  cucumerina).  A  small 
parasite  very  common  in  the  dog  and  occasionally  found  in  man;  the  larvse 
develop  in  the  lice  and  fleas  of  the  dog. 

(d)  Hijmenolepsis  diminuta  {Tcenia  flavo-punctata).  A  small  cestode  was 
found  in  the  intestine  of  a  child  in  Boston,  and  has  since  been  met  with  in 
one  or  two  cases.  It  is  common  in  rats.  The  larvae  develop  in  Lepidoptera 
and  in  beetles. 

(e)  Hymenolepsis  nana  {Tcenia  nana)  occurs  not  infrequently  in  Italy; 
the  Davainea  Madagascariensis  {Tcenia  Madagascariensis)  is  a  rare  form. 

(/)  Tcenia  confusa,  a  new  species  described  by  Ward. 

{g)  Botliriocepjliahis  latus.  A  cestode  worm  found  only  in  certain  dis- 
tricts bordering  on  the  Baltic  Sea,  in  parts  of  Switzerland,  and  in  Japan. 
So  far  as  I  know,  it  has  not  been  found  in  this  country  except  in  a  few 
imported  cases.  The  parasite  is  large  and  long,  measuring  from  25  to  30 
feet  or  more.  Its  head  is  different  from  that  of  the  taenia,  as  it  possesses 
two  lateral  grooves  or  pits  and  has  no  booklets.  The  larvge  develop  in  the 
peritonseum  and  muscles  of  the  pike  and  other  fish,  and  it  has  been  shown 
experimentally  that  they  grow  into  the  adult  worm  when  eaten  by  man. 

Symptoms. — These  parasites  are  found  at  all  ages.  They  are  not 
uncommon  in  children  and  are  occasionally  found  in  sucklings.  W.  T. 
Plant  refers  to  a  number  of  cases  in  children  under  two  years,  and  there  is 
one  in  the  literature  in  which  it  is  stated  that  the  tape-worm  was  found 
in  an  infant  five  days  old. 

The  parasites  may  cause  no  disturbance  and  are  rarely  dangerous.     A 


DISEASES  CAUSED  BY  CESTODES.  367 

knowledge  of  the  existence  of  the  worm  is  generally  a  source  of  worry  and 
anxiety;  the  patient  may  have  considerable  distress  and  complain  of  ab- 
dominal pains,  nausea,  diarrhoea,  and  sometimes  anemia.  Occasionally  the 
appetite  is  ravenous.  In  women  and  in  nervous  patients  the  constitutioual 
disturbance  may  be  considerable,  and  we  not  infrequently  see  great  mental 
depression  and  even  hypochondria.  Various  nervous  phenomena,  such  as 
chorea,  convulsions,  or  epilepsy,  are  believed  to  be  caused  by  the  parasites. 
Such  effects,  however,  are  very  rare.  The  Bothriocephalus  may  cause  a 
severe  and  even  fatal  form  of  anaemia,  which  has  been  described  fully  in 
a  recent  monograph  by  Schaumann,  of  Helsingfors. 

The  diagnosis  is  never  doubtful.  The  presence  of  the  segments  is  dis- 
tinctive. The  ova,  too,  may  be  recognized  in  the  stools.  It  makes  but  little 
difference  as  to  the  form  of  tape-worm,  but  the  ripe  segments  of  the  Tcenia 
saginata  are  larger  and  broader,  and  show  differences  in  the  generative 
system  as  already  mentioned. 

The  prophylaxis  is  most  important.  Careful  attention  should  be  given 
to  three  points.  First,  all  tape-worm  segments  should  be  burned.  They 
should  never  be  thrown  into  the  water-closet  or  outside;  secondly,  careful 
inspection  of  meat  at  the  abattoirs;  and  thirdly,  cooking  the  meat  suffi- 
ciently to  kill  the  parasites. 

In  the  case  of  the  beef  measles,  the  distribution  of  the  parasites,  as 
given  by  Ostertag,  shows  that  the  muscles  of  the  jaw  are  much  more  fre- 
quently affected  than  other  parts — 360  times,  while  other  organs  were 
infected  but  55  times.  Sometimes  there  are  instances  of  general  infec- 
tion. Stiles  states  that  no  exact  statistics  have  been  published  for  this 
country.  In  Berlin  the  proportion  of  cattle  infected  in  1892-'93  was  about 
1  to  672.  Cold  storage  kills  the  cysticercus  usually  within  three  weeks. 
The  measles  are  more  readily  overlooked  in  beef  than  in  pork,  as  they  do 
not  present  such  an  opaque  white  color. 

In  the  examination  of  hogs  for  cysticerci  "  particular  stress  should  be 
laid  upon  the  tongue,  the  muscles  of  mastication,  and  the  muscles  of  the 
shoulder,  neck^  and  diaphragm  "  (Stiles).  They  may  be  seen  very  easily 
on  the  under  surface  of  the  tongue.  American  hogs  are  comparatively 
free.  In  Prussia  one  hog  is  infected  in  about  every  637.  Specimens  have 
been  found  alive  twenty-nine  days  after  slaughtering.  In  the  examination 
of  1,000  hogs  in  Montreal,  Dr.  Clement  and  I  found  76  instances  of  cysti- 
cerci. For  full  details  with  reference  to  the  inspection  of  meat  for  animal 
parasites,  the  practitioner  is  referred  to  the  work  of  Dr.  Stiles,  in  Bulletin 
No.  19,  United  States  Department  of  Agriculture,  1898. 

Treatment. — For  two  days  prior  to  the  administration  of  the  reme- 
dies the  patient  should  take  a  very  light  diet  and  have  the  bowels  moved 
occasionally  by  a  saline  cathartic.  The  practitioner  has  the  choice  of  a 
large  number  of  drugs.  As  a  rule,  the  male  fern  acts  promptly  and  well. 
The  ethereal  extract,  in  2-drachm  doses,  may  be  given  fasting,  and  fol- 
lowed in  the  course  of  a  couple  of  hours  by  a  brisk  purgative.  This  usually 
succeeds  in  bringing  away  a  large  portion,  but  not  always  the  entire  worm. 

A  combination  of  the  remedies  is  sometimes  very  effective.  An  in- 
fusion is  made  of  pomegranate  root,  half  an  ounce;  pumpkin  seeds,  1 


368  DISEASES  DUE  TO  ANIMAL  PARASITES. 

ounce;  powdered  ergot,  a  drachm;  and  boiling  water,  10  ounces.  To  an 
emulsion  of  the  male  fern  (a  drachm  of  ethereal  extract),  made  with  acacia 
powder,  2  minims  of  croton  oil  are  added.  The  patient  should  have  had 
a  low  diet  the  previous  day  and  have  taken  a  dose  of  salts  in  the  evening. 
The  emulsion  and  infusion  are  mixed  and  taken  fasting  at  nine  in  the 
morning. 

The  pomegranate  root  is  a  very  efficient  remedy,  and  may  be  given  as 
an  infusion  of  the  bark,  3  ounces  of  which  may  be  macerated  in  10  ounces 
of  water  and  then  reduced  to  one  half  by  evaporation.  The  entire  quan- 
tity is  then  taken  in  divided  doses.  It  occasionally  produces  colic,  but  is 
a  very  effective  remedy.  The  active  principle  of  the  root,  pelletierine,  is 
now  much  employed.  It  is  given  in  doses  of  6  to  8  or  even  10  grains,  with 
a  little  tannin  (grs.  v)  in  sweetened  water,  and  is  followed  in  an  hour  by  a 
purge. 

Pumpkin  seeds  are  sometimes  very  efficient.  Three  or  4  ounces  should 
be  carefuUy  bruised  and  then  macerated  for  twelve  or  fourteen  hours  and 
the  entire  quantity  taken  and  followed  in  an  hour  by  a  purge.  Of  other 
remedies,  koosso,  turpentine  in  ounce  doses  in  honey,  and  kamala  may  be 
mentioned.  ~^ 

Unless  the  head  is  brought  away,  the  parasite  continues  to  grow,  and 
within  a  few  months  the  segments  again  appear.  Some  instances  are 
extraordinarily  obstinate.  Doubtless  almost  everything  depends  upon  the 
exposure  of  the  worm.  The  head  and  neck  may  be  thoroughly  protected 
beneath  the  valvulse  conniventes,  in  which  case  the  remedies  may  not  act. 
Owing  to  its  armature  the  imnxa  solium  is  more  difficult  to  expel.  It  is 
probable  that  no  degree  of  peristalsis  could  dislodge  the  head,  and  unless 
the  worm  is  killed  it  does  not  let  go  its  extraordinarily  firm  hold  on  the 
mucous  membrane.  If  warm  water  be  put  in  the  commode  the  worm  is  less 
likely  to  contract  and  be  broken. 

11.    ViSCEEAL    CeSTODES. 

Whereas  adult  t^nise  may  give  rise  to  little  or  no  disturbance,  and  rarely, 
if  ever,  prove  directly  fatal,  the  affections  caused  by  the  larvae  or  immature 
forms  in  the  solid  organs  are  serious  and  important.  There  are  two  chief 
cestode  larvje  known  to  frequent  man  (a)  the  Cysticercus  celluhsce,  the 
larva  of  the  Tcenia  solium,  and  (b)  the  Echinococcus,  the  larva  of  the  Tcenia 
ecMnococcus.  The  Cysticercus  tcenice  saginatce  has  been  found  only  two  or 
three  times  in  man. 

I,  Cysticercus  celMosse. — When  man  accidentally  takes  into  his  stom- 
ach the  rip'e  ova  of  Tcenia  solium  he  is  liable  to  become  the  intermediate 
host,  a  part  usually  played  for  this  tape-worm  by  the  pig.  This  accident 
may  occur  in  an  individual  the  subject  of  Tcenia  solium,  in  which  case  the 
mature  proglottides  either  themselves  wander  into  the  stomach  or,  what 
is  more  likely,  are  forced  into  the  organ  in  attacks  of  prolonged  vomiting. 
Of  course  the  accidental  ingestion  from  the  outside  of  a  few  ova  is  quite 
possible,  and  the  liability  of  infection  should  always  be  borne  in  mind  in 
handling  the  segments  of  the  worm. 


DISEASES  CAUSED  BY  CESTODES.  369 

The  symptoms  depend  entirely  upon  the  number  of  ova  ingested  and 
the  localities  reached.  In  the  hog  the  cysticerci  produce  very  little  dis- 
turbance. The  muscles,  the  connective  tissue,  and  the  brain  may  be  swarm- 
ing with  the  measles,  as  they  are  called,  and  yet  the  nutrition  is  maintained 
and  the  animal  does  not  appear  to  be  seriously  incommoded.  In  the  in- 
vasion period,  if  large  numbers  of  the  parasites  are  taken,  there  is,  in  all 
probability,  constitutional  disturbance;  certainly  this  is  seen  in  the  calf, 
when  fed  with  the  ripe  segments  of  Tcenia  saginata. 

In  man  a  few  cysticerci  lodged  beneath  the  skin  or  in  the  muscles  may 
cause  no  damage,  and  in  time  the  larvae  die  and  become  calcified.  They 
are  occasionally  found  in  dissection  subjects  or  in  post  mortems  as  ovoid 
white  bodies  in  the  muscles  or  subcutaneous  tissue.  In  this  country  they 
are  very  rare.  I  have  seen  but  one  instance  in  my  post-mortem  experience. 
Depending  on  the  number  and  the  locality  specially  affected,  the  symptoms 
may  be  grouped  into  general,  cerebro-spinal,  and  ocular.  In  155  eases  com- 
piled by  Stiles,  the  parasite  in  117  was  found  in  the  brain,  in  32  in  the 
muscles,  in  9  in  the  heart,  in  3  in  the  lungs,  subcutaneously  in  5,  in  the  liver 
in  2. 

(1)  General. — As  a  rule  the  invasion  of  the  larvae  in  man,  unless  in  very 
large  numbers,  does  not  cause  very  definite  symptoms.  It  occasionally 
happens,  however,  that  a  striking  picture  is  produced.  For  instance, 
a  patient  was  admitted  to  my  wards  very  stiff  and  helpless,  so  much  so 
that  he  had  to  be  assisted  upstairs  and  into  bed.  He  complained  of  numb- 
ness and  tingling  in  the  extremities  and  general  weakness,  so  that  at  first 
he  was  thought  to  have  a  peripheral  neuritis.  At  the  examination,  how- 
ever, a  number  of  painful  subcutaneous  nodules  were  discovered,  which 
proved  on  excision  to  be  the  cysticerci.  Altogether  75  could  be  felt  sub- 
cutaneously, and  from  the  soreness  and  stiffness  they  probably  existed  in 
large  numbers  in  the  muscles.  There  were  none  in  his  eyes,  and  he  had 
no  symptoms  pointing  to  brain  lesions. 

(2)  Cerelro-spinal. — Eemarkable  symptoms  may  result  from  the  pres- 
ence of  the  cysticerci  in  the  brain  and  cord.  In  the  silent  region  they  may 
be  abundant  without  producing  any  symptoms.  I  have  in  my  possession 
the  brain  of  a  pig  containing  scores  of  "  measles,"  yet  the  animal  in  the 
few  moments  in  which  I  saw  it  just  prior  to  death  did  not  present  any 
symptoms  to  attract  attention.  In  the  ventricles  of  the  brain  the  cysti- 
cerci may  attain  a  considerable  size,  owing  to  the  fact  that  in  regions  in 
which  they  are  unrestrained  in  their  growth,  as  in  the  peritonaeum,  the 
bladder-like  body  grows  freely.  When  in  the  fourth  ventricle,  remarkable 
irritative  symptoms  may  be  produced.  In  1884  I  saw  with  Friedlander  in 
Berlin  a  case  from  Riess's  wards  in  which  during  life  there  had  been  symp- 
toms of  diabetes  and  anomalous  nervous  symptoms.  Post  mortem,  the 
cysticercus  was  found  beneath  the  valve  of  Vieussens,  pressing  upon  the 
floor  of  the  fourth  ventricle. 

(3)  Ocular. — Since  von  Graefe  demonstrated  the  presence  of  the  cysti- 
cercus in  the  vitreous  humor  many  cases  have  been  placed  on  record,  and 
it  is  a  condition  easily  recognized  by  oculists. 

Except  in  the  eye,  the  diagnosis  can  rarely  be  made;  when  the  cysti- 


370  DISEASES  DUE  TO  ANIMAL  PARASITES. 

cerci  are  subcutaneous,  one  may  be  excised.  It  is  possible  that  when 
numerous  throughout  the  muscles  they  may  be  seen  under  the  tongue,  in 
which  situation  they  may  exist  in  the  pig  in  numbers. 

II.  Echinococcus  Disease. — The  hydatid  worms  or  echinococci  are  the 
larvae  of  the  Tcenid  echinococcus  of  the  dog.  This  is  a  tiny  ^cestode  not 
more  than  4  or  5  mm.  in  length,  consisting  of  only  three  or  four  segments, 
of  which  the  terminal  one  alone  is  mature,  and  has  a  length  of  about  2  mm. 
and  a  breadth  of  0.6  mm.  The  head  is  small  and  provided  with  four  suck- 
ing disks  and  a  rostellum  with  a  double  row  of  booklets.  This  is  an  exceed- 
ingly rare  parasite  in  the  dog.  Cobbold  states  that  he  has  never  met  with 
a  natural  specimen  in  England.  Leidy  had  not  one  in  his  large  collection. 
I  have  not  met  with  an  instance  in  this  country;  Curtice,  of  Washington, 
found  it  once  in  an  American  dog.  The  only  specimens  in  my  cabinet  I 
procured  experimentally  by  feeding  a  dog  with  echinococcus  cysts  from  an 
ox.  The  worms  are  so  small  that  they  may  be  readily  overlooked,  since 
they  form  small  white,  thread-like  bodies  closely  adherent  among  the  villi 
of  the  small  intestines.  The  ripe  segment  contains  about  5,000  eggs, 
which  attain  their  development  in  the  solid  organs  of  various  animals, 
particularly  the  hog  and  ox,  more  rarely  the  horse  and  the  sheep.  In  some 
countries  man  is  a  common  intermediate  host,  owing  to  the  accidental 
ingestion  of  the  ova. 

Development. — The  little  six-hooked  embryo,  freed  from  the  eggshell 
by  digestion,  burrows  through  the  intestinal  wall  and  reaches  the  perito- 
neal cavity  or  the  muscles;  it  may  enter  the  portal  vessels  and  be  carried  to 
the  liver.  It  may  enter  the  systemic  vessels,  and,  passing  the  pulmonary 
capillaries,  as  it  is  protoplasmic  and  elastic,  may  reach  the  brain  or  other 
parts.  Once  having  reached  its  destination,  it  undergoes  the  following 
changes:  The  booklets  disappear  and  the  little  embryo  is  gradually  con- 
verted into  a  small  cyst  which  presents  two  distinct  layers — an  external, 
laminated,  cuticular  membrane  or  capsule,  and  an  internal,  granular,  par- 
enchymatous layer,  the  endocyst.  The  little  cyst  or  vesicle  contains  a 
clear  fluid.  There  is  more  or  less  reaction  in  the  neighboring  tissues,  and 
the  cyst  in  time  has  a  fibrous  investment.  When  this  primary  cyst  or 
vesicle  has  attained  a  certain  size,  buds  develop  from  the  parenchymatous 
layer,  which  are  gradually  converted  into  cysts,  presenting  a  structure  iden- 
tical with  that  of  the  original  cyst,  namely,  an  elastic  chitinous  membrane 
lined  with  a  granular  parenchymatous  layer.  These  secondary  or  daughter 
cysts  are  at  first  connected  with  the  lining  membrane  of  the  primary- 
cyst,  but  are  soon  set  free.  In  this  way  the  parent  cyst  as  it  grows  may- 
contain  a  dozen  or  more  daughter  cysts.  Inside  these  daughter  cysts  a  simi- 
lar process  may  occur,  and  from  buds  in  the  walls  granddaughter  cysts  arc 
developed.  From  the  granular  layer  of  the  parent  and  daughter  cysts  buds 
arise  which  develop  into  brood  capsules.  From  the  lining  membrane  the 
little  outgrowths  arise  and  gradually  develop  into  bodies  known  as  scolices, 
which  represent  in  reality  the  head  of  the  Tcenia  echinococcus  and  present 
four  sucking  disks  and  a  circle  of  booklets.  Each  scolex  is  capable  when 
transferred  to  the  intestines  of  a  dog  of  developing  into  an  adult  tape-worm. 
The  differejice  between  the  ovum  of  an  ordinary  tape-worm,  such  as  the 


DISEASES  CAUSED  BY  CESTODES.  371 

Tcenia  solium,  and  the  Tcenia  echinococcus  is  in  this  way  very  striking.  In 
the  former  case  the  ovum  develops  into  a  single  larva — the  Cysticercus  cellu- 
losce — whereas  the  egg  of  the  Tcenia  echinococcus  develops  into  a  cjst  which 
is  capable  of  multiplying  enormously  and  from  the  lining  membranie  of 
which  millions  of  larval  tape-worms  develop.  Ordinarily  in  man  the  de- 
velopment of  the  echinococcus  takes  place  as  above  mentioned  and  by 
an  endogenous  form  in  which  the  secondary  and  tertiary  cysts  are  com- 
tained  within  the  primary;  but  in  animals  the  formation  may  be  diffeient^. 
as  the  buds  from  the  primary  cyst  penetrate  between  the  layers  and  develop* 
externally,  forming  the  exogenous  variety.  A  third  form  is  the  multilocular 
echinococcus,  in  which  from  the  primary  cysts  buds  develop  which  are  cut 
off  completely  and  are  surrounded  by  thick  capsules  of  a  connective  tissue, 
which  join  together  and  ultimately  form  a  hard  mass  represented  by 
strands  of  connective  tissue  enclosing  alveolar  spaces  about  the  size  of  peas 
or  a  little  larger.  In  these  spaces  are  found  the  remnants  of  the  echinococ- 
cus cyst,  occasionally  the  scolices  or  booklets,  but  they  are  often  sterile. 

The  fluid  is  limpid,  non-albuminous;  specific  gravity  1.005  io  1.009, 
.occasionally  higher.  It  may  contain  sugar  and  succinic  acid,  and  after 
repeated  tapping  of  the  cyst,  albumin.  When  not  degenerated,  the  hydlaitid 
heads  or  the  characteristic  booklets  are  found  in  the  contents  of  the  cyst- 

Changes  in  the  Cyst. — It  is  not  known  definitely  how  long  the  echino- 
coccus remains  alive,  but  it  probably  lives  many  years — according  to  some 
authors  as  long  as  twenty  years.  The  most  common  change  is  death  and 
the  gradual  inspissation  of  the  contents  and  conversion  of  the  cyst  into  a 
mass  containing  putty-like  or  granular  material  which  may  be  partially 
calcified.  Eemnants  of  the  chitinous  cyst  wall  or  booklets  may  be  found. 
These  obsolete  hydatid  cysts  are  not  infrequently  found  in  the  liver.  A 
more  serious  termination  is  rupture,  which  may  take  place  into  a  serous  sac, 
or  perforation  may  take  place  externally,  when  the  cysts  are  discharged,  as 
into  the  bronchi  or  alimentary  canal  or  urinary  passages.  More  unfa- 
vorable are  the  instances  in  which  rupture  occurs  into  the  bile-passages  or 
into  the  inferior  cava.  Eecovery  may  follow  the  rupture  and  discharge  of 
the  hydatids  externally.  Sudden  death  has  been  known  to  follow  the 
rupture.  A  third  and  very  serious  mode  of  termination  is  suppuration, 
which  may  occur  spontaneously  or  follow  rupture  and  is  found  most  fre- 
quently in  the  liver.  Large  abscesses  may  be  formed  which  contain  the 
hydatid  membranes. 

Geographical  Distribution  of  the  Echinococcus. — The  disease  prevails  most 
extensively  in  those  countries  in  which  man  is  brought  into  close  contact 
with  the  dog,  particularly  when,  as  in  Australia,  the  dogs  are  used  for 
herding  sheep,  the  animal  in  which  the  larval  form  of  the  Tmnia  echinococcus. 
is  most  often  found.  In  Iceland  the  cases  are  very  numerous.  In  Europe 
the  disease  is  not  uncommon.  In  Great  Britain  and  in  this  country  it  is. 
rare,  and  a  majority  of  the  cases  are  in  foreigners.  Statistics  of  the  preva- 
lence of  the  disease  in  America  have  been  published  by  Osier  (1882),  Som- 
mer  (1895-'96),  and  by  Lyon  (1903),  who  has  collected  241  cases.  Of  these, 
136  cases  were  in  foreigners;  in  92  the  nationality  was  not  stated;  10  were 
negroes;  2  Canadians,  and  only  1  a  native  American.     Fifty-six  cases  oc- 


372  DISEASES  DUB  TO  ANIMAL  PARASITES. 

curred  in  Manitoba,  in  which  province  there  is  a  large  settlement  of  Ice- 
landers, who  have  brought  the  disease  with  them.  Only  one  instance  is 
known  in  a  Canadian-born  offspring  of  an  Icelandic  emigrant. 

Distribution  in  the  Body. — Of  1634  cases  comprised  in  the  statistics  of 
Davaine,  Booker,  Finsen,  and  Neisser,  the  parasite  existed  in  the  liver  in 
820;  in  the  lung  or  pleura  in  137;  in  the  abdominal  organs,  including  the 
kidneys,  bladder,  and  genitalia,  in  334;  in  the  nervous  system  in  122;  in  the 
circulatory  system  in  42;  in  other  organs  179.  Of  the  241  cases  in  Lyon's 
series  in  this  country  the  liver  was  the  seat  in  177,  and  the  omentum,  peri- 
toneal cavity,  and  mesentery  in  5.  In  11  cases  cysts  were  passed  per  rectum, 
in  7  cases  cysts  or  booklets  were  expectorated,  and  in  2  cases  passed  per 
urethram. 

Symptoms. — (a)  Hydatids  of  the  Liver. — Small  cysts  may  cause  no 
disturbance;  large  and  growing  cysts  produce  signs  of  tumor  of  the  liver 
with  great  increase  in  the  size  of  the  organ.  ISTaturally  the  physical  signs 
depend  much  upon  the  situation  of  the  growth.  Near  the  anterior  sur- 
face in  the  epigastric  region  the  tumor  may  form  a  distinct  prominence 
and  have  a  tense,  firm  feeling,  sometimes  with  fluctuation.  A  not  infre- 
quent situation  is  to  the  left  of  the  suspensory  ligament,  the  resulting  tu- 
mor pushing  up  the  heart  and  causing  an  extensive  area  of  dulness  in  the 
lower  sternal  and  left  hypochondriac  regions.  In  the  right  lobe,  if  the 
tumor  is  on  the  posterior  surface,  the  enlargement  of  the  organ  is  chiefly 
upward  into  the  pleura  and  the  vertical  area  of  dulness  in  the  posterior 
axillary  line  is  increased.  Superficial  cysts  may  give  what  is  known  as  the 
hydatid  fremitus.  If  the  tumor  is  palpated  lightly  with  the  fingers  of  the 
left  hand  and  percussed  at  the  same  time  with  those  of  the  right,  there  is 
felt  a  vibration  or  trembling  movement  which  persists  for  a  certain  time. 
It  is  not  always  present,  and  it  is  doubtful  whether  it  is  peculiar  to  the 
hydatid  tumors  or  is  due,  as  Briangon  held,  to  the  collision  of  the  daugh- 
ter cysts.  Very  large  cysts  are  accompanied  by  feelings  of  pressure  or 
dragging  in  the  hepatic  region,  sometimes  actual  pain.  The  general  con- 
dition of  the  patient  is  at  first  good  and  the  nutrition  little,  if  at  all,  in- 
terfered with.  Unless  some  of  the  accidents  already  referred  to  occur,  the 
symptoms  indeed  may  be  trifling  and  due  only  to  the  pressure  or  weight 
of  the  tumor. 

Suppuration  of  the  cyst  changes  the  clinical  picture  into  one  of  pyaemia. 
There  are  rigors,  sweats,  more  or  less  jaundice,  and  rapid  loss  of  weight. 
Perforation  may  occur  into  the  stomach,  colon,  pleura,  bronchi,  or  exter- 
nally, and  in  some  instances  recovery  has  taken  place.  Perforation  into 
the  pericardium  and  inferior  vena  cava  is  fatal.  In  the  latter  case  the 
daughter  cysts  have  been  found  in  the  heart,  plugging  the  tricuspid  ori- 
fice and  the  pulmonary  artery.  Perforation  of  the  bile-passages  causes 
intense  jaundice,  and  may  lead  to  suppurative  cholangitis."" 

An  interesting  symptom  connected  with  the  rupture  of  hydatid  cysts 
is  the  development  of  urticaria,  which  may  also  follow  aspiration  of  the 
cysts.  Brieger  has  separated  a  highly  toxic  material  from  the  fluid,  and  to 
it  the  symptoms  of  poisoning  may  be  due. 

Diagnosis. — Cysts  of  moderate  size  may  exist  without  producing  symp- 


DISEASES  CAUSED  BY  CESTODES.  373 

toms.  Large  multiple  echinococci  may  cause  great  enlargement  with 
irregularity  of  the  outline,  and  such  a  condition  persisting  for  any  time 
with  retention  of  the  health  and  strength  suggests  hydatid  disease.  An 
irregular,  painless  enlargement,  particularly  in  the  left  lobe,  or  the  pres- 
ence of  a  large,  smooth,  fluctuating  tumor  of  the  epigastric  region  is  also 
very  suggestive,  and  in  this  situation,  when  accessible  to  palpation,  it 
gives  a  sensation  of  a  smooth  elastic  growth  and  possibly  also  the  hydatid 
tremor.  When  suppuration  occurs  the  clinical  picture  is  really  that  of 
abscess,  and  only  the  existence  of  previous  enlargement  of  the  liver  with 
good  health  would  point  to  the  fact  that  the  suppuration  was  associated 
with  hydatids.  Syphilis  may  produce  irregular  enlargement  without  much 
disturbance  in  the  health,  sometimes  also  a  very  definite  tumor  in  the 
epigastric  region,  but  this  is  usually  firm  and  not  fluctuating.  The  clinical 
features  may  simulate  cancer  very  closely.  In  a  case  which  I  reported  the 
liver  was  greatly  enlarged  and  there  were  many  nodular  tumors  in  the 
abdomen.  The  post  mortem  showed  enormous  suppurating  hydatid  cysts 
in  the  left  lobe  of  the  liver  which  had  perforated  the  stomach  in  two 
places  and  also  the  duodenum.  The  omentum,  mesentery,  and  pelvis  also 
contained  numerous  cysts.  As  a  rule,  the  clinical  course  of  the  disease 
would  suffice  to  separate  it  clearly  from  cancer.  Dilatation  of  the  gall- 
bladder and  hydronephrosis  have  both  been  mistaken  for  hydatid  disease. 
In  the  former  the  mobility  of  the  tumor,  its  shape,  and  the  mucoid  char- 
acter of  the  contents  suffice  for  the  diagnosis.  In  some  instances  of  hydro- 
nephrosis only  the  exploratory  puncture  could  distinguish  between  the 
conditions.  More  frequent  is  the  mistake  of  confounding  a  hydatid  cyst 
of  the  right  lobe  pushing  up  the  pleura  with  pleural  effusion  of  the  right 
side.  The  heart  may  be  dislocated,  the  liver  depressed,  and  dulness,  feeble 
breathing,  and  diminished  fremitus  are  present  in  both  conditions.  Fre- 
richs  lays  stress  upon  the  different  character  of  the  line  of  dulness;  in  the 
echinococcus  cyst  the  upper  limit  presents  a  curved  line,  the  maximum 
of  which  is  usually  in  the  scapular  region.  Suppurative  pleurisy  may  be 
caused  by  the  perforation  of  the  cyst.  If  adhesions  result,  the  perforation 
takes  place  into  the  lung,  and  fragments  of  the  cysts  or  small  daughter 
cysts  may  be  coughed  up.  For  diagnostic  purposes  the  exploratory  punc- 
ture should  be  used.  As  stated,  the  fluid  is  usually  perfectly  clear  or  slightly 
opalescent,  the  reaction  is  neutral,  and  the  specific  gravity  varies  from  1.005 
to  1.009.  It  is  non-albuminous,  but  contains  chlorides  and  sometimes  traces 
of  sugar.  Hooklets  may  be  found  either  in  the  clear  fluid  or  in  the  sup- 
purating cysts.  They  are  sometimes  absent,  however,  as  the  cyst  may  be 
sterile. 

(b)  Echinococcus  of  the  Bespiratory  System. — Of  809  cases  of  single 
hydatid  cyst  collected  by  Thomas  in  Australia,  the  lung  was  affected  in 
134  cases.  The  larvEC  may  develop  primarily  in  the  pleura  and  attain  a 
large  size.  The  symptoms  are  at  first  those  of  eomj^ression  of  the  lung 
and  dislocation  of  the  heart.  The  physical  signs  are  those  of  fluid  in  the 
pleura  and  the  condition  could  scarcely  be  distinguished  from  ordinary 
effusion.  The  line  of  dulness  may  be  quite  irregular.  As  in  the  echino- 
coccus of  the  liver,  the  general  condition  of  the  patient  may  be  excellent 


374  DISEASES  DUE  TO  ANIMAL  PARASITES. 

in  spite  of  the  existence  of  extensive  disease.  Pleurisy  is  rarely  excited. 
The  cysts  may  become  inflamed  and  perforate  the  chest  wall.  Gary  and  Lyon 
have  analyzed  40  cases  of  primary  echinococcus  cyst  of  the  pleura;  death 
results  in  a  majority  of  the  cases  from  the  toxgemia  follo^u-ing  the  rupture 
and  the  absorption  of  the  fluid  or  from  the  sepsis  following  suppura- 
tion. 

Echinococci  occur  more  frequently  in  the  lung  than  in  the  pleura.  If 
small,  they  may  exist  for  some  time  without  causing  serious  symptoms. 
In  their  growth  they  compress  the  lung  and  sooner  or  later  lead  to  inflam- 
matory processes,  often  to  gangrene,  and  the  formation  of  cavities  which 
connect  with  the  bronchi.  Fragments  of  membrane  or  small  cysts  may  be 
expectorated.  Hsemorrhage  is  not  infrequent.  Perforation  into  the  pleura 
with  empyema  is  common.  A  majority  of  the  cases  are  regarded  during 
life  as  either  phthisis  or  gangrene,  and  it  is  only  the  detection  of  the  char- 
acteristic membranes  or  the  booklets  which  leads  to  the  diagnosis.  The 
condition  is  usually  fatal;  only  a  few  cases  have  recovered.  Of  the  85 
American  cases,  in  6  the  cysts  occurred  in  the  lung  or  pleura. 

(c)  Echinococcus  of  tlie  Kidneys. — In  the  collected  statistics  referred 
to  above  the  genito-urinary  system  comes  second  as  the  seat  of  hydatid 
disease,  though  here  the  affection  is  rare  in  comparison  with  that  of  the 
liver.  Of  the  85  American  cases,  there  were  only  3  in  which  the  kidneys 
or  bladder  were  involved.  The  kidney  may  be  converted  into  an  enormous 
cyst  resembling  a  hydronephrosis. 

The  diagnosis  is  only  possible  by  puncture  and  examination  of  the 
fluid.  The  cyst  may  perforate  into  the  pelvis  of  the  kidney,  and  portions 
of  the  membrane  or  cysts  may  be  discharged  with  the  urine,  sometimes 
producing  renal  colic.  I  have  reported  a  case  in  which  for  many  months^ 
the  patient  passed  at  intervals  numbers  of  small  cysts  with  the  urine.  The 
general  health  was  little  if  at  all  disturbed,  except  by  the  attacks  of  colic 
during  the  passage  of  the  parasites. 

{d)  Echinococcus  of  the  Nervous  System. — In  this  country  very  few  in- 
stances have  occurred  in  the  brain.  One  or  two  reports  indicate  clearly 
that  the  common  cystic  disease  of  the  choroidal  plexuses  has  been  mistaken 
for  hydatids.  Davies  Thomas,  of  Australia,  has  tabulated  97  cases,  includ- 
ing some  of  the  Cysticercus  celluloscB.  According  to  his  statistics,  the  cyst 
is  more  common  on  the  right  than  on  the  left  side,  and  is  most  frequent 
in  the  cerebrum. 

The  symptoms  are  very  indefinite,  as  a  rule,  being  those  of  tumor. 
Persistent  headache,  convulsions,  either  limited  or  general,  and  gradually 
developing  blindness  have  been  prominent  features  in  many  cases. 

Multilocular  Echinococcus. — This  form  merits  a  brief  separate  descrip- 
tion, as  it  differs  so  remarkably  from  the  usual  type  of  the  disease.  It  has 
been  met  with  only  in  Bavaria,  Wiirtemberg,  the  adjacent  districts  of 
Switzerland,  and  in  the  Tyrol.  Possett  has  reported  13  cases  from  von 
Kokitansky's  clinic  at  Innsbruck.  In  this  country  two  cases  have  been 
reported,  both  in  Germans.  Delafield  and  Prudden's  patient  had  been  here 
five  years,  and  for  a  year  before  his  death  had  been  jaundiced.  A  fluctuat- 
ing tumor  was  found  in  the  right  flank,  apparently  connected  with  the 


PARASITIC  ARACHNIDA.  8Y5 

liver.  This  was  opened,  and  death  followed  from  hsemorrhage.  In  Oer- 
teFs  ease  the  patient  had  lived  here  ten  years.  He  was  deeply  jaundiced, 
and  had  a  tumor  mass  at  the  right  horder  of  the  liver,  which  was  enlarged. 
Dr.  Bacon,  Jr.,  resected  a  cyst  from  the  left  lobe  of  the  liver.  The 
primary  tumor  presents  irregularly  formed  cavities  separated  from  each 
other  by  strands  of  connective  tissue,  and  lined  with  the  echinococcus 
membrane.  The  cavities  are  filled  with  a  gelatinous  material,  so  that  the 
tumor  has  very  much  the  appearance  of  an  alveolar  colloid  cancer.  It  is 
quite  possible  that  a  special  form  of  taenia  echinococcus  represents  the 
adult  type  of  this  peculiar  parasite.  This  form  is  almost  exclusively 
confined  to  the  liver,  and  the  symptoms  resemble  more  those  of  tumor  or 
cirrhosis.  The  liver  is,  as  a  rule,  enlarged  and  smooth,  not  irregular  as 
in  presence  of  the  ordinary  echinococcus.  Jaundice  is  a  common  symptom. 
The  spleen  is  usually  enlarged,  there  is  progressive  emaciation,  and  toward 
the  close  haemorrhages  are  common. 

Treatment  of  Echinococcus  Disease. — Medicines  are  of  no 
avail.  Post-mortem  reports  show  that  in  a  considerable  number  of  cases 
the  parasite  dies  and  the  cyst  becomes  harmless.  Operative  measures  should 
be  resorted  to  when  the  cyst  is  large  or  troublesome.  The  simple  aspira- 
tion of  the  contents  has  been  successful  in  a  large  number  of  cases,  and  as 
it  is  not  in  any  way  dangerous,  it  may  be  tried  before  the  more  radical 
procedure  of  incision  and  evacuation  of  the  cysts.  Suppuration  has  oc- 
casionally followed  the  puncture.  Injections  into  the  sac  should  not  be 
practised.  "With  modern  methods  surgeons  now  open  and  evacuate  the 
echinococcus  cysts  with  great  boldness,  and  the  Australian  records,  which 
are  the  most  numerous  and  important  on  this  subject,  show  that  recovery 
is  the  rule  in  a  large  proportion  of  the  cases.  Suppurative  cysts  in  the 
liver  should  be  treated  as  abscess.  Naturally  the  outlook  is  less  favorable. 
The  practical  treatment  of  hydatid  disease  has  been  greatly  advanced 
by  Australian  surgeons.  The  works  of  the  Australian  physicians  James 
Graham  and  Thomas  may  be  consulted  for  interesting  details  in  diagnosis 
and  treatment. 


VI.    PARASITIC   ARACHNIDA. 

(1)  Pentastomes. — (a)  Linguatula  rhmaria  {Pentastoma  tcBnioides)  has 
a  somewhat  lancet-shaped  body,  the  female  being  from  3  to  4  inches  in 
length,  the  male  about  an  inch  in  length.  The  body  is  tapering  and  marked 
by  numerous  rings.  The  adult  worm  infests  the  frontal  sinuses  and  nostrils 
of  the  dog,  more  rarely  of  the  horse.  The  larval  form,  which  is  known  as 
the  Linguatula  serrata  (Pentastomum  denticulatum),  is  seen  in  the  internal 
organs,  particularly  the  liver,  but  has  also  been  found  in  the  kidney.  The 
adult  worm  has  been  found  in  the  nostril  of  man,  but  is  very  rare  and 
seldom  occasions  any  inconvenience.  The  larvae  are  by  no  means  uncom- 
mon, particularly  in  parts  of  Germany. 

{h)  The  Porocephalus  constridus  {Pentastomum  constrictum),  which  is 
about  the  length  of  half  an  inch,  with  twenty-three  rings  on  the  abdomen. 


376  DISEASES  DUE  TO  ANIMAL  PARASITES. 

was  found  by  Aitken  in  the  liver  and  lungs  of  a  soldier  of  a  West  Indian 
regiment. 

The  parasite  is  very  rare  in  this  country.  Flint  refers  to  a  Missouri 
case  in  which  from  75  to  100  of  the  parasites  were  expectorated.  The 
liver  was  enlarged  and  the  parasites  probably  occupied  this  region.  In 
1869  I  saw  a  specimen  which  had  been  passed  with  the  urine  by  a  patient 
of  James  H.  Eichardson,  of  Toronto. 

(2)  Demodex  (Acarus)  follieuloruin  (var.  hominls). — A  minute  para- 
site, from  0.3  mm.  to  0.4  mm.  in  length,  which  lives  in  the  sebaceous  folli- 
cles, particularly  of  the  face.  It  is  doubtful  whether  it  produces  any  symp- 
toms. Possibly  when  in  large  numbers  they  may  excite  inflammation  of 
the  follicles,  leading  to  acne. 

(3)  Sarcoptes  (Acarus)  scabiei  {Itch  Insect). — This  is  the  most  impor- 
tant of  the  arachnid  parasites,  as  it  produces  troublesome  and  distressing 
skin  eruptions.  The  male  is  0.23  mm.  in  length  and  0.19  mm.  in  breadth; 
the  female  is  0.45  mm.  in  length  and  0.35  mm.  in  width.  The  female  can 
be  seen  readily  with  the  naked  eye  and  has  a  pearly-white  color.  It  is  not 
so  common  a  parasite  in  the  United  States  and  Canada  as  in  Europe. 

The  insect  lives  in  a  small  burrow,  about  1  cm.  in  length,  which  it  makes 
for  itself  in  the  epidermis;  At  the  end  of  this  burrow  the  female  lives. 
The  male  is  seldom  found.  The  chief  seat  of  the  parasite  is  in  the  folds 
where  the  skin  is  most  delicate,  as  in  the  web  between  the  fingers  and  toes, 
the  backs  of  the  hands,  the  axilla,  and  the  front  of  the  abdomen.  The  head 
and  face  are  rarely  involved.  The  lesions  which  result  from  the  presence 
of  the  itch  insect  are  very  numerous  and  result  largely  from  the  irritation 
of  the  scratching.  The  commonest  is  a  papular  and  vesicular  rash,  or,  in 
children,  an  ecthymatous  eruption.  The  irritation  and  pustulation  which 
follow  the  scratching  may  completely  destroy  the  burrows,  but  in  typical 
cases  there  is  rarely  doubt  as  to  the  diagnosis. 

The  treatment  is  simple.  It  should  consist  of  warm  baths  with  a  thor- 
ough use  of  a  soft  soap,  after  which  the  skin  should  be  anointed  with  sul- 
phur ointment,  which  in  the  case  of  children  should  be  diluted.  An  oint- 
ment of  naphthol  (drachm  to  the  ounce)  is  very  efficacious. 

(4)  Leptus  autumnalis  {Harvest  Bug). — This  reddish-colored  parasite, 
about  half  a  millimetre  in  size,  is  often  found  in  large  numbers  in  fields 
and  in  gardens.  They  attach  themselves  to  animals  and  man  with  their 
sharp  proboscides,  and  the  booklets  of  their  legs  produce  a  great  deal  of 
irritation.  They  are  most  frequently  found  on  the  legs.  They  are  readily 
destroyed  by  sulphur  ointment  or  corrosive-sublimate  lotions. 

Several  varieties  of  ticks  are  occasionally  found  on  man — ^the  Ixodes 
ricinus  and  the  Dermacentor  americanus,  which  are  met  with  in  horses 
and  oxen. 

VII.    PARASITIC    INSECTS. 

(1)  Pediculi  {PMMriasis ;  Pediculosis). — There  are  three  varieties  of  the 
body  louse,  which  are  found  only  in  persons  of  uncleanly  habits. 

Pediculus  capitis. — The  male  is  from  1  to  1.5  mm.  in  length  and  the 


PARASITIC  INSECTS.  37Y 

female  nearly  2  mm.  The  color  varies  somewhat  with  the  different  races 
of  men.  It  is  light  gray  with  a  black  margin  in  the  European,  and  very 
much  darker  in  the  negro  and  Chinese.  They  are  oviparous,  and  the  female 
lays  about  sixty  eggs,  which  mature  in  a  week.  The  ova  are  attached  to 
the  hairs,  and  can  be  readily  seen  as  white  specks,  known  popularly  as  nits. 
The  symptoms  are  irritation  and  itching  of  the  scalp.  When  numerous 
the  insects  may  excite  an  eczema  or  a  pustular  dermatitis,  which  causes 
crusts  and  scabs,  particularly  at  the  back  of  the  head.  In  the  most  extreme 
cases  the  hair  becomes  tangled  in  these  crusts  and  matted  together,  form- 
ing at  the  occiput  a  firm  mass  which  is  known  as  plica  polonica,  as  it  was 
not  infrequent  among  the  Jewish  inhabitants  of  Poland. 

Pediculus  corporis  (vestimentorum). — This  is  considerably  larger  than 
the  head  louse.  It  lives  on  the  clothing,  and  in  sucking  the  blood  causes 
minute  hsemorrhagic  specks,  which  are  very  common  about  the  neck,  back, 
and  abdomen.  The  irritation  of  the  bites  may  cause  urticaria,  and  the 
scratching  is  usually  in  linear  lines.  In  long-standing  cases,  particularly 
in  old  dissipated  characters,  the  skin  becomes  rough  and  greatly  pigmented, 
a  condition  which  has  been  termed  the  vagabond's  disease — morbus  errorum 
— and  which  may  be  mistaken  for  the  bronzing  of  Addison's  disease. 

PMhirius  pubis  differs  somewhat  from  the  other  forms,  and  is  found 
in  the  parts  of  the  body  covered  with  short  hairs,  as  the  pubes;  more  rarely 
the  axilla  and  eyebrows. 

The  taclies  bleudtres  are  stated  by  French  writers  to  be  excited  by  the 
irritation  of  pediculi. 

Treatment. — For  the  Pediculus  capitis,  when  the  condition  is  very 
bad,  the  hair  should  be  cut  short,  as  it  is  very  difficult  to  destroy  thor- 
oughly all  the  nits.  Repeated  saturations  of  the  hair  in  coal-oil  or  in  tur- 
pentine are  usually  efficacious,  or  with  lotions  of  carbolic  acid,  1  to  50. 
Scrupulous  cleanliness  and  care  are  sufficient  to  prevent  recurrence.  In 
the  case  of  the  Pediculus  corporis  the  clothing  should  be  placed  for  sev- 
eral hours  in  a  disinfecting  oven.  To  allay  the  itching  a  warm  bath  con- 
taining 4  or  5  ounces  of  bicarbonate  of  soda  is  useful.  The  skin  may  be 
rubbed  with  a  lotion  of  carbolic  acid,  2  drachms  to  the  pint,  with  2  ounces 
of  glycerin.  For  the  PMhirius  pubis  white  precipitate  or  ordinary  mer- 
curial ointment  should  be  used,  and  the  parts  should  be  thoroughly  washed 
two  or  three  times  a  day  with  soft  soap  and  water. 

(2)  Cimex  lectularius  (Common  Bed-bug). — This  parasite  is  from  3  to 
4  mm.  in  length  and  has  a  reddish-brown  color.  It  lives  in  the  crevices  of 
the  bedstead  and  in  the  cracks  in  the  floor  and  in  the  walls.  It  is  noc- 
turnal in  its  habits.  The  peculiar  odor  of  the  insect  is  caused  by  the  secre- 
tion of  a  special  gland.  The  parasite  possesses  a  long  proboscis,  with  which 
it  sucks  the  blood.  Individuals  differ  remarkably  in  the  reaction  to  the 
bite  of  this  insect;  some  are  not  disturbed  in  the  slightest  by  them,  in 
others  the  irritation  causes  hyperasmia  and  often  intense  urticaria.  Fumi- 
gation with  sulphur  or  scouring  with  corrosive-sublimate  solution  or  kero- 
sene destroys  them.    Iron  bedsteads  should  be  used. 

(3)  Pulex  irritans  (The  Common  Flea). — The  male  is  from  2  to  2.5 
mm.  in  length,  the  female  from  3  to  4  mm.    The  flea  is  a  transient  para- 


378  DISEASES  DtJB  TO  ANIMAL  PARASITES. 

site  on  man.  The  bite  causes  a  circular  red  spot  of  hypergemia  in  the  centre 
of  which  is  a  little  speck  where  the  boring  apparatus  has  entered.  The 
amount  of  irritation  caused  by  the  bite  is  variable.  Many  persons  suffer 
intensely  and  a  diffuse  erythema  or  an  irritable  urticaria  develops;  others 
suffer  no  inconvenience  whatever. 

The  Pulex  penetrans  (sand-flea;  jigger)  is  found  in  tropical  countries, 
particularly  in  the  West  Indies  and  South  America.  It  is  much  smaller 
than  the  common  flea,  and  not  only  penetrates  the  skin,  but  burrows  and 
produces  an  inflammation  with  pustular  or  vesicular  swelling.  It  most 
frequently  attacks  the  feet.  It  is  readily  removed  with  a  needle.  Where 
they  exist  in  large  numbers  the  essential  oils  are  used  on  the  feet  as  a 
preventive. 

VIII.    MYIASIS. 

Of  these,  the  most  important  are  the  larvae  of  certain  diptera,  particu- 
larly the  flesh  flies — Creophila.     The  condition  is  called  myiasis. 

The  most  common  form  is  that  in  which  an  external  wound  becomes 
living,  as  it  is  called.  This  myiasis  vulnerum  is  caused  by  the  larvae  of 
either  the  blue-bottle  or  the  common  flesh  fly.  The  larvae  of  the  Lucilia 
macellaria,  the  so-called  screw-worm,  have  been  found  in  the  nose,  in 
wounds,  and  in  the  vagina  after  delivery.  They  can  be  removed  readily 
with  the  forceps;  if  there  is  any  difficulty,  thorough  cleansing  and  the 
application  of  an  antiseptic  bandage  is  sufficient  to  kill  them.  The  ova 
of  these  flies  may  be  deposited  in  the  nostrils,  the  ears,  or  the  conjunctiva — 
the  myiasis  narium,  aurium,  conjunctivae.  This  invasion  rarely  takes  place 
unless  these  regions  are  the  seat  of  disease.  In  the  nose  and  in  the  ear  the 
larvae  may  cause  serious  inflammation. 

The  cutaneous  myiasis  may  be  caused  by  the  larvae  of  the  Musca  vomi- 
toria,  but  more  commonly  by  the  bot-flies  of  the  ox  and  sheep,  which 
occasionally  attack  man.  This  condition  is  rare  in  temperate  climates. 
Matas  has  described  a  ease  in  which  oestrus  larvae  were  found  in  the  glu- 
teal region.  In  parts  of  Central  America  the  eggs  of  another  bot-fly,  the 
Dermatobia,  are  not  infrequently  deposited  in  the  skin  and  produce  a 
swelling  very  like  the  ordinary  boil. 

A  specimen  of  the  Homalomyia  scalaris,  one  of  the  privy  flies,  was  sent 
to  me  by  Dr.  Hartin,  of  Kaslo  City,  British  Columbia,  the  larvae  of  which 
were  passed  in  large  numbers  in  the  stools  of  a  man  aged  twenty-four, 
a  native  of  Louisiana.  They  were  present  in  the  stools  from  May  1  to  July 
15,  1897. 

Myiasis  interna  may  result  from  the  swallowing  of  the  larvae  of  the 
common  house  fly  or  of  species  of  the  genus  Anthomyia.  There  are  many 
cases  on  record  in  which  the  larvae  of  the  Musca  domestica  have  been  dis- 
charged by  vomiting.  Instances  in  which  dipterous  larvae  have  been  passed 
in  the  faeces  are  less  common.  Pinlayson,  of  Glasgow,  has  recently  re- 
ported an  interesting  case  in  a  physician,  who,  after  protracted  constipa- 
tion and  pain  in  the  back  and  sides,  passed  large  numbers  of  the  larvae 
of  the  flower  fly — Anthomyia  canicularis.     Among  other  forms  of  larvae 


MYIASIS.  3T9 

or  gentles,  as  they  are  sometimes  called,  which  have  been  found  in  the 
faeces,  are  those  of  the  common  house  fly,  the  blue-bottle  fly,  and  the 
Techomyza  fusca.  The  larvae  of  other  insects  are  extremely  rare.  It  is 
stated  that  the  caterpillar  of  the  tabby  moth  has  been  found  in  the  faeces. 

Here  may  be  mentioned  among  the  effects  of  insects  the  remarkable 
urticaria  epidemica,  which  is  caused  in  some  districts  by  the  procession 
caterpillars,  particularly  the  species  Cnethocampa.  There  are  districts  in 
the  Kahlberger  Sehweiz  which  have  been  rendered  almost  uninhabitable 
by  the  irritative  skin  eruptions  caused  by  the  presence  of  these  insects,  the 
action  of  which  is  not  necessarily  in  consequence  of  actual  contact  with 
them. 

In  Africa  the  larvae  of  the  Cayor  fly  are  not  uncommonly  found  be- 
neath the  skin,  in  little  boils. 


24 


SECTION  in. 

THE  ie^toxioatio:n"s 

AND  SUN-STROKE. 


I.   ALCOHOLISM. 

(1)  Acute  Alcoholism. — When  a  large  quantity  of  alcohol  is  taken,  its 

influence  on  the  nervous  system  is  manifested  in  muscular  incoordina- 
tion, mental  disturbance,  and,  finally,  narcosis.  The  indiridual  presents 
a  flushed,  sometimes  slightly  cyanosed  face,  a  full  pulse,  with  deep  but  rarely 
stertorous  respirations.  The  pupils  are  dilated.  The  temperature  is  fre- 
quently below  normal,  particularly  if  the  patient  has  been  exposed  to  cold. 
Perhaps  the  lowest  reported  temperatures  have  been  in  cases  of  this  sort. 
An  instance  is  on  record  in  which  the  patient  on  admission  to  hospital  had 
a  temperature  of  24°  C.  (ca.  75°  F.),  and  ten  hours  later  the  temperature 
had  not  risen  to  91°.  The  unconsciousness  is  rarely  so  deep  that  the  pa- 
tient cannot  be  roused  to  some  extent,  and  in  reply  to  questions  he  mutters 
incoherently.  Muscular  twitchings  may  occur,  but  rarely  convulsions. 
The  breath  has  a  heavy  alcoholic  odor. 

The  diagnosis  is  not  difficult,  yet  mistakes  are  frequently  made.  Per- 
sons are  sometimes  brought  to  hospital  by  the  police  supposed  to  be  drunk 
when  in  reality  they  are  dying  from  apoplexy.  Too  great  care  cannot  be 
exercised,  and  the  patient-^  should  receive  the  benefit  of  the  doubt.  In 
some  instances  the  mistake  has  arisen  from  the  fact  that  a  person  who  has 
been  drinking  heavily  has  been  stricken  with  apoplexy.  In  this  condition 
the  coma  is  usually  deeper,  stertor  is  present,  and  there  may  be  evidence  of 
hemiplegia  in  the  greater  flaccidity  of  the  limbs  on  one  side.  The  subject 
will  be  considered  in  the  section  upon  uraemic  coma. 

Dipsomania  is  a  form  of  acute  alcoholism  seen  in  persons  with  a  strong 
hereditary  tendency  to  drink.  Periodically  the  victims  go  "  on  a  spree," 
but  in  the  intervals  they  are  entirely  free  from  any  craving  for  alcohol. 

(2)  Chronic  Alcoholism. — In  moderation,  wine,  beer,  and  spirits  may 
be  taken  throughout  a  long  life  without  impairing  the  general  health. 

According  to  Payne,  the  poisonous  effects  of  alcohol  are  manifested  (1) 
as  a  functional  poison,  as  in  acute  narcosis;  (2)  as  a  tissue  poison,  in  which 
its  effects  are  seen  on  the  parenchymatous  elements,  particularly  epithe- 
380 


ALCOHOLISM.  381 

Hum  and  nerve,  producing  a  slow  degeneration,  and  on  the  blood-vessels, 
causing  thickening  and  ultimately  fibroid  changes;  and  (3)  as  a  checker 
of  tissue  oxidation,  since  the  alcohol  is  consumed  in  place  of  the  fat.  This 
leads  to  fatty  changes  and  sometimes  to  a  condition  of  general  steatosis. 

The  chief  effects  of  chronic  alcohol  poisoning  may  be  thus  summa- 
rized. 

Nervous  System. — Functional  disturbance  is  common.  Unsteadiness 
of  the  muscles  in  performing  any  action  is  a  constant  feature.  The  tremor 
is  best  seen  in  the  hands  and  in  the  tongue.  The  mental  processes  may 
be  dull,  particularly  in  the  early  morning  hours,  and  the  patient  is  unable 
to  transact  any  business  until  he  has  had  his  accustomed  stimulant.  Irri- 
tability of  temper,  forgetfulness,  and  a  change  in  the  moral  character  of 
the  individual  gradually  come  on.  The  judgment  is  seriously  impaired, 
the  will  enfeebled,  and  in  the  final  stages  dementia  may  supervene.  The 
relation  of  chronic  alcoholism  to  insanity  has  been  much  discussed.^  Ac- 
cording to  Savage,  of  4,000  patients  admitted  to  the  Bethlehera  Hospital, 
133  gave  drink  as  the  cause  of  their  insanity.  Chronic  alcoholism  is  be- 
lieved by  many  to  be  one  of  the  special  causes  of  dementia  paralytica,  but 
the  opinions  of  experts  on  this  question  are  still  discordant.  Savage  states 
that  not  more  that  7  per  cent  are  caused  by  alcohol  alone.  In  many  cases 
it  is  certainly  one  of  the  important  elements  in  the  strain  which  leads  to 
this  breakdown.  Epilepsy  may  result  directly  from  chronic  drinking.  It 
is  a  hopeful  form,  and  may  disappear  entirely  with  a  return  to  habits  of 
temperance. 

No  characteristic  changes  are  found  in  the  nervous  system.  Hasmor- 
rhagic  pachymeningitis  is  not  very  uncommon.  Opacity  and  thickening 
of  the  pia-arachnoid  membranes,  with  more  or  less  wasting  of  the  convo- 
lutions, generally  occur.  These  are  in  no  way  peculiar  to  chronic  alcohol- 
ism, but  are  found  in  old  persons  and  in  chronic  wasting  diseases.  In  the 
very  protracted  cases  there  may  be  chronic  encephalo-meningitis  with  ad- 
hesions of  the  membranes.  Finer  changes  in  the  nerve-cells,  their  pro- 
cesses, and  the  neuroglia  have  been  described  by  Berkley,  Hoch,  and  others. 
By  far  the  most  striking  effect  of  alcohol  on  the  nervous  system  is  the  pro- 
duction of  the  alcoholic  neuritis,  which  will  be  considered  later. 

Digestive  System. — Catarrh  of  the  stomach  is  the  most  common  symp- 
tom. The  toper  has  a  furred  tongue,  heavy  breath,  and  in  the  morning  a 
sensation  of  sinking  at  the  stomach  until  he  has  had  his  dram.  The  appe- 
tite is  usually  impaired  and  the  bowels  are  constipated.  In  beer-drinkers 
dilatation  of  the  stomach  is  common. 

Alcohol  produces  definite  changes  in  the  liver,  leading  ultimately  to 
the  various  forms  of  cirrhosis,  to  be  described.  In  Welch's  laboratory  J. 
Friedenwald  has  caused  typical  cirrhosis  in  rabbits  by  the  administration 
of  alcohol.  The  effect  is  probably  a  primary  degenerative  change  in  the 
liver-cells,  although  many  good  observers  still  hold  that  the  poison  acts 
first  upon  the  connective-tissue  elements.  It  is  probable  that  a  special 
vulnerability  of  the  liver-cells  is  necessary  in  the  etiology  of  alcoholic 
cirrhosis.  There  are  cases  in  which  comparatively  moderate  drinking  for 
a  few  years  has  been  followed  by  cirrhosis;  on  the  other  hand,  the  livers 


382  .    THE  INTOXICATIONS  AND  SUN-STROKE. 

of  persons  who  have  been  steady  drinkers  for  thirty  or  forty  years  may 
show  only  a  moderate  grade  of  sclerosis.  For  years  before  cirrhosis  develops 
heavy  drinkers  may  present  an  enlarged  and  tender  liver,  with  at  times 
swelling  of  the  spleen.  With  the  gastric  and  hepatic  disorders  the  facies 
often  becomes  very  characteristic.  The  venules  of  the  cheeks  and  nose  are- 
dilated;  the  latter  becomes  enlarged,  red,  and  may  present  the  condition 
known  as  acm  rosacea.  The  eyes  are  watery,  the  conjunctivae  hyperaemic 
and  sometimes  bile-tinged. 

The  heart  and  arteries  in  chronic  topers  show  important  degenerative 
changes.  Alcoholism  is  one  of  the  special  factors  in  causing  arterio- 
sclerosis. Steell  has  pointed  out  the  frequency  of  cardiac  dilatation  in 
these  cases. 

Kidneys. — The  influence  of  chronic  alcoholism  upon  these  organs  is 
by  no  means  so  marked.  According  to  Dickinson  the  total  of  renal  disease 
is  not  greater  in  the  drinking  class,  and  he  holds  that  the  effect  of  alcohol 
on  the  kidj^eys  has  been  much  overrated.  Formad  has  directed  attention 
to  the  fact  that  in  a  large  proportion  of  chronic  alcoholics  the  kidneys  are 
increased  in  size.  The  Guy's  Hospital  statistics  support  this  statement, 
and  Pitt  notes  that  in  43  per  cent  of  the  bodies  of  hard  drinkers  the  kidneys 
were  hypertrophied  without  showing  morbid  change.  The  typical  granu- 
lar kidney  seems  to  result  indirectly  from  alcohol  through  the  arterial 
changes. 

It  was  formerly  thought  that  alcohol  was  in  some  way  antagonistic  to 
tuberculous  disease,  but  the  observations  of  late  years  indicate  clearly  that 
the  reverse  is  the  case  and  that  chronic  drinkers  are  much  more  liable  to 
both  acute  and  pulmonary  tuberculosis.  It  is  probably  altogether  a  ques- 
tion of  altered  tissue-soil,  the  alcohol  lowering  the  vitality  and  enabling  the 
bacilli  more  readily  to  develop  and  grow. 

(3)  Deliriuin  Tremens  (mania  a  potu)  is  really  only  an  incident  in  the 
history  of  chronic  alcoholism,  and  results  from  the  long-continued  action 
of  the  poison  on  the  brain.  The  condition  was  first  accurately  described 
early  in  this  century  by  Sutton,  of  Grreenwich,  who  had  numerous  oppor- 
tunities for  studying  the  different  forms  among  the  sailors.  One  of  the 
most  thorough  and  careful  studies  of  the  disease  was  made  by  Ware,  of 
Boston.  A  spree  in  a  temperate  person,  no  matter  how  prolonged,  is  rarely 
if  ever  followed  by  delirium  tremens;  but  in  the  case  of  an  habitual 
drinker  a  temporary  excess  is  apt  to  bring  on  an  attack.  It  sometimes 
develops  in  consequence  of  the  sudden  withdrawal  of  the  alcohol.  There 
are  circumstances  which  in  a  heavy  drinker  determine,  sometimes  with 
abruptness,  the  onset  of  delirium.  Such  are  an  accident,  a  sudden  fright 
or  shock,  and  an  acute  inflammation,  particularly  pneumonia.  At  the 
outset  of  the  attack  the  patient  is  restless  and  depressed  and  sleeps  badly, 
symptoms  which  cause  him  to  take  alcohol  more  freely.  After  a  day  or 
two  the  characteristic  delirium  sets  in.  The  patient  talks  constantly  and 
incoherently;  he  is  incessantly  in  motion,  and  desires  to  go  out  and  attend 
to  some  imaginary  business.  Hallucinations  of  sight  and  hearing  develop. 
He  sees  objects  in  the  room,  such  as  rats,  mice,  or  snakes,  and  fancies  that 
they  are  crawling  over  his  body.     The  terror  inspired  by  these  imaginary 


ALCOHOLISM.  383 

objects  is  great,  and  has  given  the  popular  name  "  horrors  "  to  the  disease. 
The  patients  need  to  be  watched  constantly,  for  in  their  delusions  they 
may  jump  out  of  the  window  or  escape.  Auditory  hallucinations  are  not 
so  common,  but  the  patient  may  complain  of  hearing  the  roar  of  animals 
or  the  threats  of  imaginary  enemies.  There  is  much  muscular  tremor; 
the  tongue  is  covered  with  a  thick  white  fur,  and  when  protruded  is  tremu- 
lous. The  pulse  is  soft,  rapid,  and  readily  compressed.  There  is  usually 
fever,  but  the  temperature  rarely  registers  above  102°  or  103°.  In  fatal 
cases  it  may  be  higher.  Insomnia  is  a  constant  feature.  On  the  third  or 
fourth  day  in  favorable  cases  the  restlessness  abates,  the  patient  sleeps, 
and  improvement  gradually  sets  in.  The  tremor  persists  for  some  days, 
the  hallucinations  gradually  disappear,  and  the  appetite  returns.  In  more 
serious  cases  the  insomnia  persists,  the  delirium  is  incessant,  the  pulse  be- 
comes more  frequent  and  feeble,  the  tongue  dry,  the  prostration  extreme, 
and  death  takes  place  from  gradual  heart-failure. 

Diagnosis. — The  clinical  picture  of  the  disease  can  scarcely  be  con- 
founded with  any  other.  Cases  with  fever,  however,  may  be  mistaken  for 
meningitis.  By  far  the  most  common  error  is  to  overlook  some  local  dis- 
ease, such  as  pneumonia  or  erysipelas,  or  an  accident,  as  a  fractured  rib, 
which  in  a  chronic  drinker  may  precipitate  an  attack  of  delirium  tremens. 
In  every  instance  a  careful  examination  should  be  made,  particularly  of 
the  lungs.  It  is  to  be  remembered  that  in  the  severer  forms,  particularly 
the  febrile  cases,  congestion  of  the  bases  of  the  lungs  is  by  no  means  un- 
common. Another  point  to  be  borne  in  mind  is  the  fact  that  pneumonia 
of  the  apex  is  apt  to  be  accompanied  by  delirium  similar  to  mania  a  potu. 

Prognosis. — Eecovery  takes  place  in  a  large  proportion  of  the  cases 
in  private  practice.  In  hospital  practice,  particularly  in  the  large  city 
hospitals  to  which  the  debilitated  patients  are  taken,  the  death-rate  is 
higher.  Gerhard  states  that  of  1,241  cases  admitted  to  the  Philadelphia 
Hospital  121  proved  fatal.  Recurrence  is  frequent,  almost  indeed  the  rule, 
if  the  drinking  is  kept  up. 

Treatment. — Acute  alcoholism  rarely  requires  any  special  measures, 
as  the  patient  sleeps  off  the  effects  of  the  debauch.  In  the  case  of  pro- 
found alcoholic  coma  it  may  be  advisable  to  wash  out  the  stomach,  and  if 
collapse  symptoms  occur  the  limbs  should  be  rubbed  and  hot  applications 
made  to  the  body.  Should  convulsions  supervene,  chloroform  may  be 
carefully  administered.  In  the  acute,  violent  alcoholic  mania  the  hypo- 
dermic injection  of  apomorphia,  one  eighth  or  one  sixth  of  a  grain,  is 
usually  very  effectual,  causing  nausea  and  vomiting,  and  rapid  disappear- 
ance of  the  maniacal  symptoms. 

Chronic  alcoholism  is  a  condition  very  difficult  to  treat,  and  once  fully 
established  the  habit  is  rarely  abandoned.  The  most  obstinate  cases  are 
those  with  marked  hereditary  tendency.  Withdrawal  of  the  alcohol  is  the 
first  essential.  This  is  most  effectually  accomplished  by  placing  the  pa- 
tient in  an  institution,  in  which  he  can  be  carefully  watched  during  the 
trying  period  of  the  first  week  or  ten  days  of  abstention.  The  absence  of 
temptation  in  institution  life  is  of  special  advantage.  For  the  sleepless- 
ness the  bromides  or  hyoscine  may  be  employed.     Quinine  and  strychnine 


384  THE  INTOXICATIONS  AND  SUN-STROKE. 

in  tonic  doses  may  be  given.  Cocaine  or  the  fluid  extract  of  coca  has  been 
recommended  as  a  substitute  for  alcohol,  but  it  is  not  of  much  service. 
Prolonged  seclusion  in  a  suitable  institution  is  in  reality  the  only  effectual 
means  of  cure.  When  the  hereditary  tendency  is  strongly  developed  a  lapse 
into  the  drinking  habit  is  almost  inevitable. 

In  delirium  tremens  the  patient  should  be  confined  to  bed  and  care- 
fully watched  night  and  day.  The  danger  of  escape  in  these  cases  is  very 
great,  as  the  patient  imagines  himself  pursued  by  enemies  or  demons. 
Flint  mentions  the  case  of  a  man  who  escaped  in  his  night-clothes  and  ran 
barefooted  for  fifteen  miles  on  the  frozen  ground  before  he  was  over- 
taken. The  patient  should  not  be  strapped  in  bed,  as  this  aggravates  the 
delirium;  sometimes,  however,  it  may  be  necessary,  in  which  case  a  sheet 
tied  across  the  bed  may  be  sufficient,  and  this  is  certainly  better  than  vio- 
lent restraint  by  three  or  four  men.  Alcohol  should  be  withdrawn  at  once 
unless  the  pulse  is  feeble. 

Delirium  tremens  is  a  disease  which,  in  a  large  majority  of  cases,  runs 
a  course  very  slightly  influenced  by  medicine.  The  indications  for  treat- 
ment are  to  procure  sleep  and  to  support  the  strength.  In  mild  cases  half 
a  drachm  of  bromide  of  potassium  combined  with  tincture  of  capsicum 
may  be  given  every  three  hours.  Chloral  is  often  of  great  service,  and  may 
be  given  without  hesitation  unless  the  heart's  action  is  feeble.  Good  re- 
sults sometimes  follow  the  hypodermic  use  of  hyoscine,  one  one-hundredth 
of  a  grain.  Opium  must  be  used  cautiously.  A  special  merit  of  Ware's 
work  was  the  demonstration  that  on  a  rational  or  expectant  plan  of  treat- 
ment the  percentage  of  recoveries  was  greater  than  with  the  indiscriminate 
use  of  sedatives,  which  had  been  in  vogue  for  many  years.  When  opium  is 
indicated  it  should  be  given  as  morphia,  hypodermically.  The  effect  should 
be  carefully  watched,  and  if  after  three  or  four  quarter-grain  doses  have 
been  given  the  patient  is  still  restless  and  excited,  it  is  best  not  to  push  it 
farther.  When  fever  is  present  the  tranquillizing  effects  of  a  cold  douche 
or  cold  bath  may  be  tried,  or  the  cold  pack.  The  large  doses  of  digitalis 
formerly  employed  are  not  advisable. 

Careful  feeding  is  the  most  important  element  in  the  treatment  of 
these  cases.  Milk  and  concentrated  broths  should  be  given  at  stated  inter- 
vals. If  the  pulse  becomes  rapid  and  shows  signs  of  flagging  alcohol  may 
be  given  in  combination  with  the  aromatic  spirits  of  ammonia. 


II.    MORPHIA    HABIT    (Morphinomania ;  Morphinism). 

This  habit  arises  from  the  constant  use  of  morphia — taken  at  first,  as  a 
rule,  for  the  purpose  of  allaying  pain.  The  craving  is  gradually  engen- 
dered, and  the  habit  in  this  way  acquired.  The  injurious  effects  vary 
very  much,  and  in  the  East,  where  opium-smoking  is  as  common  as  tobacco- 
smoking  with  us,  the  ill  effects  are,  according  to  good  observers,  not  so 
striking. 

The  habit  is  particularly  prevalent  among  women  and  physicians  who 
use  the  hypodermic  syringe  for  the  alleviation  of  pain,  as  in  neuralgia  or 


MORPHIA  HABIT.  385 

sciatica.  The  acquisition  of  the  habit  as  a  pure  luxury  is  rare  in  this 
country. 

The  symptoms  at  first  are  slight,  and  moderate  doses  may  be  taken  for 
months  without  serious  injury  and  without  disturbance  of  health.  There 
are  exceptional  instances  in  which  for  a  period  of  years  excessive  amounts 
have  been  taken  without  deterioration  of  the  mental  or  bodily  functions. 
As  a  rule,  the  dose  necessary  to  obtain  the  desired  sensation  has  grad- 
ually to  be  increased.  As  the  effects  wear  off  the  victim  experiences  sensa- 
tions of  lassitude  and  mental  depression,  accompanied  often  with  slight 
nausea  and  epigastric  distress,  or  even  recurring  colic,  which  may  be  mis- 
taken for  appendicitis.  The  confirmed  opium-eater  usually  has  a  sallow, 
pasty  complexion,  is  emaciated,  and  becomes  prematurely  gray.  He  is 
restless,  irritable,  and  unable  to  remain  quiet  for  any  time.  Itching  is  a 
common  symptom.  The  sleep  is  disturbed,  the  appetite  and  digestion  are 
deranged,  and  except  when  directly  under  the  influence  of  the  drug  the 
mental  condition  is  one  of  depression.  Occasionally  there  are  profuse 
sweats,  which  may  be  preceded  by  chills.  The  pupils,  except  when  under 
the  direct  influence  of  the  drug,  are  dilated,  sometimes  unequal.  Persons 
addicted  to  morphia  are  inveterate  liars,  and  no  reliance  whatever  can  be 
placed  upon  their  statements.  In  many  instances  this  is  not  confined  to 
matters  relating  to  the  vice.  In  women  the  symptoms  may  be  associated 
with  those  of  pronounced  hysteria  or  neurasthenia.  The  practice  may  be 
continued  for  an  indefinite  time,  usually  requiring  increase  in  the  dose 
until  ultimately  enormous  quantities  may  be  needed  to  obtain  the  desired 
effect.  Finally  a  condition  of  asthenia  is  induced,  in  which  the  victim 
takes  little  or  no  food  and  dies  from  the  extreme  bodily  debility.  An 
increase  in  the  dose  is  not  always  necessary,  and  there  are  habitues  who  reach 
the  point  of  satisfaction  with  a  daily  amount  of  2  or  3  grains  of  morphia, 
and  who  are  able  to  carry  on  successfully  for  many  years  the  ordinary  busi- 
ness of  life.  They  may  remain  in  good  physical  condition,  and  indeed  often 
look  ruddy. 

The  treatment  of  the  morphia  habit  is  extremely  difficult,  and  can  rarely 
be  successfully  carried  out  by  the  general  practitioner.  Isolation,  sys- 
tematic feeding,  and  gradual  withdrawal  of  the  drug  are  the  essential 
elements.  As  a  rule,  the  patients  must  be  under  control  in  an  institution 
and  should  be  in  bed  for  the  first  ten  days.  It  is  best  in  a  majority  of 
cases  to  reduce  the  morphia  gradually.  The  diet  should  consist  of  beef- 
Juice,  milk,  and  egg-white,  which  should  be  given  at  short  intervals.  The 
sufferings  of  the  patients  are  usually  very  great,  more  particularly  the  ab- 
dominal pains,  sometimes  nausea  and  vomiting,  and  the  distressing  rest- 
lessness. Usually  within  a  week  or  ten  days  the  opium  may  be  entirely 
withdrawn.  In  all  cases  the  pulse  should  be  carefully  Avatchod  and,  if 
feeble,  stimulants  should  be  given,  with  the  aromatic  spirits  of  ammonia 
and  digitalis.  For  the  extreme  restlessness  a  hot  bath  is  serviceable.  The 
sleeplessness  is  the  most  distressing  symptom,  and  various  drugs  may  have 
to  be  resorted  to,  particularly  hyoscine  and  sulphonal  and  sometimes,  if 
the  insomnia  persist,  morphia  itself. 

It  is  essential  in  the  treatment  of  a  case  to  be  certain  that  the  patient 


386  THE  INTOXICATIONS  AND  SUN-STROKE. 

has  no  means  of  obtaining  morpliia.  Even  under  the  favorable  circum- 
stances of  seclusion  in  an  institution,  and  constant  watching  by  a  night  and 
a  day  nurse,  I  have  knovn  a  patient  to  practice  deception  for  a  period  of 
three  months.  After  an  apparent  cure  the  patients  are  only  too  apt  to 
lapse  into  the  habit. 

The  condition  is  one  which  has  become  so  common,  and  is  so  much  on 
the  increase,  that  physicians  should  exercise  the  utmost  caution  in  pre- 
scribing morphia,  particularly  to  female  patients.  Under  no  circumstances 
whatever  should  a  patient  with  neuralgia  or  sciatica  be  allowed  to  use  the 
hypodermic  syringe,  and  it  is  even  safer  not  to  intrust  this  dangerous 
instrument  to  the  hands  of  the  nurse.  * 


III.    LEAD-POISONING  {PlumUsm;  Saturnism). 

Etiology. — The  disease  is  widespread,  particularly  in  lead-workers 
and  among  plumbers,  painters,  and  glaziers.  The  metal  is  introduced  into 
the  system  in  many  forms.  Miners  usually  escape,  but  those  engaged  in 
the  smelting  of  lead-ores  are  often  attacked.  Animals  in  the  neighbor- 
hood of  smelting  furnaces  have  suffered  with  the  disease,  and  even  the 
birds  that  feed  on  the  berries  in  the  neighborhood  may  be  affected.  Men 
engaged  in  the  white-lead  factories  are  particularly  prone  to  plumbism. 
Accidental  poisoning  may  come  in  many  ways;  most  commonly  by  drink- 
ing water  which  has  passed  through  lead  pipes  or  been  stored  in  lead- 
lined  cisterns.  Wines  and  cider  which  contain  acids  quickly  become  con- 
taminated in  contact  with  lead.  It  was  the  frequency  of  colic  in  certain 
of  the  cider  districts  of  Devonshire  which  gave  the  name  of  Devonshire  colic, 
as  the  frequency  of  it  in  Poitou  gave  the  name  colica  Pictonum.  Among 
the  innumerable  sources  of  accidental  poisoning  may  be  mentioned  milk, 
various  sorts  of  beverages,  hair  dyes,  false  teeth,  and  thread.  A  serious 
outbreak  of  lead-poisoning,  which  was  investigated  by  David  D.  Stewart, 
occurred  recently  in  Philadelphia,  owing  to  the  disgraceful  adulteration 
of  a  baking-powder  with  chromate  of  lead,  which  was  used  to  give 
a  yellow  tint  to  the  cakes.  Lead  given  medicinally  rarely  produces  poi- 
soning. 

All  ages  are  attacked,  but  J.  J.  Putnam  states  that  children  are  rela- 
tively less  liable.  The  largest  number  of  cases  occur  between  thirty  and 
forty.  According  to  Oliver,  from  whose  recent  Goulstonian  lectures  I  here 
quote,  females  are  more  susceptible  than  males.  He  states  that  they  are 
much  more  quickly  brought  under  its  influence,  and  in  a  recent  epidemic 
in  which  a  thousand  cases  were  involved  the  proportion  of  females  to  males 
was  four  to  one. 

The  lead  gains  entrance  to  the  system  through  the  lungs,  the  digestive 
organs,  or  the  skin.  Poisoning  may  follow  the  use  of  cosmetics  contain- 
ing lead.  Through  the  lungs  it  is  freely  absorbed.  The  chief  channel, 
according  to  Oliver,  is  the  digestive  system.  It  is  rapidly  eliminated  by 
the  kidneys  and  skin,  and  is  present  in  the  urine  of  lead-workers.  The 
susceptibility  is  remarkably  varied.    The  symptoms  may  be  manifest  within 


LEAD-POISONING.  387 

a  month  of  exposure.  On  the  other  hand,  Tanquerel  (des  Planches)  met 
with  a  case  in  a  man  who  had  been  a  lead-worker  for  fifty-two  years. 

Morbid  Anatomy. — Small  quantities  of  lead  occur  in  the  body  in 
health.  J.  J.  Putnam's  reports  show  that  of  150  persons  not  presenting 
symptoms  of  lead-poisoning  traces  of  lead  occurred  in  the  urine  of  25  per 
cent. 

In  chronic  poisoning  lead  is  found  in  the  various  organs.  The  affected 
muscles  are  yellow,  fatty,  and  fibroid.  The  nerves  present  the  features  of 
a  peripheral  degenerative  neuritis.  The  cord  and  the  nerve-roots  are,  as  a 
rule,  uninvolved.  In  the  primary  atrophic  form  the  ganglion  cells  of  the 
anterior  horns  are  probably  implicated.  In  the  acute  fatal  cases  there  may 
be  the  most  intense  entero-colitis. 

Olinical  Forms. — Acute' Poisoning. — We  do  not ^ refer  here  to  the 
accidental  or  suicidal  cases,  which  present  vomiting,  pain  in  the  abdomen, 
and  collapse  symptoms.  In  workers  in  lead  there  are  several  manifesta- 
tions which  follow  a  short  time  after  exposure  and  set  in  acutely.  There 
may  be,  in  the  first  place,  a  rapidly  developing  anaemia.  Acute  neuritis  has 
been  described,  and  convulsions,  epilepsy,  and  a  delirium,  which  may  be, 
as  Stephen  Mackenzie  has  noted,  not  unlike  that  produced  by  alcohol. 
There  are  also  cases  in  which  the  gastro-intestinal  symptoms  are  most 
intense  and  rapidly  prove  fatal.  There  was  admitted  under  my  care  in  the 
Philadelphia  Hospital  a  painter,  aged  fifty,  suffering  with  anaemia  and 
severe  abdominal  pain,  which  had  lasted  about  a  week.  He  had  vomiting, 
constipation  at  first,  afterward  severe  diarrhoea  and  melgena,  with  distention 
and  tenderness  of  the  abdomen.  There  were  albumin  and  tube-casts  in  the 
urine.  The  temperature  was  usually  subnormal.  Death  occurred  at  the 
end  of  the  second  week.  There  was  found  the  most  intense  entero-colitis 
with  haemorrhages  and  exudation.  These  acute  forms  develop  more  fre- 
quently in  persons  recently  exposed,  and,  according  to  Mackenzie,  are  more 
frequent  in  winter  than  in  summer.  Da  Costa  has  reported  a  case  of  hemi- 
plegia developing  after  three  days'  exposure  to  the  poison. 

Chronic  poisoning. 

(a)  Ancemia,  so-called  saturnine  cachexia;  the  corpuscles  do  not  often  fall 
below  50  per  cent.  The  red  cells  show  a  remarkable  granular  or  basic  de- 
generation (Hausal  and  Behrendt),  which  White  and  Pepper  (3d)  found 
in  all  lead  workers.    In  obscure  cases  it  is  of  diagnostic  value. 

(&)  Blue  line  on  the  gums,  which  is  a  valuable  indication,  but  not  invari- 
ably present.  Two  lines  must  be  distinguished:  one,  at  the  margin  be- 
tween the  gums  and  teeth,  is  on,  not  in  the  gums,  and  is  readily  removed  by 
rinsing  the  mouth  and  cleansing  the  teeth.  The  other  is  the  well-known 
characteristic  blue-black  line  at  the  margin  of  the  gum.  The  color  is  not 
uniform,  but  being  in  the  papilla  of  the  gums  the  line  is,  as  seen  with  a 
magnifying-glass,  interrupted.  The  lead  is  absorbed  and  converted  in  the 
tissues  into  a  black  sulphide  by  the  action  of  sulphuretted  hydrogen  from 
the  tartar  of  the  teeth.  The  line  may  form  in  a  few  days  after  exposure 
(Oliver)  and  disappear  within  a  few  weeks,  or  may  persist  for  many  months. 
Philipson  has  noted  the  occurrence  of  a  black  line  in  miners,  due  to  the 
deposition  of  carbon. 


388  THE  INTOXICATIONS  AND  SUN-STROKE. 

The  most  important  symptoms  of  chronic  lead-poisoning  are  colic, 
■~3ead-palsy,  and  the  encephalopathy.     Of  these,  the  colic  is  the  most  fre- 
quent.    Of  Tanquerel's  cases,  there  were  1,217  of  colic,  101  of  paralysis, 
and  72  of  encephalopathy. 

(c)  Colic  is  the  most  common  symptom  of  chronic  lead-poisoning.  It 
is  often  preceded  by  gastric  or  intestinal  symptoms,  particularly  constipa- 
tion. The  pain  is  over  the  whole  abdomen.  The  colic  is  usually  parox- 
ysmal, like  true  colic,  and  is  relieved  by  pressure.  There  is  often,  in  addi- 
tion, between  the  paroxysms  a  dull,  heavy  pain.  There  may  be  vomiting. 
During  the  attack,  as  Eiegel  noted,  the  pulse  is  increased  in  tension  and 
the  heart's  action  is  retarded.  Attacks  of  pain  with  acute  diarrhoea  may 
recur  for  weeks  or  even  for  three  or  four  years. 

(d)  Lead-palsy. — This  is  rarely  a  primary  manifestation.  The  onset 
may  be  actite,  subacute,  or  chronic.  It  usually  develops  without  fever. 
In  its  distribution  it  may  be  partial,  limited  to  a  muscle  or  to  certain  mus- 
cle groups,  or  generalized,  involving  in  a  short  time  the  muscles  of  the 
extremities  and  the  trunk.  Madame  Dejerine-Klumpke  recognizes  the 
following  localized  forms: 

(1)  Antebrachial  type,  paralysis  of  the  extensors  of  the  fingers  and  of 
the  wrist.  In  this  the  musculo-spiral  nerve  is  involved,  causing  the  char- 
acteristic wrist-drop.  The  supinator  longus  usually  escapes.  In  the  long- 
continued  flexion  of  the  carpus  there  may  be  slight  displacement  back- 
ward of  the  bones,  with  distention  of  the  synovial  sheaths,  so  that  there 
is  a  prominent  swelling  over  the  wrist.  This,  which  is  sometimes  known 
as  Gruebler's  tumor,  though  not  of  any  moment,  is  often  very  annoying  to 
the  patient. 

(2)  Brachial  type,  which  involves  the  deltoid,  the  biceps,  the  brachi- 
alis  anticus,  and  the  supinator  longus,  rarely  the  pectorals.  The  atrophy 
is  of  the  scapulo-humeral  form.  It  is  bilateral,  and  sometimes  follows  the 
first  form,  but  it  may  be  primary. 

(3)  The  Aran-Duchenne  type,  in  which  the  small  muscles  of  the  hand 
and  of  the  thenar  and  hypothenar  eminences  are  involved,  so  that  we  have  a 
paralysis  closely  resembling  that  of  the  early  stage  of  polio -myelitis  anterior 
chronica.  The  atrophy  is  marked,  and  may  be  the  first  manifestation  of 
the  lead-palsy.  Mobius  has  shown  that  this  form  is  particularly  developed 
in  tailors. 

(4)  The  peroneal  type.  According  to  Tanquerel,  the  lower  limbs  are 
involved  in  the  proportion  of  13  to  100  of  the  upper  limbs.  The  lateral 
peroneal  muscles,  the  extensor  communis  of  the  toes,  and  the  extensor 
proprius  of  the  big  toe  are  involved,  producing -the  steppage  gait. 

(5)  Laryngeal  form.  Adductor  paralysis  has  been  noted  by  Morell 
Mackenzie  and  others  in  lead-palsy. 

Generalized  Palsies. — There  may  be  a  slow,  chronic  paralysis,  gradually 
involving  the  extremities,  beginning  with  the  classical  picture  of  wrist- 
drop. More  frequently  there  is  a  rapid  generalization,  producing  complete 
paralysis  in  all  the  muscles  of  the  parts  in  a  few  days.  It  may  pursue  a 
course  like  an  ascending  paralysis,  associated  with  rapid  wasting  of  all 
four  limbs.     Such  cases,  however,  are  very  rare.     Death  has  occurred  by 


LEAD-POISONING.  389 

involvement  of  the  diaphragm.  Oliver  reports  a  case  of  Philipson's  in 
which  complete  paralysis  supervened.  Dejerine-Klumpke  also  recognizes 
a  febrile  form  of  general  paralysis  in  lead-poisoning,  which  may  closely 
resemble  the  subacute  spinal  paralysis  of  Duchenne. 

There  is  also  a  primary  saturnine  muscular  atrophy  in  which  the  weak- 
ness and  wasting  come  on  together  and  develop  proportionately.  It  is  this 
form,  according  to  Gowers,  which  most  frequently  assumes  the  Aran- 
Duchenne  type. 

The  electrical  reactions  are  those  of  lesions  of  the  lower  motor  seg- 
ment, and  will  be  described  under  diseases  of  the  nerves.  The  degener- 
ative reaction  in  its  different  grades  may  be  present,  depending  upon  the 
severity  of  the  disease. 

Usually  with  the  onset  of  the  paralysis  there  are  pains  in  the  legs  and 
joints,  the  so-called  saturnine  arthralgias.  Sensation  may,  however,  be 
unaffected. 

(e)  The  cerebral  symptoms  are  numerous.  Optic  neuritis  or  neuro- 
retinitis  may  develop.  Hysterical  symptoms  occasionally  occur  in  girls. 
Convulsions  are  not  uncommon,  and  in  fits  developing  in  the  adult  the 
possibility  of  lead-poisoning  should  always  be  considered.  True  epilepsy 
may  follow  the  convulsions.  An  acute  delirium  may  occur  with  hallucina- 
tions. The  patients  may  have  trance-like  attacks,  which  follow  or  alternate 
with  convulsions.  A  few  cases  of  lead  encephalopathy  finally  drift  into 
lunatic  asylums.  Tremor  is  one  of  the  commonest  manifestations  of  lead- 
poisoning. 

(f)  Arteriosclerosis. — Lead-workers  are  notoriously  subject  to  arterio- 
sclerosis with  contracted  kidneys  and  hypertrophy  of  the  heart.  The  cases 
usually  show  distinct  gouty  deposits,  particularly  in  the  big-toe  joint;  but 
in  this  country  acute  gout  in  lead-workers  is  rare.  According  to  Sir  Wil- 
liam Eoberts,  the  lead  favors  the  precipitation  of  the  crystalline  urates  of 
the  tissues.  Ealfe  has  shown  that  lead  diminishes  the  alkalinity  of  the 
blood,  and  so  lessens  the  solubility  of  the  uric  acid. 

Prognosis. — In  the  minor  manifestations  of  lead-poisoning  this  is 
good.  According  to  Gowers,  the  outlook  is  bad  in  the  primary  atrophic 
form  of  paralysis.  Convulsions  are,  as  a  rule,  serious,  and  the  mental 
symptoms  which  succeed  may  be  permanent.  Occasionally  the  wrist-drop 
persists. 

Treatment. ^ — Prophylactic  measures  should  be  taken  at  all  lead-works, 
but,  unless  employes  are  careful,  poisoning  is  apt  to  occur  even  under  the 
most  favorable  conditions.  Cleanliness  of  the  hands  and  of  the  finger-nails, 
frequent  bathing,  and  the  use  of  respirators  when  necessary,  should  be  in- 
sisted upon.  When  the  lead  is  in  the  system,  the  iodide  of  potassium 
should  be  given  in  from  5-  to  10-grain  doses  three  times  a  day.  For  the 
colic,  local  applications  and,  if  severe,  morphia  may  be  used.  An  occa- 
sional morning  purge  of  magnesium  sulphate  may  be  given.  For  the  anae- 
mia iron  should  be  used.  In  the  very  acute  cases  it  is  well  not  to  give  the 
iodide,  as,  according  to  some  Avriters,  the  liberation  of  the  lead  which  has 
been  deposited  in  the  tissues  may  increase  the  severity  of  the  symptoms. 
For  the  local  palsies  massage  and  the  constant  current  should  be  used. 


390  THE  INTOXICATIONS  AND  SUN-STKOKE. 


IV.    ARSENICAL    POISONING. 

Acute  poisoning  by  arsenic  is  common,  particularly  by  Paris  green  and 
such,  mixtures  as  "  Rough  on  Rats/'  which  are  used  to  destroy  vermin  and 
insects.  The  chief  symptoms  are  intense  pain  in  the  stomach,  vomiting, 
and,  later,  colic,  with  diarrhoea  and  tenesmus;  occasionally  the  symptoms 
are  those  of  collapse.  If  recovery  takes  place,  paralysis  may  follow.  The 
treatment  should  be  similar  to  that  of  other  irritant  poisons — rapid  re- 
moval with  the  stomach,  pump,  the  promotion  of  vomiting,  and  the  use 
of  milk  and  eggs.  If  the  poison  has  been  taken  in  solution,  dialyzed  iron 
may  be  used  in  doses  of  from  6  to  8  drachms. 

Chronic  Arsenical  Poisoning. — Arsenic  is  used  extensively  in  the  arts, 
particularly  in  the  manufacture  of  colored  papers,  artificial  flowers,  and 
in  many  of  the  fabrics  employed  as  clothing.  The  glazed  green  and  red 
papers  used  in  kindergartens  also  contain  arsenic.  It  is  present,  too,  in 
many  wall-papers  and  carpets.  Much  attention  has  been  paid  to  this  ques- 
tion of  late  years,  as  instances  of  poisoning  have  been  thought  to  depend 
upon  wall-papers  and  other  household  fabrics.  The  arsenic  compounds 
may  be  either  in  the  form  of  solid  particles  detached  from  the  paper  or  as 
gaseous  volatile  bodies  formed  from  arsenical  organic  matter  by  the  action 
of  several  moulds,  notably  penicilium  brevicaule,  mucor  mucedo,  etc, 
(Gosio).  In  moisture,  and  at  a  temperature  of  from  60°  to  95°  F.,  a  vola- 
tile compound  is  set  free,  probably  "  an  organic  derivative  of  arsenic  pen- 
toxide  "  (Sanger).  The  chronic  poisoning  from  fabrics  and  wall-papers 
may  be  due,  according  to  this  author,  to  the  ingestion  of  minute  continued 
doses  of  this  derivative.  Contaminated  glucose,  used  in  manufacturing 
beer,  caused  the  recent  epidemic  of  poisoning  at  Manchester.  The  asso- 
ciated presence  of  selenium  compounds  may  have  played  a  part  in  the  pro- 
duction of  the  poisoning  (Tunnicliffe  and  Rosenheim).  Arsenic  is  elimi- 
nated in  all  the  secretions,  and  has  been  found  in  the  milk.  J.  J.  Putnam, 
it  should  be  remembered,  has  shown  that  it  is  not  uncommon  to  find  traces 
of  arsenic  in  the  urine  of  many  persons  in  apparent  health  (30  per  cent). 
The  effects  of  moderate  quantities  of  arsenic  are  not  infrequently  seen  in 
medical  practice.  In  chorea  and  in  pernicious  anaemia,  steadily  increasing 
doses  are  often  given  until  the  patient  takes  from  15  to  20  drops  of  Fowler's 
solution  three  times  a  day.  Flushing  and  hypereemia  of  the  skin,  puffiness 
of  the  eyelids  or  above  the  eyebrows,  nausea,  vomiting,  and  diarrhoea  are 
the  most  common  symptoms.  Redness  and  sometimes  bleeding  of  the  gums 
and  salivation  occur.  In  the  protracted  administration  of  arsenic  patients 
may  complain  of  numbness  and  tingling  in  the  fingers.  Cutaneous  pig- 
mentation and  keratosis  are  very  characteristic.  In  chorea  neuritis  has 
occurred,  and  a  patient  of  mine  with  Hodgkin's  disease  developed  multiple 
neuritis  after  taking  §iv  3j  of  Fowler's  solution  in  seventy-five  days,  dur- 
ing which  time  there  were  fourteen  days  on  which  the  drug  was  omitted. 

In  the  Manchester  epidemic  nearly  all  cases  presented  signs  of  neuritis 
and  lesions  of  the  skin.  In  some  the  sensory  disturbances  predominated, 
in  others  the  motor,  the  individuals  being  unable  to  walk  or  to  use  their 


FOOD  POISONING.  391 

hands.  In  a  certain  number  muscular  inco-ordination,  resembling  that  of 
locomotor  ataxia,  developed.  Eapid  muscular  atrophy  characterized  some 
cases.  In  not  a  few  patients  a  condition  of  erythromelalgia  was  present. 
Occasionally  a  catarrh  of  the  respiratory  and  alimentary  tracts  was  the 
chief  feature.  Pigmentation,  keratosis,  and  herpes  were  the  most  charac- 
teristic cutaneous  manifestations  (Kelynack  and  Kirkby,  Arsenical  Poison- 
ing in  Beer  Drinkers).  How  far  similar  symptoms  are  to  be  attributed  to 
the  small  quantities  of  arsenic  absorbed  from  wall-papers  and  fabrics  is  by 
some  considered  doubtful.  That  children  and  adults  may  take  with  im- 
punity large  doses  for  months  without  unpleasant  effects,  and  the  fact  of 
the  gradual  establishment  of  a  toleration  which  enables  Styrian  peasants 
to  take  as  much  as  8  grains  of  arsenious  acid  in  a  day,  speak  strongly 
against  it.  On  the  other  hand,  as  Sanger  states,  we  do  not  know  accurately 
the  effects  of  many  of  the  compounds  in  minute  and  long-continued  doses, 
notably  the  arsenates. 

Arsenical  paralysis  has  the  same  characteristics  as  lead-palsy,  but  the 
legs  are  more  affected  than  the  arms,  particularly  the  extensors  and  pero- 
neal group,  so  that  the  patient  has  the  characteristic  steppage  gait  of 
peripheral  neuritis. 

The  electrical  reaction  in  the  muscles  may  be  disturbed  before  there  is 
any  loss  of  power,  and  when  the  patient  is  asked  to  extend  the  wrist  fully 
and  to  spread  the  fingers  slight  weakness  may  be  detected  early. 


V.    FOOD    POISONING.     (Bromatotoxismus :  Vaughan). 

There  may  be  "  death  in  the  pot "  from  many  causes.  Food  may  con- 
tain the  specific  organisms  of  disease,  as  of  tuberculosis  or  trichinosis;  milk 
and  other  foods  may  become  infected  with  typhoid  bacilli,  and  so  convey 
the  disease. 

Animals  (or  insects,  as  bees)  may  feed  on  substances  which  cause  their 
flesh  or  products  to  be  poisonous  to  man. 

The  grains  used  as  food  may  be  infected  with  fungi  and  cause  the  epi- 
demics of  ergotism,  etc. 

Foods  of  all  sorts  may  become  contaminated  with  the  bacteria  of  putre- 
faction, the  products  of  which  may  be  highly  poisonous. 

For  a  full  description  of  food  poisoning  see  Vaughan's  section  on  the 
subject  in  vol.  xiii  of  the  Twentieth  Century  Practice. 

Among  the  more  common  forms  are  the  following: 

(1)  Meat  Poisoning  (Kreotoxismus). — Cases  have  usually  followed  the 
eating  of  sausages  or  pork-pie  or  head-cheese,  and  also  occasionally  beef,  veal, 
and  mutton.  Sausage  poisoning,  which  is  known  by  the  name  of  hotulism 
or  allantiMis,  has  long  been  recognized,  and  there  have  been  numerous 
outbreaks,  particularly  in  parts  of  Germany.  Similar  attacks  have  been 
produced  by  ham  and  by  head-cheese.  The  precise  nature  of  the  kreotoxi- 
cons  has  not  yet  been  determined.  Other  outbreaks  have  followed  the 
eating  of  beef  and  veal.  In  the  majority  of  these  cases  the  meat  has  under- 
gone decomposition,  though  the  change  may  not  have  been  evident  to  the 


392  THE  INTOXICATIONS  AND  SUN-STROKE. 

taste.  The  symptoms  of  meat  poisoning  are  those  of  acute  gastro-intestinal 
irritation.  Ballard^s  description  of  the  Wellbeck  cases,  quoted  by  Vaughan, 
holds  good  for  a  majority  of  them: 

"  A  period  of  incubation  preceded  the  illness.  In  51  cases  where  this 
could  be  accurately  determined,  it  was  twelve  hours  or  less  in  5  cases;  be- 
tween twelve  and  thirty-six  hours  in  34  cases;  between  thirty-six  and 
forty-eight  hours  in  8  cases;  and  later  than  this  in  only  4  cases.  In  many 
cases  the  first  definite  symptoms  occurred  suddenly,  and  evidently  unex- 
pectedly, but  in  some  cases  there  were  observed  during  the  incubation 
more  or  less  feeling  of  languor  and  ill-health,  loss  of  appetite,  nausea,  or 
fugitive,  griping  pains  in  the  belly.  In  about  a  third  of  the  cases  the  first 
definite  symptom  was  a  sense  of  chilliness,  usually  with  rigors,  or  trem- 
bling, in  one  case  accompanied  by  dyspnoea;  in  a  few  cases  it  was  giddi- 
ness with  faintness,  sometimes  accompanied  by  a  cold  sweat  and  tottering; 
in  others  the  first  symptom  was  headache  or  pain  somewhere  in  the  trunk 
of  the  body — e.  g.,  in  the  chest,  back,  between  the  shoulders,  or  in  the  ab- 
domen, to  which  part  the  pain,  wherever  it  might  have  commenced,  subse- 
quently extended.  In  one  case  the  first  symptom  noticed  was  a  difficulty 
in  swallowing.  In  two  cases  it  was  intense  thirst.  But  however  the  attack 
may  have  commenced,  it  was  usually  not  long  before  pain  in  the  abdomen, 
diarrhoea,  and  vomiting  came  on,  diarrhoea  being  of  more  certain  occur- 
rence than  vomiting.  The  pain  in  several  cases  commenced  in  the  chest 
or  between  the  shoulders,  and  extended  first  to  the  upper  and  then  to  the 
lower  part  of  the  abdomen.  It  was  usually  very  severe  indeed,  quickly 
producing  prostration  or  faintness,  with  cold  sweats.  It  was  variously  de- 
scribed as  crampy,  burning,  tearing,  etc.  The  diarrhoeal  discharges  were 
in  some  cases  quite  unrestrainable,  and  (where  a  description  of  them  could 
be  obtained)  were  said  to  have  been  exceedingly  offensive  and  usually  of  a 
dark  color.  Muscular  weakness  was  an  early  and  very  remarkable  symp- 
tom in  nearly  all  the  cases,  and  in  many  it  was  so  great  that  the  patient 
could  only  stand  by  holding  on  to  something.  Headache,  sometimes  severe, 
was  a  common  and  early  symptom;  and  in  most  cases  there  was  thirst,  often 
intense  and  most  distressing.  The  tongue,  when  observed,  was  described 
usually  as  thickly  coated  with  a  brown,  velvety  fur,  but  red  at  the  tip  and 
edges.  In  the  early  stage  the  skin  was  often  cold  to  the  touch,  but  after- 
ward fever  set  in,  the  temperature  rising  in  some  cases  to  101°,  103°,  and 
104°  F.  In  a  few  severe  cases,  where  the  skin  was  actually  cold,  the  patient 
complained  of  heat,  insisted  on  throwing  off  the  bedclothes,  and  was  very 
restless.  The  pulse  in  the  height  of  the  illness  became  quick,  counting 
in  some  cases  100  to  128.  The  above  were  the  symptoms  most  frequently 
noted.  Other  symptoms  occurred,  however,  some  in  a  few  cases,  and  some 
only  in  solitary  cases.  These  I  now  proceed  to  enumerate.  Excessive 
sweating,  cramps  in  the  legs,  or  in  both  legs  and  arms,  convulsfve  flexion 
of  the  hands  or  fingers,  muscular  twitchings  of  the  face,  shoulders,  or 
hands,  aching  pain  in  the  shoulders,  joints,  or  extremities,  a  sense  of  stiff- 
ness of  the  joints,  prickling  or  tingling  or  numbness  of  the  hands  lasting 
far  into  convalescence  in  some  cases,  a  sense  of  general  compression  of  the 
skin,  drowsiness,  hallucinations,  imperfection  of  vision,  and  intolerance 


FOOD  POISONINa.  393 

of  light.  In  three  cases  (one  that  of  a  medical  man)  there  was  observed 
yellowness  of  the  skin,  either  general  or  confined  to  the  face  and  eyes.  In 
one  case,  at  a  late  stage  of  the  illness,  there  was  some  pulmonary  congestion 
and  an  attack  of  what  was  regarded  as  gout.  In  the  fatal  cases  death  was 
preceded  by  collapse  like  that  of  cholera,  coldness  of  the  surface,  pinched 
features,  and  blueness  of  the  fingers  and  toes  and  around  the  sunken  eyes. 
The  debility  of  convalescence  was  in  nearly  all  cases  protracted  to  several 
weeks. 

"  The  mildest  cases  were  characterized  usually  by  little  remarkable  be- 
yond the  following  symptoms,  viz.,  abdominal  pains,  vomiting,  diarrhoea, 
thirst,  headache,  and  muscular  weakness,  any  one  or  two  of  which  might 
be  absent." 

Many  instances  are  on  record  of  poisoning  by  canned  goods,  particu- 
larly meat.  Some  of  these,  according  to  John  G.  Johnson,  have  been  cases 
of  corrosive  poisoning  from  muriate  of  zinc  and  muriate  of  tin  used  as  an 
amalgam,  but  poisonous  effects  identical  with  those  just  described  have 
followed  the  use  of  canned  meats. 

Certain  game  birds,  particularly  the  grouse,  are  stated  to  be  poisonous^ 
in  special  districts  and  at  certain  seasons  of  the  year. 

(3)  Poisoning  by  Milk  Products. — (a)  Galadotoxismus,  indicating  the 
poisonous  effects  which  follow  the  drinking  of  milk  infected  with  sapro- 
phytic bacteria,  is  considered  in  the  section  on  the  diarrhoea  of  infants. 

(b)  Cheese  Poisoning  (Tyrotoxismus). — Various  milk  products,  ice  cream, 
custard,  and  cheese  may  prove  highly  poisonous.  Among  the  poisons 
Vaughan  now  states  that  the  tyrotoxicon  "  is  not  the  one  most  frequently 
present,  nor  is  it  the  most  active  one."  In  one  epidemic  he  and  JSTovy  have 
isolated  from  cheese  a  substance  belonging  to  the  poisonous  albumins, 
and  in  an  extensive  ice-cream  epidemic  Vaughan  and  Perkins  found 
in  the  ice  cream  a  highly  pathogenic  bacillus,  but  its  toxine  has  not  been 
separated. 

The  symptoms  are  those  of  acute  gastro-intestinal  irritation,  and  are 
similar  to  those  already  detailed  by  Ballard. 

(3)  Poisoning  by  Shell-fish  and  Fish. — (a)  Mussel  Poisoning  (Mytilo- 
toxismus). — Brieger  has  separated  a  ptomaine — mytilotoxin — which  exists 
chiefly  in  the  liver  of  the  mussel.  The  observations  of  Schmidtmann  and 
Cameron  have  shown  that  the  mussel  from  the  open  sea  only  becomes 
poisonous  when  placed  in  filthy  waters,  as  at  Wilhelmshafen. 

Dangerous,  even  fatal,  effects  may  follow  the  eating  of  either  raw  or 
cooked  mussels.  The  symptoms  are  those  of  an  acute  poisoning  with  pro- 
found action  on  the  nervous  system,  and  without  gastro-intestinal  manifes- 
tations. There  are  numbness  and  coldness,  no  fever,  dilated  pupils,  and 
rapid  pulse;  death  occurs  sometimes  within  two  hours  witli  collapse  symp- 
toms. Poisoning  occasionally  follows  the  eating  of  oysters  which  are  stale 
or  decomposed.    The  symptoms  are  usually  gastro-intestinal. 

(h)  Fish  Poisoning  (Ichthyotoxismus). — There  are  two  distinct  varie- 
ties; in  one  tbe  poison  is  a  physiological  product  of  certain  glanrls  of  the 
fish,  in  the  other  it  is  a  product  of  bacterial  growth.  Tbe  salted  sturgeon 
used  in  parts  of  Russia  has  sometimes  proved  fatal  to  large  numbers  of 


394  THE  INTOXICATIONS  AND  SUN-STROKE. 

persons.  In  the  middle  parts  of  Europe  the  barb  is  stated  to  be  sometimes 
poisonous,  producing  the  so-called  "  barben  cholera."  In  China  and  Japan 
various  species  of  the  tetrodon  are  also  toxic,  sometimes  causing  death  within 
an  hour,  with  symptoms  of  intense  disturbance  of  the  nervous  system. 
Beri-beri  is  thought  by  some  to  be  due  to  the  consumption  of  certain  kinds 
of  fish. 

(4)  Grain  Poisoning  (Sitotoxismus). 

(1)  Ergotism. — The  prolonged  use  of  meal  made  from  grains  contam- 
inated with  the  ergot  fungus  (daviceps  purpurea)  causes  a  series  of  symp- 
toms known  as  ergotism,  epidemics  of  which  have  prevailed  in  difEerent 
parts  of  Europe.  Two  forms  of  this  chronic  ergotism  are  described — the 
one,  gangrenous,  is  believed  to  be  due  to  the  sphacelinic  acid,  the  other, 
convulsive,  or  spasmodic,  is  due  to  the  cornutin.  In  the  former,  mortifica- 
tion affects  the  extremities — usually  the  toes  and  fingers,  less  commonly 
the  ears  and  nose.  Preceding  the  onset  of  the  gangrene  there  are  usually 
anaesthesia,  tingling,  pains,  spasmodic  movements  of  the  muscles,  and  grad- 
ual blood  stasis  in  certain  vascular  territories. 

The  nervous  manifestations  are  very  remarkable.  After  a  prodromal 
stage  of  ten  to  fourteen  days,  in  which  the  patient  complains  of  weakness, 
headache,  and  tingling  sensations  in  different  parts  of  the  body,  perhaps 
accompanied  with  slight  fever,  symptoms  of  spasm  develop,  producing 
cramps  in  the  mufecles  and  contractures.  The  arms  are  flexed  and  the 
legs  and  toes  extended.  These  spasms  may  last  from  a  few  hours  to  many 
days  and  relapses  are  frequent.  In  severer  cases  epilepsy  develops  and  the 
patient  may  die  in  convulsions.  Mental  symptoms  are  common,  manifested 
sometimes  in  a  preliminary  delirium,  but  more  commonly,  in  the  chronic 
poisoning,  as  melancholia  or  dementia.  Posterior  spinal  sclerosis  occurs 
in  chronic  ergotism.  In  the  interesting  group  of  29  cases  studied  by 
Tuczek  and  Siemens,  9  died  at  various  periods  after  the  infection,  and 
four  post  mortems  showed  degeneration  of  the  posterior  columns.  A  con- 
dition similar  to  tabes  dorsalis  is  gradually  produced  by  this  slow  degenera- 
tion in  the  spinal  cord. 

(2)  Lathyrism  (Lupinosis). — An  affection  produced  by  the  use  of  meal 
from  varieties  of  vetches,  chiefly  the  Lathyrus  sativus  and  L.  cicera.  The 
grain  is  popularly  known  as  the  chick-pea.  The  grains  are  usually  pow- 
dered and  mixed  with  the  meal  from  other  cereals  in  the  preparation  of 
bread.  As  early  as  the  seventeenth  century  it  was  noticed  that  the  use 
of  flour  with  which  the  seeds  of  the  Lathyrus  were  mixed  caused  stiffness 
of  the  legs.  The  subject  did  not,  however,  attract  much  attention  before 
the  studies  of  James  Irving,  in  India,  who  between  1859  and  1868  pub- 
lished several  important  communications,  describing  a  form  of  spastic 
paraplegia  affecting  large  numbers  of  the  inhabitants  in  certain  regions  of 
India  and  due  to  the  use  of  meal  made  from  the  Lathyrus  seeds.  It  also 
produces  a  spastic  paraplegia  in  animals.  The  Italian  observers  describe 
a  similar  form  of  paraplegia,  and  it  has  been  observed  in  Algiers  by  the 
French  physicians.  The  condition  is  that  of  a  spastic  paralysis,  involving 
chiefly  the  legs,  which  may  proceed  to  complete  paraplegia.  The  arms 
are  rarely,  if  ever,  affected.    It  is  evidently  a  slow  sclerosis  induced  under 


StJN-STROItE.  *  395 

the  influence  of  this  toxic  agent.  The  precise  anatomical  condition,  so 
far  as  I  can  ascertain,  has  not  yet  bfeen  determined. 

(3)  Pellagra  (Maidismus). — This  is  a  nutritional  disturbance  due  to 
the  use  of  altered  maize.  The  disease  occurs  extensively  in  parts  of  Italy, 
in  the  south  of  France,  and  in  Spain.  It  has  not  been  observed  in  this 
country.  It  prevails  extensively  among  the  poorer  classes,  particularly  in 
the  country  districts,  and  appears  to  be  associated  in  some  way  with  the 
use  of  maize  which  (according  to  most  authorities)"  is  fermented  or  diseased. 
In  the  early  stage  the  symptoms  are  indefinite,  characterized  by  debility, 
pains  in  the  spine,  insomnia,  digestive  disturbances,  more  rarely  diarrhosa. 
The  first  clear  manifestation  of  the  disease  is  the  pellagral  erythema,  which 
almost  invariably  appears  in  the  spring.  This  is  followed  by  desiccation 
and  exfoliation  of  the  epidermis,  which  becomes  very  rough  and  dry,  and 
occasionally  crusts  form,  beneath  which  there  is  suppuration.  "With  these 
cutaneous  manifestations  there  are  digestive  troubles — salivation,  dyspepsia, 
and  diarrhoea — which  may  be  of  a  dysenteric  nature.  After  lasting  for  a 
few  months  improvement  occurs  in  the  milder  eases  and  convalescence  is 
gradually  established.  In  the  more  severe  and  chronic  forms  there  are 
pronounced  nervous  symptoms — headache,  backache,  spasms,  and  finally 
paralysis  and  mental  disturbance.  The  paralytic  condition  affects  the  legs 
and  leads  gradually  to  paraplegia.  The  mental  manifestations,  which 
are  rarely  met  with  until  the  third  or  fourth  attack,  are  melancholia  or 
suicidal  mania.  Finally,  there  may  be  a  condition  of  the  most  pronounced 
cachexia. 

The  anatomical  findings  are  indefinite.  Chronic  degenerative  changes 
have  been  found,  particularly  fatty  degeneration  and  a  peculiar  pigmenta- 
tion in  the  viscera.  The  measures  to  be  employed  are  change  in  diet,  re- 
moval from  the  infected  district,  and,  as  a  prophylaxis,  proper  preserva- 
tion of  the  maize. 

VI.    SUN-STROKE  {Siriasis). 

{Heat  Exhaustion  ;  Insolation  ;  Thermic  Fever  ;  Heat-stroke  ;  Coup  de  Soleil.) 

Definition. — A  condition  produced  by  exposure  to  excessive  heat. 

It  is  one  of  the  oldest  of  recognized  diseases;  two  instances  are  men- 
tioned in  the  Bible.  It  was  long  confounded  with  apoplexy.  The  Anglo- 
Indian  surgeons  gave  admirable  descriptions  of  it.  In  this  country  the 
most  important  contributions  have  come  from  the  New  York  Hospital  and 
the  Pennsylvania  Hospital;  from  the  former,  the  studies  of  Swift  and 
Darrach,  from  the  latter,  the  papers  of  Gerhard,  George  B.  Wood,  the 
elder  Pepper,  and  Levick.  In  N"ew  Orleans,  Bennett  Dowler  studied  the 
disease  and  recognized  the  difference  between  heat  exhaustion  and  sun- 
stroke.    Two  forms  are  recognized,  heat  exhaustion  and  heat-stroke. 

Heat  Exhaustion. — Prolonged  exposure  to  high  temperatures,  particu- 
larly when  combined  with  physical  exertion,  is  liable  to  be  followed  by 
extreme  prostration,  collapse,  restlessness,  and  in  severe  cases  by  delirium. 
The  surface  is  usually  cool,  the  pulse  small  and  rapid,  and  the  temperature 
may  be  subnormal — as  low  as  95°  or  96°.  The  individual  need  not  neces- 
2fi 


396  '   THE  INTOXICATIONS  AND  SUN-STROKE. 

sarily  be  exposed  to  the  direct  rays  of  the  sun,  but  the  condition  may 
come  on  at  night  or  when  working  in  close,  confined  rooms.  It  may  also 
follow  exposure  to  great  artificial  heat,  as  in  the  engine  rooms  of  the  Atlan- 
tic steamships. 

Sun-stroke  or  Thermic  Fever. — The  cases  are  chiefly  found  in  persons 
who,  while  working  very  hard,  are  exposed  to  the  sun.  Soldiers  on  the 
march  with  their  heavy  accoutrements  are  particularly  liable  to  attack. 
In  the  larger  cities  of  this  country  the  cases  are  almost  exclusively  con- 
fined to  workmen  who  are  much  exposed  and,  at  the  same  time,  have  been 
drinking  beer  and  whisky. 

Morbid  Anatomy  and  Pathology. — Eigor  mortis  occurs  early. 
Putrefactive  changes  develop  with  great  rapidity.  The  venous  engorge- 
ment is  extreme,  particularly  in  the  cerebrum.  The  left  ventricle  is  con- 
tracted (Wood),  and  the  right  chamber  dilated.  The  blood  is  usually  fluid; 
the  lungs  are  intensely  congested.  Parenchymatous  changes  occur  in  the 
liver  and  kidneys. 

According  to  Wood,  "  heat  exhaustion  with  lowered  temperature  repre- 
sents a  sudden  vaso-motor  palsy,  i.  e.,  a  condition  in  which  the  existing 
effect  of  the  heat  paralyzes  the  centre  in  the  medulla."  On  the  other  hand, 
thermic  fever  is  held  to  be  due  to  paralysis  under  the  influence  of  the  ex-<. 
treme  external  heat  of  the  centre  in  the  medulla  which  regulates  the  dis- 
position of  the  bodily  heat.  Owing  to  this  disturbance,  more  heat  is  pro- 
duced and  less  given  off  than  normally. 

Sambron  has  recently  (B.  M.  J.,  1898,  i)  advanced  the  view  that  siriasis 
is  an  infectious  disease.  He  argues  that  heat  alone  cannot  cause  it,  that 
it  occurs  in  certain  localities  and  in  epidemic  outbursts,  and  persons  ac- 
climatized have  a  relative  immunity,  etc.  The  question  is  one  worthy  of 
most  careful  study. 

Symptoms. — The  patient  may  be  struck  down  and  die  within  an^ 
hour  with  symptoms  of  heart-failure,  dyspnoea,  and  coma.  This  form, 
sometimes  known  as  the  asphyxial,  occurs  chiefly  in  soldiers  and  is  graphic- 
ally described  by  Parkes.  Death  indeed  may  be  almost  instantaneous,  the 
victims  falling  as  if  struck  upon  the  head.  The  usual  form  in  this  lati- 
tude comes  on  during  exposure,  with  pain  in  the  head,  dizziness,  a  feel- 
ing of  oppression,  and  sometimes  nausea  and  vomiting.  Visual  disturb- 
ances are  common,  and  a  patient  may  have  colored  vision.  Diarrhoea  or 
frequent  micturition  may  supervene.  Insensibility  follows,  which  may 
be  transient  or  which  deepens  into  a  profound  coma.  The  patients  are 
usually  admitted  to  hospital  in  an  unconscious  state,  with  the  face  flushed, 
the  skin  pungent,  the  pulse  rapid  and  full,  and  the  temperature  ranging 
from  107°  to  110°,  or  even  higher,  as  shown  in  the  accompanying  chart. 
F.  A.  Packard  states  that  of  the  31  cases  admitted  to  the  Pennsylvania 
Hospital  in  the  summer  of  1887,  in  a  majority  of  them  the  temperature 
was  between  110°  and  111°.  In  one  case  the  temperature  was  112°.  The 
breathing  is  labored  and  deep,  sometimes  stertorous.  Usually  there  is 
complete  relaxation  of  the  muscles,  but  twitchings,  jactitation,  or  very 
rarely  convulsions  may  occur.  The  pupils  may  at  first  be  dilated,  but  by 
the  time  the  cases  are  admitted  to  hospital  they  are  (in  a  majority)  ex- 


SUN-STROKE. 


397 


tremely  contracted.  Petechias  may  be  present  upon  the  skin.  In  the  fatal 
cases  the  coma  deepens,  the  cardiac  pulsations  become  more  rapid  and 
feeble,  the  breathing  becomes  hurried  and  shallow  and  of  the  Cheyne- 
Stokes  type.  The  fatal  termination  may  occur  within  twenty-four  or 
thirty-six  hours.  Favorable  indications  are  the  return  of  consciousness 
and  a  fall  in  the  fever.  The  recovery  in  these  cases  may  be  complete.  In 
other  instances  there  are  remarkable  after-effects,  the  most  constant  of  which 
is  a  permanent  inability  to  bear  high  temperatures.  Such  patients  become 
very  uneasy  when  the  thermometer  reaches  80°  F.  in  the  shade.  Loss  of 
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Chart  XIIT. — Case  of  sun-stroke  treated  with  the  ice-bath  ;   recovery, 
(Rectal  temperatures). 


hot  weather.  Occasionally  convulsions  and  marked  mental  disturbance 
may  develop.  Dercum  has  described  peripheral  neuritis  as  a  sequence,  and 
the  patient  whose  chart  is  here  given  developed  an  acute  neuritis  in 
the  legs.  This  is  a  point  in  favor  of  the  infectious  nature  of  the  dis- 
ease. 

Guiteras  has  called  attention  to  a  form  of  fever  occurring  in  the  Soutli, 
known  in  Florida  as  "  Florida  fever,"  in  the  Carolinas  as  "  country  fever," 
and  in  tropical  countries  as  fevr^  inflammatoire.  The  cases  last  for  a  vari- 
able time,  and  are  mistaken  for  malaria  or  typhoid;  but  he  believes  them 


398  THE  INTOXICATIONS  AND  SUN-STROKE. 

to  be  entirely  distinct  and  due  to  a  prolonged  action  of  the  high  tempera- 
tures.    He  has  called  the  condition  a  "  continued  thermic  fever." 

The  diagnosis  of  heat  exhaustion  from  thermic  fever  is  readily  made, 
as  the  difference  between  the  two  conditions  is  striking.  "  In  solar  ex- 
haustion the  skin  is  moist,  pale,  and  coolj  the  breathing  is  easy  though 
hurried;  the  pulse  is  small  and  soft;  the  vital  forces  fall  into  a  temporary 
collapse;  the  senses  remain  entire "  (Dowler);  whereas  in  sun-stroke  or 
heat  apoplexy  there  is  usually  unconsciousness  and  pyrexia. 

The  mode  of  onset,  together  with  the  circumstances  under  which  it 
occurs  and  the  high  temperature,  permits  thermic  fever  to  be  readily  dif- 
ferentiated from  apoplexy  and  coma  from  other  conditions. 

Treatment. — In  heat  exliaustion  stimulants  should  be  given  freely, 
and  if  the  temperature  is  below  normal  the  hot  bath  should  be  used. 
Ammonia  may  be  given  if  necessary.  In  thermic  fever  the  indications 
are  to  reduce  the  temperature  as  rapidly  as  possible.  This  may  be  done 
by  packing  the  patient  in  a  bath  with  ice.  Eubbing  the  body  with  ice  was 
practised  at  the  New  York  Hospital  by  Darrach  in  1857,  and  is  an  excel- 
lent procedure  to  lower  the  temperature  rapidly.  Ice-water  enemata  may 
also  be  employed.  At  the  Pennsylvania  Hospital  in  the  summer  of  1887 
the  ice-pack  was  used  with  great  advantage.  Of  31  cases  only  13  died, 
results  probably  as  satisfactory  as  can  be  obtained,  considering  that  many 
of  the  patients  are  almost  moribund  when  brought  to  hospital.  They  should 
be  compared  with  Swift's  statistics,  in  which  of  150  cases  78  died.  In  the 
cases  in  which  the  symptoms  are  those  of  intense  asphyxia,  and  in  which 
death  may  take  place  in  a  few  minutes,  free  bleeding  should  be  practised, 
a  procedure  which  saved  Weir  Mitchell  when  a  young  man.  For  the  con- 
vulsions chloroform  should  be  given  at  once.  Of  other  remedies,  the  anti- 
pyretics have  been  employed,  and  may  be  given  when  there  is  any  special 
objection  to  hydrotherapy,  for  which,  however,  they  cannot  be  substituted. 


SECTION  IV. 
COI^STITUTIOISrAL  DISEASES. 


I.    ARTHRITIS    DEFORMANS. 

Definition. — A  chronic  disease  of  the  joints  of  doubtful  etiology, 
characterized  by  changes  in  the  cartilages  and  synovial  membranes,  with 
peri-articular  formation  of  bone  and  great  deformity. 

Long  believed  to  be  intimately  associated  with  gout  and  rheumatism 
(whence  the  names  rheumatic  gout  and  rheumatoid  arthritis),  this  close 
relationship  seems  now  very  doubtful,  since  in  a  majority  of  the  cases  no 
history  of  either  affection  can  be  determined. 

Etiology. — Age. — A  majority  of  the  cases  are  between  the  ages  of 
thirty  and  fifty.  In  A.  E.  Garrod's  analysis  of  500  cases  there  were  only  25 
under  twenty  years  of  age. 

8ex. — ^Among  Garrod's  500  cases  there  were  411  in  women.  In  James 
Stewart's  recent  report  of  40  cases  from  the  Eoyal  Victoria  Hospital  only 
30  were  in  females.  In  women  its  close  association  with  the  menopause 
has  been  noted.  It  seems  to  be  more  frequent,  too,  in  those  who  have  had 
ovarian  or  uterine  trouble  or  who  are  sterile. 

Hereditary  Predisposition. — In  216  cases  in  Garrod's  series  there  was  a 
family  history  of  joint  troubles.  Two  or  three  children  in  a  family  may 
be  affected.  It  is  stated  also  that  the  disease  is  more  common  in  families 
with  a  phthisical  history. 

Rheumatism  and  Gout. — In  nearly  a  third  of  Garrod's  cases  there  was 
a  history  of  gout  in  the  family;  of  rheumatism  in  only  64  cases. 

Exposure  to  cold,  wet  and  damp,  errors  in  diet,  worry  and  care,  and 
local  injuries  are  all  spoken  of  as  possible  exciting  causes. 

At  present  there  are  two  chief  views  prevailing  as  to  the  etiology  of 
arthritis  deformans — one  that  it  is  of  nervous  origin,  the  other  that  it  is  a 
chronic  infection. 

The  Relation  of  Arthritis  Deformans  to  Diseases  of  the  Nervous  Sys- 
tem.— Our  accurate  knowledge  of  arthropathies  of  nervous  origin  dates 
from  the  papers  of  J.  K.  Mitchell,  of  Philadelphia,  in  1831  and  1833,  in 
which  he  reported  cases  of  inflammation  of  the  joints  in  connection  with 
caries  of  the  spine  and  concussion  of  the  cord.  Acute  and  chronic  forms 
of  arthritis  may  occur  with  gross  lesions  of  the  cord;  the  former  are  found 

399 


400  CONSTITUTIONAL  DISEASES. 

in  acute  myelitis,  the  latter  with  tabes  and  syringomyelia.  The  acute 
spinal  arthritis  presents  anatomically  inflammation  of  the  synovial  sheaths 
and  of  the  fibrous  investment  of  the  articulations.  The  chronic  arthritis 
which  we  see  in  syringomyelia,  tabes,  and  hemiplegia  presents  a  combination  1 
of  atrophy  and  hyperplasia  of  the  bones,  with  thickening  of  the  liga- 
ments and  more  or  less  efliusion.  Again,  there  are  joint  lesions  which 
follow  injuries  of  the  nerve  trunks  themselves,  cases  of  which  have  been 
reported  by  S.  Weir  Mitchell.  The  following  are  the  main  points  urged  in 
favor  of  the  nervous  origin  of  the  disease:  First,  the  articular  changes  are 
similar  to,  if  not  identical  with,  those  of  the  chronic  spinal  arthrop- 
athies. Secondly,  the  frequent  association  in  arthritis  deformans  of  dys- 
trophies of  the  skin  (glossy  skin),  nails,  bones,  and  muscles — changes  which 
are  evidently  of  neurotic  origin.  In  certain  cases  there  is  marked  and  early 
atrophy  of  the  muscles.  Ord,  indeed,  thinks  that  this  atrophy  with  the 
articular  lesions  forms  a  dystrophy  analogous  to  progressive  muscular  atro- 
phy. Thirdly,  the  symmetrical  onset  and  progress  of  the  disease.  Fourthly, 
the  implication  of  nerve  trunks.  There  may  be  not  only  numbness  and 
tingling,  but  in  certain  cases  excruciating  pains.  Post  mortem,  neuritis 
has  been  found  in  several  cases,  but  whether  primary  or  secondary  is  doubt- 
ful. The  reflexes  are  not  infrequently  increased,  in  32  of  50  of  Garrod's 
cases.  We  need  information  as  to  the  condition  of  the  spinal  cord  in  these 
cases  of  arthritis  deformans.  Triboulet  and  Thomas  have  reported  from 
Dejerine's  service  a  case  of  a  woman  with  chronic  arthritis,  in  whom  the 
autopsy  showed  a  sclerosis  of  the  posterior  columns  of  the  cord  in  the  dorsal 
region  and  of  the  columns  of  Goll  in  the  cervical  region,  with  degeneration 
of  the  posterior  roots.  The  history  indicated  that  the  arthritis  developed 
after  a  puerperal  infection. 

Arthritis  Deformans  as  a  Chronic  Infection. — During  the  past  few 
years  the  idea  has  been  gaining  ground  that  the  disease  is  of  microbic  origin. 
Satisfactory  evidence  for  this  view  is  not  yet  forthcoming.  Schiiller,  Ban- 
natyne  and  Blaxall,  and  several  French  observers  have  found  micro-organ- 
isms in  the  fluid  of  the  joints.  More  valuable  really  is  the  frequent  asso- 
ciation of  arthritis  deformans  with  previous  acute  infections;  thus  in  James 
Stewart's  cases  there  was  a  history  of  gonorrhoea  in  30  per  cent  of  the  males, 
and  in  his  series  of  40  cases  50  per  cent  had  had  previously  some  infectious 
trouble.  Of  late  years  we  have  learned  to  recognize  cases  which  have  fol- 
lowed directly  upon  a  severe  attack  of  influenza. 

The  acute  mode  of  onset  in  some  instances  is  suggestive  of  an  infection. 
The  joints  may  be  red  and  swollen  and  painful,  and  present  the  clinical 
picture  of  an  acute  infective  process. 

And,  lastly,  a  consideration  of  the  form  in  children  described  by  Still 
lends  weight  to  this  view,  particularly  in  the  widespread  enlargement  of 
the  lymph-glands  and  the  swelling  of  the  spleen.  A  number  of  the  very 
best  students  of  the  disease,  as  Baumler,  of  Freiburg,  have  accepted  the 
infective  theory  of  origin,  which  is  gaining  adherents,  though  it  still 
lacks  demonstration. 

Morbid  Anatomy. — The  changes  in  the  joints  differ  essentially 
from  those  of  gout  in  the  absence  of  deposits  of  urate  of  soda,  and  from 


ARTHRITIS  DEFORMANS.  401 

chronic  rheumatism  in  the  existence  of  extensive  structural  alterations, 
particularly  in  the  cartilages.  We  are  largely  indebted  to  the  magnificent 
work  of  Adams  for  our  knowledge  of  the  anatomy  of  this  disease.  The 
changes  begin  in  the  cartilages  and  synovial  membranes,  the  cells  of  which 
proliferate.  The  cartilage  covering  the  joint  undergoes  a  peculiar  fibrilla- 
tion, becomes  soft,  and  is  either  absorbed  or  gradually  thinned  by  attri- 
tion, thus  laying  bare  the  ends  of  the  bone,  which  become  smooth,  polished, 
and  eburnated.  At  the  margins,  where  the  pressure  is  less,  the  proliferating 
elements  may  develop  into  irregular  nodules,  which  ossify  and  enlarge  the 
heads  of  the  bones,  forming  osteophytes  which  completely  lock  the  Joint. 
The  periosteum  may  also  form  new  bone.  There  is  usually  great  thicken- 
ing of  the  ligaments,  and  finally  complete  anchylosis  results.  This  is  rarely, 
however,  a  true  anchylosis,  but  is  caused  by  the  osteophytes  and  thickened 
ligaments.  There  are  often  hyperostosis  and  increase  in  the  articular  ends 
of  the  bone  in  length  and  thickness.  In  long-standing  cases  and  in  old 
persons  there  may,  on  the  other  hand,  be  great  atrophy  of  the  heads  of  the 
affected  bones.  The  spongy  substance  becomes  friable,  and  in  the  hip-Joint 
the  wasting  may  reach  such  an  extreme  grade  that  the  articulating  surface 
lies  between  the  trochanters.  This  is  sometimes  called  morbus  coxce  senilis. 
The  anatomical  changes  may  lead  to  great  deformity.  The  metacarpal 
Joints  are  enlarged  and  thickened,  and  the  fingers  are  deflected  toward  the 
ulnar  side.  The  toes  often  show  a  similar  deflection.  The  exostoses  at  the 
Joints  are  known  as  Haygarth's  nodosities. 

The  radiographs  of  arthritis  deformans  are  very  instructive.  The  clear 
interosseous  spaces  at  the  level  of  the  Joints  disappear  early,  the  hyper- 
trophy and  deformity  of  the  articular  extremities,  and  more  particularly 
the  exostoses  at  the  margins,  give  a  very  distinctive  picture  of  the  dis- 
ease. 

The  muscles  become  atrophied,  and  in  some  cases  the  wasting  reaches 
a  high  grade.  Neuritis  has  been  demonstrated  in  the  nerves  about  the 
Joints. 

Symptoms. — For  convenience  the  forms  may  be  described  as  those 
with  Heberden's  nodes,  general  progressive  arthritis,  the  mono-articular 
form,  the  vertebral  form,  and  the  arthritis  deformans  of  children. 

Heberden's  Nodes. — In  this  form  the  fingers  are  affected,  and  "  little 
hard  knobs  "  develop  gradually  at  the  sides  of  the  distal  phalanges.  They 
are  much  more  common  in  women  than  in  men.  They  begin  usually  be- 
tween the  thirtieth  and  fortieth  year.  The  subjects  may  have  had  digestive 
troubles  or  gout.  Heberden,  however,  says  "  they  have  no  connection  with 
gout,  being  found  in  persons  who  never  had  it."  In  the  early  stage  the 
Joints  may  be  swollen,  tender,  and  slightly  red,  particularly  when  knocked. 
The  attacks  of  pain  and  swelling  may  come  on  in  the  Joints  at  long  inter- 
vals or  follow  indiscretion  in  diet.  The  little  tubercles  at  the  sides  of  the 
dorsal  surface  of  the  second  phalanx  increase  in  size,  and  give  the  charac- 
teristic appearance  to  the  affection.  The  cartilages  also  become  soft, 
and  the  ends  of  the  bones  eburnated.  Urate  of  soda  is  never  deposited 
(Charcot).  The  condition  is  not  curable;  but  there  is  this  hopeful 
feature — the  subjects  of  these  nodosities  rarely  have  involvement  of  the 


402  CONSTITUTIONAL  DISEASES. 

larger  joints.  They  have  been  regarded,  too,  as  an  indication  of  longevity. 
Charcot  states  that  in  women  with  these  nodes  cancer  seems  more  fre- 
quent. 

General  Progressive  Form. — This  occurs  in  two  varieties,  acute  and 
chronic.  The  acute  form  may  resemble,  at  its  outset,  ordinary  articular 
rheumatism.  There  is  involvement  of  many  joints;  swelling,  particularly 
of  the  synovial  sheaths  and  bursge;  not  often  redness;  but  there  is  mod- 
erate fever.  Howard  describes  this  condition  as  most  frequent  in  young 
women  from  twenty  to  thirty  years  of  age,  often  in  connection  with  recent 
delivery,  lactation,  or  rapid  child-bearing.  Acute  cases  may  develop  at 
the  menopause.  It  may  also  come  on  in  children.  "  These  patients  suffer 
in  their  general  health,  become  weak,  pale,  depressed  in  spirits,  and  lose 
flesh.  In  several  cases  of  this  form  marked  intervals  of  improvement  have 
occurred;  the  local  disease  has  ceased  to  progress,  and  tolerable  comfort 
has  been  experienced  perhaps  until  pregnancy,  delivery,  or  lactation  again 
determines  a  fresh  outbreak  of  the  disease.^' 

The  chronic  form  is  by  far  the  most  common.  The  joints  are  usually 
involved  symmetrically.  The  first  symptoms  are  pain  on  movement  and 
slight  swelling,  which  may  be  in  the  joint  itself  or  in  the  peri-articular 
sheaths.  In  some  cases  the  effusion  is  marked,  in  others  slight.  The  local 
conditions  vary  greatly,  and  periods  of  improvement  alternate  with  attacks 
of  swelling,  redness,  and  pain.  At  first  only,  one  or  two  joints  are  affected; 
usually  the  joints  of  the  hands,  then  the  knees  and  feet;  gradually  other 
articulations  are  involved,  and  in  extreme  cases  every  joint  in  the  body 
is  affected.  Pain  is  an  extremely  variable  symptom.  Some  cases  pro- 
ceed to  the  most  extreme  deformity  without  it;  in  others  the  suffering  is 
very  great,  particularly  at  night  and  during  exacerbations  of  the  disease. 
There  are  cases  in  which  pain  of  an  agonizing  character  is  an  almost  con- 
stant symptom,  requiring  for  years  the  use  of  morphia. 

Gradually  the  shape  of  the  joints  is  greatly  altered,  partly  by  the  pres- 
ence of  osteophytes,  partly  by  the  great  thickening  of  the  capsular  liga- 
ments, and  still  more  by  the  retraction  of  the  muscles.  In  moving  the 
affected  joint  crepitation  can  be  felt,  due  to  the  eburnation  of  the  articular 
surfaces.  Ultimately  the  joints  become  completely  locked,  not  by  a  true 
bony  anchylosis,  but  by  the  osteophytes  which  form  around  the  articular 
surfaces,  like  ring-bone  in  horses.  There  is  also  a  spurious  anchylosis, 
caused  by  the  thickening  of  the  capsular  ligaments  and  fibrous  adhesions. 
The  muscles  about  the  joints  undergo  important  changes.  Atrophy  from 
disuse  gradually  supervenes,  and  contractures  tend  to  flex  the  thigh  upon 
the  abdomen  and  the  leg  upon  the  thigh.  There  are  cases  with  rapid 
muscular  wasting,  symmetrical  involvement  of  the  joints,  increased  reflexes, 
and  trophic  changes,  which  strongly  suggest  a  central  origin.  Numbness, 
tingling,  pigmentation  or  glossiness  of  the  skin,  and  onychia  may  be  pres- 
ent. In  extreme  cases  the  patient  is  completely  helpless,  and  lies  on  one 
side  with  the  legs  drawn  up,  the  arms  fixed,  and  all  the  articulations  of  the 
extremities  locked.  Fortunately,  it  often  happens  in  these  severe  general 
cases  that  the  joints  of  the  hand  are  not  so  much  affected,  and  the  patient 
may  be  able  to  knit  or  to  write,  though  unable  to  walk  or  to  use  the  arms. 


ARTHRITIS  DEFORMANS.  403 

In  many  cases,  after  involving  two  or  three  joints,  the  disease  becomes  ar- 
rested, and  no  further  development  occurs.  It  may  be  limited  to  the 
wrists,  or  to  the  knees  and  wrists,  or  to  the  knees  and  ankles.  A  majority 
of  the  patients  finally  reach  a  quiescent  stage,  in  which  they  are  free  from 
pain  and  enjoy  excellent  health,  sufEering  only  from  the  inconvenience 
and  crippling  necessarily  associated  with  the  disease.  Coincident  affec- 
tions are  not  uncommon.  In  the  active  stage  the  patients  are  often  anaemic 
and  suffer  from  dyspepsia,  which  may  recur  at  intervals.  There  is  no  tend- 
ency to  involvement  of  the  heart. 

The  partial  or  mono-articular  form  affects  chiefly  old  persons,  and  is 
seen  particularly  in  the  hip,  the  knee,  the  spinal  column,  or  shoulder.  It 
is,  in  its  anatomical  features,  identical  with  the  general  disease.  In  the 
hip  and  shoulder  the  muscles  early  show  wasting,  and  in  the  hip  the  con- 
dition ultimately  becomes  that  already  described  as  morbus  coxce  senilis. 
These  cases  seem  not  infrequently  to  follow  an  injury.  They  differ  from  the 
polyarticular  form  in  occurring  chiefly  in  men  and  at  a  later  period  of  life. 

The  Vertebral  Form. — There  is  a  progressive  anchylosis  of  the  verte- 
bras, causing  rigidity  of  the  spine — "  poker-back  " — spondylitis  deformans. 
There  are  two  varieties.  In  one  (von  Bechterew),  in  which  the  disease  may 
follow  trauma  or  be  hereditary,  the  spine  alone  is  involved,  and  there  are 
pronounced  nerve-root  symptoms — pain,  anaesthesia,  atrophy  of  muscles,  and 
ascending  degeneration  in  the  cord;  in  the  other — Striimpell-Marie  type — 
the  hip  and  shoulder  joints  may  be  involved  (spondylose  rhizomelique),  and 
the  nervous  symptoms  are  less  prominent.  I  believe  they  are  both  forms 
of  arthritis  deformans,  and  should  neither  be  regarded  nor  described  as 
separate  diseases.  The  cases  are  more  frequent  in  males  than  in  females; 
the  onset  may  be  in  the  upper  or  in  the  lower  part  of  the  spine.  It  may 
be  limited  to  the  neck.  There  is  gradually  induced  complete  immobility, 
with  some  kyphosis.  The  other  joints  may  not  be  affected,  or  the  hips  and 
shoulders  may  be  anchylosed.  The  ribs  are  fixed,  the  thorax  immobile, 
and  the  breathing  abdominal.  Pressure  on  the  nerve-roots  may  cause  great 
pain,  paraesthesia,  and  atrophy  of  muscles.  Von  Bechterew  thinks  that 
the  disease  begins  as  a  meningitis,  leads  to  compression  of  the  nerve-roots, 
loss  of  function  of  the  spinal  muscles,  atrophy  of  the  intervertebral  disks, 
and  gradually  anchylosis  of  the  spines.  Seguin  reported  three  children  in 
one  family. 

Arthritis  Deformans  in  Children. — Some  examples  certainly  resemble 
closely  the  disease  in  adults.  In  others  there  are  very  striking  differences. 
A  very  interesting  variety  has  been  differentiated  by  George  F.  Still,  in 
which  the  general  enlargement  of  the  joints  is  associated  with  swelling  of 
the  lymph-glands  and  of  the  spleen.  He  has  studied  22  cases  of  this  char- 
acter. The  following  are  among  the  more  striking  peculiarities:  The 
onset  is  almost  always  before  the  second  dentition.  Girls  are  more  fre- 
quently affected  than  boys.  The  symptoms  complained  of  are  usually  slight 
stiffness  in  one  or  two  joints;  gradually  others  become  involved.  The  onset 
may  be  more  acute  with  fever,  or  even  with  chills.  The  enlargement  of 
the  joints  is  due  rather  to  a  general  thickening  of  the  soft  tissues  than  to 
a  bony  enlargement.     There  is  no  bony  grating.     The  limitation  of  move- 


404  CONSTITUTIONAL  DISEASES. 

ment  may  be  extreme,  owing  to  the  fixation  of  the  joints,  and  there  may 
be  much  muscular  wasting.  The  enlargement  of  the  lymph-glands  is  most 
striking,  and  may  be  general;  even  the  supratrochlear  glands  may  be  as 
large  as  hazel-nuts.  They  increase  with  the  fever.  The  edge  of  the  spleen 
can  usually  be  felt  below  the  costal  margin.  Sweating  is  often  profuse 
and  there  may  be  anaemia,  but  heart  complications  are  rare.  The  chil- 
dren look  puny  and  generally  show  arrest  of  development. 

Diagnosis. — Arthritis  deformans  in  an  advanced  stage  can  rarely  be 
mistaken  for  either  rheumatism  or  gout.  Early  cases  are  difficult  or  impos- 
sible to  distinguish  from  chronic  rheumatism.  It  is  important  to  distin- 
guish from  the  mono-articular  form  the  local  arthritis  of  the  shoulder- joint 
which  is  characterized  by  pain,  thickening  of  the  capsule  and  of  the  liga- 
ments, wasting  of  the  shoulder-girdle  muscles,  and  sometimes  by  neuritis. 
This  is  an  affection  which  is  quite  distinct  from  arthritis  deformans,  and  is, 
moreover,  in  a  majority  of  cases  curable. 

Treatment. — Once  established,  the  disease  is  rarely  curable.  After 
attacking  two  or  three  joints  it  may  be  arrested.  Too  often  it  is  a  slow, 
but  progressive,  crippling  of  the  joints,  with  a  disability  that  makes  the 
disease  one  of  the  most  terrible  of  human  afflictions. 

In  the  acute  febrile  form,  usually  mistaken  for  rheumatic  fever,  moder- 
ate doses  of  the  salicylates  should  be  given,  and  the  joints  require  the 
local  measures  mentioned  in  the  section  on  acute  rheumatism. 

The  treatment  of  the  ordinary  form  may  be  considered  under: 

(1)  Medicinal. — No  single  remedy  is  of  special  value.  General  tonics 
are  indicated.  Arsenic  in  full  doses  is  helpful  in  some  cases.  Potassium 
iodide  is  useful  in  the  form  with  much  periarthritis. 

(2)  General  Hygiene  and  Diet. — The  disease  is  one  of  progressive  debil- 
ity, and  measures  of  a  supporting  character  are  indicated.  Fresh  air  and 
careful  attention  to  personal  hygiene  are  most  essential.  The  question 
of  diet  is  of  the  first  importance.  There  is  one  rule — ^let  the  patient  eat 
all  the  good  food  she  can  digest.  So  many  persons  are  afflicted  not  only 
with  the  disease,  but  reduced  by  dieting,  that  I  often  find  "  full  diet "  the 
best  prescription.  One  has  to  remember  that  gastro-intestinal  disturb- 
ances are  common  in  the  disease. 

(3)  Hydrotherapy. — Early  and  thorough  treatment  at  the  thermal 
springs  offers  the  best  hope  of  arresting  the  progress.  The  Hot  Springs, 
Bath  County,  Va.,  and  the  Hot  Springs,  Ark.,  in  this  country,  and  those  of 
Bath,  England,  give  very  good  results.  Much  may  be  effected  at  home  by 
hot-air  baths,  hot  baths,  and  compresses  at  night  to  the  tender  joints. 

(4)  Local  Treatment. — Massage,  carefully  given,  reduces  the  periarticu- 
lar infiltrations,  increases  the  mobility  of  stiffened  joints,  and,  most  impor- 
tant of  all,  prevents  the  atrophy  of  the  muscles  adjacent  to  the  affected 
joints.  The  hot-air  treatment,  thoroughly  carried  out,  helps  many  cases, 
and  should  be  given  a  trial. 

And  lastly,  surgical  measures  may  be  needed.  The  thermo-cautery  is 
most  useful  in  relieving  the  pain  and  in  lessening  the  ligamentous  thicken- 
ing. Eepeated  applications  are  helpful  along  the  spine  in  the  spondylitis 
deformans.  Goldthwaite  and  others  have  reported  good  results  from  the 
breaking  up  of  adhesions  and  the  use  of  orthopaedic  appliances. 


CHRONIC  RHEUMATISM.  405 


II.    CHRONIC    RHEUMATISM. 


Etiology. — This  affection  may  follow  an  acute  or  subacute  attack,  but 
more  commonly  comes  on  insidiously  in  persons  who  have  passed  the 
middle  period  of  life.  In  my  experience  it  is  extremely  rare  as  a  sequence 
of  acute  rheumatism.  It  is  most  common  among  the  poor,  particularly 
washer-women,  day-laborers,  and  those  whose  occupation  exposes  them  to 
cold  and  damp. 

Morbid  Anatomy. — The  synovial  membranes  are  injected,  but  there 
is  usually  not  much  eifusion.  The  capsule  and  ligaments  of  the  joints  are 
thickened,  and  the  sheaths  of  the  tendons  in  the  neighborhood  undergo 
similar  alterations,  so  that  the  free  play  of  the  joint  is  greatly  impaired. 
In  long-standing  cases  the  cartilages  also  undergo  changes,  and  may  show 
erosions.  Even  in  cases  with  the  severest  symptoms,  the  joint  may  be 
very  slightly  altered  in  appearance.  Important  changes  take  place  in  the 
muscles  and  nerves  adjacent  to  chronically  inflamed  joints,  particularly 
in  the  mono-articular  lesions  of  the  shoulder  or  hip.  Muscular  atrophy 
supervenes  partly  from  disuse,  partly  through  nervous  influences,  either 
centric  or  reflex  (Vulpian),  or  as  a  result  of  peripheral  neuritis.  In  some 
cases  when  the  joint  is  much  distended  the  wasting  may  be  due  to  pressure, 
either  on  the  muscles  themselves  or  on  the  vessels  supplying  them.        ^ 

Symptoms. — Stiffness  and  pain  are  the  chief  features  of  chronic 
rheumatism.  The  latter  is  very  liable  to  exacerbations,  especially  dur- 
ing changes  in  the  weather.  The  joints  may  be  tender  to  the  touch  and  a 
little  swollen,  but  are  seldom  reddened.  As  a  rule,  many  joints  are  affected; 
but  there  are  instances  in  which  the  disease  is  confined  to  one  shoulder, 
knee,  or  hip.  The  stiffness  and  pain  are  more  marked  after  rest,  and  as  the 
day  advances  the  joints  may,  with  exertion,  become  much  more  supple. 
The  general  health  may  not  be  seriously  impaired.  The  disease  is  not  im- 
mediately dangerous.  Anchylosis  may  occur,  and  ultimately  the  joints 
may  become  much  distorted.  In  many  instances,  particularly  those  in 
which  the  pain  is  severe,  the  general  health  may  be  seriously  involved  and 
the  subjects  become  angemic  and  very  apt  to  suffer  with  neuralgia  and  dys- 
pepsia. Valvular  lesions,  due  to  slow  sclerotic  changes,  are  not  uncommon. 
They  are  associated  with,  not  dependent  upon,  the  articular  disease. 

The  prognosis  is  not  favorable,  as  a  majority  of  the  cases  resist  all  meth- 
ods of  treatment.  It  is,  however,  a  disease  which  persists  indefinitely,  and 
does  not  necessarily  shorten  life. 

Treatment. — Internal  remedies  are  of  little  service.  It  is  important 
to  maintain  the  digestive  functions  and  to  keep  the  general  health  at  a 
high  standard.  Potassium  iodide,  sarsaparilla,  and  guaiacum  are  some- 
times beneficial.     The  salicylates  are  useless. 

Local  treatment  is  very  iDeneficial.  "  Firing  "  with  the  Paquolin  cautery 
relieves  the  pain,  and  it  is  perhaps  the  best  form  of  counter-irritation. 
Massage,  with  passive  motion,  helps  to  reduce  swelling,  and  prevents  anchy- 
losis. It  is  particularly  useful  in  cases  which  are  associated  with  atrophy 
of  the  muscles.     Electricity  is  not  of  much  benefit.     Climatic  treatment 


406  CONSTITUTIONAL  DISEASES. 

is  very  advantageous.  Many  cases  are  greatly  helped  by  prolonged  resi- 
dence in  southern  Europe  or  Southern  California.  Eich  patients  should 
always  winter  in  the  South,  and  in  this  way  avoid  the  cold,  damp  weather. 
Hydrotherapeutic  measures  are  specially  beneficial  in  chronic  rheuma- 
tism. Great  relief  is  afforded  by  wrapping  the  affected  joints  in  cold  cloths, 
covered  with  a  thin  layer  of  blanket,  and  protected  with  oiled  silk.  The 
Turkish  bath  is  useful,  but  the  full  benefit  of  this  treatment  is  rarely  seen 
except  at  bathing  establishments.  The  hot  alkaline  waters  are  particularly 
useful,  and  a  residence  at  the  Hot  Springs  of  Virginia,  Arkansas,  or  Santa 
Rosalia,  Mexico,  or  at  Banff,  in  the  Eocky  Mountains,  on  the  Canadian 
Pacific  Eailway,  will  sometimes  cure  even  obstinate  cases. 


III.    MUSCULAR    RHEUMATISM   {Myalgia). 

Definition. — A  painful  affection  of  the  voluntary  muscles  and  of  the 
fascise  and  periosteum  to  which  they  are  attached.  The  affection  has  re- 
ceived various  names,  according  to  its  seat,  as  torticollis,  lumbago,  pleuro- 
dynia, etc. 

Etiology. — The  attacks  follow  cold  and  exposure,  the  usual  conditions 
favorable  to  the  development  of  rheumatism.  It  is  by  no  means  certain 
that  the  muscular  tissues  are  the  seat  of  the  disease.  Many  writers  claim, 
perhaps  correctly,  that  it  is  a  neuralgia  of  the  sensory  nerves  of  the  mus- 
cles. Until  our  knowledge  is  more  accurate,  however,  it  may  be  considered 
under  the  rheumatic  affections. 

It  is  most  commonly  met  with  in  men,  particularly  those  exposed  to 
cold  and  whose  occupations  are  laborious.  It  is  apt  to  follow  exposure  to 
a  draught  of  air,  as  from  an  open  window  in  a  railway  carriage.  A  sudden 
chilling  after  heavy  exertion  may  also  bring  on  an  attack  of  lumbago. 
Persons  of  a  rheumatic  or  gouty  habit  are  certainly  more  prone  to  this 
affection.  One  attack  renders  an  individual  more  liable  to  another.  It  is 
usually  acute,  but  may  become  subacute  or  even  chronic. 

Symptoms. — The  affection  is  entirely  local.  The  constitutional  dis- 
turbance is  slight,  and,  even  in  severe  cases,  there  may  be  no  fever.  Pain 
is  a  prominent  symptom.  It  may  be  constant,  or  may  occur  only  when 
the  muscles  are  drawn  into  certain  positions.  It  may  be  a  dull  ache,  like 
the  pain  of  a  bruise,  or  sharp,  severe,  and  cramp-like.  It  is  often  sufficiently 
intense  to  cause  the  patient  to  cry  out.  Pressure  on  the  affected  part  usually 
gives  relief.  As  a  rule,  myalgia  is  a  transient  affection,  lasting  from  a  few 
hours  to  a  few  days.  Occasionally  it  is  prolonged  for  several  weeks.  It  is 
very  apt  to  recur. 

The  following  are  the  principal  varieties: 

(1)  Lumbago,  one  of  the  most  common  and  painful  forms,  affects  the 
muscles  of  the  loins  and  their  tendinous  attachments.  It  occurs  chiefly  in 
workingmen.  It  comes  on  suddenly,  and  in  very  severe  cases  completely 
incapacitates  the  patient,  who  may  be  unable  to  turn  in  bed  or  to  rise  from 
the  sitting  posture. 

(2)  Stiff  neck  or  torticollis  affects  the  muscles  of  the  antero-lateral 


GOUT.  407 

region  of  the  neck.  It  is  very  common,  and  occurs  most  frequently  in 
the  young.  The  patient  holds  the  head  in  a  peculiar  manner,  and  rotates 
the  whole  body  in  attempting  to  turn  it.  Usually  the  attack  is  confined  to 
one  side.    The  muscles  at  the  back  of  the  neck  may  also  be  affected. 

(3)  Pleurodynia  involves  the  intercostal  muscles  on  one  side,  and  in 
some  instances  the  pectorals  and  serratus  magnus.  This  is,  perhaps,  the 
most  painful  form  of  the  disease,  as  the  chest  cannot  be  at  rest.  It  is  more 
common  on  the  left  than  on  the  right  side.  A  deep  breath,  or  coughing, 
causes  very  intense  pain,  and  the  respiratory  movements  are  restricted  on 
the  affected  side.  There  may  be  pain  on  pressure,  sometimes  over  a  very 
limited  area.  It  may  be  difficult  to  distinguish  from  intercostal  neuralgia, 
in  which  affection,  however,  the  pain  is  usually  more  circumscribed  and 
paroxysmal,  and  there  are  tender  points  along  the  course  of  the  nerves. 
It  is  sometimes  mistaken  for  pleurisy,  but  careful  physical  examination 
readily  distinguishes  between  the  two  affections. 

(4)  Among  other  forms  which  may  be  mentioned  are  cephalodynia, 
affecting  the  muscles  of  the  head;  scapulodynia,  omodynia,  and  dorsodynia, 
affecting  the  muscles  about  the  shoulder  and  upper  part  of  the  back.  My- 
algia may  also  occur  in  the  abdominal  muscles  and  in  the  muscles  of  the 
extremities. 

Treatment. — Eest  of  the  affected  muscles  is  of  the  first  importance. 
Strapping  the  side  will  sometimes  completely  relieve  pleurodynia.  No 
belief  is  more  widespread  among  the  public  than  in  the  efficacy  of  porous 
plasters  for  muscular  pains  of  all  sorts,  particularly  those  about  the  trunk. 
If  the  pain  is  severe  and  agonizing,  a  hypodermic  of  morphia  gives  im- 
mediate relief.  For  lumbago  acupuncture  is,  in  acute  cases,  the  most  effi- 
cient treatment.  Needles  of  from  three  to  four  inches  in  length  (ordinary 
bonnet-needles,  sterilized,  will  do)  are  thrust  into  the  lumbar  muscles  at 
the  seat  of  the  pain,  and  withdrawn  after  five  or  ten  minutes.  In  many 
instances  the  relief  is  immediate,  and  I  can  corroborate  fully  the  state- 
ments of  Einger,  who  taught  me  this  practice,  as  to  its  extraordinary  and 
'prompt  efficacy  in  many  instances.  The  constant  current  is  sometimes 
very  beneficial.  In  many  forms  of  myalgia  the  thermo-cautery  gives  great 
relief.  In  obstinate  cases  blisters  may  be  tried.  Hot  fomentations  are 
soothing,  and  at  the  outset  a  Turkish  bath  may  cut  short  the  attack.  In 
chronic  cases  potassium  iodide  may  be  used,  and  both  guaiacum  and  sul- 
phur have  been  strongly  recommended.  Persons  subject  to  this  affec- 
tion should  be  warmly  clothed,  and  avoid,  if  possible,  exposure  to  cold 
and  damp.  In  gouty  persons  the  diet  should  be  restricted  and  the  alkaline 
mineral  waters  taken  freely.  Large  doses  of  nux  vomica  are  sometimes 
beneficial. 

IV.    GOUT    {Podagra). 

Definition. — A  nutritional  disorder,  one  factor  of  which  is  an  ex- 
cessive formation  of  uric  acid,  characterized  clinically  by  attacks  of  acute 
arthritis,  by  the  gradual  deposition  of  sodium  urate  in  and  about  the  joints, 
and  by  the  occurrence  of  irregular  constitutional  symptoms. 


408  CONSTITUTIONAL  DISEASES. 

Etiology. — The  precise  nature  of  the  disturbance  in  metabolism  is 
not  known.  There  is  probably  defective  oxidation  of  the  foodstuffs,  com- 
bined with  imperfect  elimination  of  the  waste  products  of  the  body. 

Among  important  etiological  factors  in  gout  are  the  following: 

(a)  Hereditary  Influences. — Statistics  show  that  in  from  50  to  60  per 
cent  of  all  eases  the  disease  existed  in  the  parents  or  grandparents.  The 
transmission  is  supposed  to  be  more  marked  from  the  male  side.  Cases 
with  a  strong  hereditary  taint  have  been  known  to  develop  before  puberty. 
The  disease  has  been  seen  even  in  infants  at  the  breast.  Males  are  more 
subject  to  the  disease  than  females.  It  rarely  develops  before  the  thirtieth 
year,  and  in  a  large  majority  of  the  cases  the  first  manifestations  appear 
before  the  age  of  fifty.  (&)  Alcohol  is  the  most  potent  factor  in  the  etiology 
of  the  disease.  Fermented  liquors  favor  its  development  much  more  than 
distilled  spirits,  and  it  prevails  most  extensively  in  countries  like  England 
and  Germany,  which  consume  the  most  beer  and  ale.  The  lighter  beers 
used  in  this  country  are  much  less  liable  to  produce  gout  than  the  heavier 
English  and  Scotch  ales,  (c)  Food  plays  a  role  equal  in  importance  to  that 
of  alcohol.  Overeating  without  active  bodily  exercise  is  regarded  as  a  very 
special  predisposing  cause.  A  form  of  gouty  dyspepsia  has  been  described. 
A  robust  and  active  digestion  is,  however,  often  met  in  gouty  persons. 
Gout  is  by  no  means  confined  to  the  rich.  In  England  the  combination 
of  poor  food,  defective  hygiene,  and  an  excessive  consumption  of  malt 
liquors  makes  the  "  poor  man^s  gout "  a  common  afi'ection.  (d)  Lead. 
Garrod  has  shown  that  workers  in  lead  are  specially  prone  to  gout.  In  30 
per  cent  of  the  hospital  cases  the  patients  had  been  painters  or  workers  in 
lead.  The  association  is  probably  to  be  sought  in  the  production  by  this 
poison  of  arterio-sclerosis  and  chronic  nephritis.  Chronic  lead-poisoning 
is  here  frequently  associated  with  arterio-sclerosis  and  contracted  kidneys, 
but  lead-gout  is  comparatively  rare.  Gouty  deposits  are,  however,  to  be 
found  in  the  big-toe  joint  and  in  the  kidneys  in  cases  of  chronic  plumbism. 

The  nature  of  gout  is  unknown.  That  there  is  faulty  metabolism,  asso- 
ciated in  some  very  special  way  with  the  chemistry  of  uric  acid,  we  know, 
but  nothing  more.  The  remainder  is  theory,  awaiting  refutation  or  con- 
firmation. The  conditions  of  life  favorable  to  the  development  of  gout  are 
present  in  too  many  of  us  after  the  middle  period  of  life — more  fuel  in  the 
form  of  meat  and  drink  than  the  machine  needs.  G.  B.  Balfour  put  it  well 
when  he  says:  "  The  gouty  diathesis  is  only  a  comprehensive  term  for  all 
those  changes  in  the  character  and  composition  of  the  blood  induced  by 
the  evils  of  civilization — deficient  exercise  and  excess  of  nutriment.  .  .  . 
Gout,  on  the  other  hand,  is  the  name  given  to  all  those  modifications  of  our 
metabolism  caused  by  the  gouty  diathesis,  as  well  as  to  all  the  symptoms 
to  which  those  modifications  give  rise." 

The  views  regarding  uric  acid  and  its  relation  to  gout  are  very  nu- 
merous. 

Garrod  holds  that  with  lessened  alkalinity  of  the  blood  there  is  an  in- 
crease in  the  uric  acid,  due  chiefly  to  diminished  elimination.  He  attrib- 
utes the  deposition  of  the  sodium  urate  to  the  diminished  alkalinity  of  the 
plasma,  which  is  unable  to  hold  it  in  solution.    In  an  acute  paroxysm  there 


GOUT.  409 

is  an  aceumiLlation  of  the  urates  in  the  blood,  and  the  inflammation  is 
caused  by  their  sudden  deposit  in  crystalline  form  about  the  joint. 

Haig  thinks  that  there  is  no  increased  formation  of  uric  acid  in  gout, 
but  that  the  blood  is  less  alkaline  than  normal,  and  less  able  to  hold  the 
uric  acid  or  its  salts  in  solution. 

According  to  Sir  William  Eoberts,  there  are  three  compounds  of  uric 
acid  (H2IJ) — the  neutral  urate,  MgU,  in_which  the  metal  replaces  all  the 
displaceable  hydrogen;  the  biurate,  MHU,  in  which  half  the  displaceable 
hydrogen  is  replaced  by  the  metal;  and  the  quadriurate,  HaUMHU,  in  which 
one-fourth  of  the  displaceable  hydrogen  of  two  molecules  is  replaced  by  the 
metal.  The  neutral  urates  do  not  exist  in  the  body:  the  biurate  only  as 
biurate  of  soda  in  gouty  concretions.  The  quadriurate  is  the  form  in  which 
uric  acid  circulates  in  the  blood  and  is  excreted  in  the  urine.  It  is  quite 
soluble.  In  the  gouty  state,  either  from  deficient  action  of  the  kidneys  or 
from  over-production  of  urates,  the  quadriurate  accumulates  in  the  blood. 
The  detained  quadriurate,  circulating  in  a  medium  rich  in  sodium  carbonate, 
takes  up  an  additional  atom  of  the  base  and  is  converted  into  the  biurate. 
The  biurate  is  less  soluble  and  less  easily  excreted  by  the  kidneys.  It  conse- 
quently accumulates  in  the  blood  and  exists  first  in  a  gelatinous  and  later 
in  the  almost  insoluble  crystalline  form.  Then  precipitation  is  imminent 
or  actually  takes  place.  This  is  apt  to  occur  where  the  circulation  is  poor 
and  the  temperature  low,  and  in  regions  in  which  the  lymph  contains  a 
relatively  high  percentage  of  sodium  chloride,  as  in  the  synovial  sheaths. 
Although  this  theory  is  very  plausible,  yet  the  work  of  Tunnicliffe  and 
Rosenheim  shows  that  there  are  objections  to  it. 

Levison  (Die  Harnsaurediathese,  Berlin,  1893)  adopts  Horbaczewski's 
views  that  the  uric  acid  is  related  especially  to  the  nucleins  of  the  body, 
and  is  derived  in  great  part  from  the  destruction  of  the  white  blood-cor- 
puscles, the  excretion  increasing  fari  passu  with  the  intensity  of  the  leuco- 
cytosis.  While  this  is  true  in  many  diseases,  as  in  pneumonia,  Richter,  in  a 
careful  study,  has  shown  that  there  are  important  exceptions. 

Ebstein  thinks  that  the  first  change  is  a  nutritive  tissue  disturbance, 
which  leads  to  necrosis,  and  in  the  necrotic  areas  the  urates  are  deposited 
— a  view  which  has  been  modified  by  von  Noorden,  who  holds  that  a  spe- 
cial ferment  leads  to  the  tissue  change,  to  which  the  deposit  of  the  urates 
is  secondary. 

Kolisch  believes  that  gout  is  due  to  the  action  of  the  xanthin  bases. 
He  holds  that  they  are  increased  in  gout,  because,  he  thinks,  the  kidneys 
are  diseased  and  unable  to  convert  the  nucleic  acid  derivatives  into  uric 
acid  in  sufficient  amounts.  Garrod  and  Luff  also  both  hold  that  uric  acid 
is  normally  produced  only  in  the  kidneys.  Latham  also  is  of  the  opinion 
that  the  final  formation  of  uric  acid  takes  place  in  the  kidneys,  where  it 
is  produced  by  the  union  of  substances  formed  in  the  liver  and  conveyed 
to  them  by  the  blood  current.  The  question  of  the  final  seat  of  the 
formation  of  uric  acid  is  still  unsolved;  experimental  research  has  as  yet 
failed  to  give  uniform  results. 

Cullen  held  that  gout  was  primarily  an  affection  of  the  nervous  system. 
On  this  nervous  theory  of  gout  there  is  a  basic,  arthritic  stock — a  diathetic 


410  CONSTITUTIONAL  DISEASES. 

habit,  of  which  gout  and  rheumatism  are  two  distinct  branches.  The 
gouty  diathesis  is  expressed  in  (a)  a  neurosis  of  the  nerve-centres,  which 
may  be  inherited  or  acquired;  and  (&)  "  a  peculiar  incapacity  for  normal 
elaboration  within  the  whole  body,  not  merely  in  the  liver  or  in  one  or  two 
organs,  of  food,  whereby  uric  acid  is  formed  at  times  in  excess,  or  is  in- 
capable of  being  duly  transformed  into  more  soluble  and  less  noxious 
products  "  (Duckworth).  The  explosive  neuroses  and  the  influence  of  de- 
pressing circumstances,  physical  or  mental,  point  strongly  to  the  part 
played  by  the  nervous  system  in  the  disease.  The  recents  works  of  Duck- 
worth and  William  Ewart  may  be  consulted  for  a  full  discussion  of  the  vari- 
ous theories  on  the  nature  of  gout. 

Morbid  Anatomy. — The  Mood  is  stated  to  have  an  excess  of  uric 
acid.  It  may  be  obtained  from  the  blood-serum  by  the  method  known  as 
Garrod's  uric-acid  thread  experiment,  or  from  the  serum  obtained  from  a 
blister.  To  3  ij  of  serum  add  tti  v-vj  of  acetic  acid  in  a  watch-glass.  A 
thread  immersed  in  this  may  show  in  a  few  hours  an  incrustation  of  uric  acid. 
The  experiment  is  rarely  successful  even  in  cases  of  manifest  gout.  This 
excess,  also,  is  not  peculiar  to  gout,  but  occurs  in  leuksemia  and  chlorosis. 

In  1894  Neusser  described  a  peculiar  black  granulation  over  and  about 
the  nuclei  of  the  leucocytes  in  the  blood  of  gouty  patients.  He  termed  them 
"  perinuclear  basophilic  granules,'^  and  demonstrated  them  by  using  a  modi- 
fied Ehrlich's  triacid  mixture.  They  were  particularly  numerous  about  the 
nuclei  of  the  mononuclear  leucocytes.  He  believed  that  they  were  of  the 
nature  of  a  nucleo-albumin,  and  claimed  that  cases  showing  them  eliminated 
uric  acid  in  excess.  He  held  that  these  granules  constituted  the  mother 
substance  from  which  the  uric  acid  was  formed,  and  that  their  presence 
was  strongly  indicative  of  a  uratic  or  gouty  diathesis.  Subsequent  work 
by  Futcher  and  others  seems  to  have  shown  that  there  is  no  association 
between  the  abundance  of  these  granules  and  the  elimination  of  uric  acid 
or  of  the  total  alloxuric  bodies. 

The  important  changes  are  in  the  articular  tissues.  The  first  joint  of 
the  great  toe  is  most  frequently  involved;  then  the  ankles,  knees,  and  the 
small  joints  of  the  hands  and  wrists.  The  deposits  may  be  in  all  the  joints 
of  the  lower  limbs  and  absent  from  those  of  the  upper  limbs  (Norman 
Moore).  If  death  takes  place  during  an  acute  paroxysm,  there  are  signs 
of  inflammation,  hyperemia,  swelling  of  the  ligamentous  tissues,  and  of 
effusion  into  the  joint.  The  primary  change,  according  to  Ebstein,  is  a 
local  necrosis,  due  to  the  presence  of  an  excess  of  urates  in  the  blood.  This 
is  seen  in  the  cartilage  and  other  articular  tissues  in  which  the  nutritional 
currents  are  slow.  His  and  Mordhorst  hold  that  the  deposition  of  the 
urates  is  primary,  and  that  the  tissue  necrosis  takes  place  as  a  result  of  this 
deposit.  In  these  areas  of  coagulation  necrosis  the  reaction  is  always  acid 
and  the  neutral  urates  are  deposited  in  crystalline  form,  as  insoluble  acid 
urates.  The  articular  cartilages  are  first  involved.  The  gouty  deposit  may 
be  uniform,  or  in  small  areas.  Though  it  looks  superficial,  the  deposit  is 
invariably  interstitial  and  covered  by  a  thin  lamina  of  cartilage.  The  de- 
posit is  thickest  at  the  part  most  distant  from  the  circulation.  The  liga- 
ments and  fibro-cartilage  ultimately  become  involved  and  are  infiltrated 


GOUT.  411 

with  chalky  deposits,  the  so-called  chalk-stones,  or  tophi.  These  are  usually 
covered  by  skin;  but  in  some  cases,  particularly  in  the  metacarpo-phalangeal 
articulations,  this  ulcerates  and  the  chalk-stones  appear  externally.  The 
synovial  fluid  may  also  contain  crystals.  In  very  long-standing  cases,  owing 
to  an  excessive  deposit,  the  Joint  becomes  immobile.  The  marginal  out- 
growths in  gouty  arthritis  are  true  exostoses  (Wynne).  The  cartilage  of 
the  ear  may  contain  tophi,  which  are  seen  as  whitish  nodules  at  the  margin 
of  the  helix.  The  cartilages  of  the  nose,  eyelids,  and  larynx  are  less  fre- 
quently affected. 

Of  changes  in  the  internal  organs,  those  in  the  renal  and  vascular  sys- 
tems are  the  most  important.  The  kidney  changes  believed  to  be  charac- 
teristic of  gout  are:  (a)  A  deposit  of  urates  chiefly  in  the  region  of  the 
papillfe.  This,  however,  is  less  common  than  is  usually  supposed.  ISTorman 
Moore  found  it  in  only  12  out  of  80  cases.  The  apices  of  the  pyramids  show 
lines  of  whitish  deposit.  On  microscopical  examination  the  material  is  seen 
to  be  largely  in  the  intertubular  tissue.  In  some  instances,  however,  the 
deposit  seems  to  be  both  in  the  tissue  and  in  the  tubules.  Ebstein  has  de- 
scribed and  figured  areas  of  necrosis  in  both  cortex  and  medulla,  in  the 
interior  of  which  were  crystalline  deposits  of  urate  of  soda.  The  presence 
of  these  uratic  concretions  at  the  apices  of  the  pyramids  is  not  a  positive 
indication  of  gout.  They  are  not  infrequent  in  this  country,  in  which  gout 
is  rare,  (h)  An  interstitial  nephritis,  either  the  ordinary  "  contracted  kid- 
ney "  or  the  arterio-sclerotic  form,  neither  of  which  are  in  any  way  dis- 
tinctive. It  is  not  possible  to  say  in  a  given  case  that  the  condition  has 
been  due  to  gout  unless  marked  evidences  of  the  disease  coexist. 

The  metatarso-phalangeal  joint  of  the  big  toe  should  be  carefully  ex- 
amined, as  it  may  show  typical  lesions  of  gout  without  any  outward  token 
of  arthritis. 

Arterio-sclerosis  is  a  very  constant  lesion.  With  it  the  heart,  particu- 
larly the  left  ventricle,  is  found  hypertrophied.  According  to  some  authors, 
concretions  of  urate  of  soda  may  occur  on  the  valves. 

Changes  in  the  respiratory  system  are  rare.  Deposits  have  been  found 
in  the  vocal  cords,  and  uric-acid  crystals  have  been  met  in  the  sputa  of  a 
gouty  patient  (J.  W.  Moore).  Emphysema  is  a  very  constant  condition 
in  old  cases. 

Symptoms. — Gout  is  usually  divided  into  acute,  chronic,  and  irregu- 
lar forms. 

Acute  Gout. — Premonitory  symptoms  are  common — twinges  of  pain  in 
the  small  joints  of  the  hands  or  feet,  nocturnal  restlessness,  irritability  of 
temper,  and  dyspepsia.  The  urine  is  acid,  scanty,  and  high-colored.  It 
deposits  urates  on  cooling,  and  there  may  be,  according  to  Garrod,  tran- 
sient albuminuria.  There  may  be  traces  of  sugar  (gouty  glycosuria).  Before 
an  attack  the  output  of  nric  acid  is  low  and  is  also  diminished  in  the  early 
part  of  the  paroxysm.  The  relation  of  uric  and  phosphoric  acids  to  the 
acute  attacks  is  well  represented  in  Chart  XIV,  prepared  by  Futcher.  Both 
were  extremely  low  in  the  intervals,  but  reached  within  normal  limits  short- 
ly after  the  onset  of  the  acute  symptoms.     The  phosphoric  acid  and  uric 


412 


CONSTITUTIONAL  DISEASES. 


acid  show  almost  parallel  curves.  The  patient  was  on  a  very  light  fixed  diet 
at  the  time  the  determinations  were  made.  Bain  holds  that  the  phosphoric 
acid  excretion  varies  directly  with  that  of  the  uric  acid.  "Watson  claims 
that  there  is  no  relationship  between  the  two.    In  some  instances  the  throat 


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Chart  XIY. — Showing  uric  acid  and  phosphoric  acid  output  in  case  of  acute  gout. 


is  sore,  and  there  may  be  asthmatic  symptoms.  The  attack  sets  in  usually 
in  the  early  morning  hours.  The  patient  is  aroused  by  a  severe  pain  in  the 
metatarso-phalangeal  articulation  of  the  big  toe,  and  more  commonly  on 


GOUT.  413 

the  right  than  on  the  left  side.  The  pain  is  agonizing,  and,  as  Sydenham 
says,  "  insinuates  itself  with  the  most  exquisite  cruelty  among  the  numer- 
ous small  bones  of  the  tarsus  and  metatarsus,  in  the  ligaments  of  which  it 
is  lurking."  The  joint  swells  rapidly,  and  becomes  hot,  tense,  and  shiny. 
The  sensitiveness  is  extreme,  and  the  pain  makes  the  patient  feel  as  if  the 
joint  were  being  pressed  in  a  vice.  There  is  fever,  and  the  temperature  may 
rise  to  102°  or  103°.  Toward  morning  the  severity  of  the  symptoms  sub- 
sides, and,  although  the  joint  remains  swollen,  the  day  may  be  passed  in 
comparative  comfort.  The  symptoms  recur  the  next  night,  and  the  fit, 
as  it  is  called,  usually  lasts  for  from  five  to  eight  days,  the  severity  of  the 
symptoms  gradually  abating.  Occasionally  other  joints  are  involved,  par- 
ticularly the  big  toe  of  the  opposite  foot.  The  inflammation,  however  in- 
tense, never  goes  on  to  suppuration.  With  the  subsidence  of  the  swelling 
the  skin  desquamates.  After  the  attack  the  general  health  may  be  much 
improved.  As  Aretseus  remarks,  a  person  in  the  interval  has  won  the  race 
at  the  Olympian  games.  Recurrences  are  frequent.  Some  patients  have 
three  or  four  attacks  in  a  year;  others  suffer  at  longer  intervals. 

The  term  retrocedent  or  suppressed  gout  is  applied  to  serious  internal 
symptoms,  coincident  with  a  rapid  disappearance  or  improvement  of  the 
local  signs.  Very  remarkable  manifestations  may  occur  under  these  cir- 
cumstances. The  patient  may  have  severe  gastro-intestinal  symptoms — 
pain,  vomiting,  diarrhoea,  and  great  depression — and  death  may  occur  dur- 
ing such  an  attack.  Or  there  may  be  cardiac  manifestations — dyspnoea, 
pain,  and  irregular  action  of  the  heart.  In  some  instances  in  which  the 
gout  is  said  to  attack  the  heart,  an  acute  pericarditis  develops  and  proves 
fatal.  So,  too,  there  may  be  marked  cerebral  manifestations — delirium 
or  coma,  and  even  apoplexy — but  in  a  majority  of  these  instances  the 
symptoms  are,  in  all  probability,  uraemic. 

Gout  in  America. — While  not  so  common  as  in  England  and  Germany, 
the  disease  is  by  no  means  infrequent,  and  is  perhaps  on  the  increase.  It  is 
more  common  among  the  lower  classes,  who  drink  beer,  than  among  the 
well-to-do,  who  have  become  of  late  much  more  temperate.  Among  about 
14,000  cases  in  my  wards  there  were  34  cases  of  gout,  all  in  white  males, 
and  almost  all  in  native  Americans  (Futcher). 

Chronic  Gout. — With  increased  frequency  in  the  attacks,  the  articular 
symptoms  persist  for  a  longer  time,  and  gradually  many  joints  become 
affected.  Deposits  of  urates  take  place,  at  first  in  the  articular  cartilages 
and  then  in  the  ligaments  and  capsular  tissues;  so  that  in  the  course  of 
years  the  joints  become  swollen,  irregular,  and  deformed.  The  feet  are 
usually  first  affected,  then  the  hands.  In  severe  cases  there  may  be  exten- 
sive concretions  about  the  elbows  and  knees  and  along  the  tendons  and  in 
the  bursge.  The  tophi  appear  in  the  ears.  Finally,  a  unique  clinical  picture 
is  produced  which  can  not  be  mistaken  for  that  of  any  other  affection.  The 
skin  over  the  tophi  may  rupture  or  ulcerate,  and  about  the  knuckles  the 
chalk-stones  may  be  freely  exposed.  Patients  with  chronic  gout  are  usually 
dyspeptic,  often  of  a  sallow  complexion,  and  show  signs  of  arterio-sclerosis. 
The  pulse  tension  is  increased,  the  vessels  are  stiff,  and  the  left  ventricle 
is  hypertrophied.  The  urine  is  increased  in  amount,  is  of  low  specific  grav- 
26 


414  CONSTITUTIONAL  DISEASES. 

ity,  and  usually  contains  a  slight  amount  of  albumin,  with  a  few  hyaline 
casts.  Intercurrent  attacks  of  acute  polyarthritis  may  develop,  in  which 
the  joints  become  inflamed,  and  the  temperature  ranges  from  101°  to  103°. 
There  may  be  pain,  redness,  and  swelling  of  several  Joints  without  fever. 
UrEemia,  pleurisy,  pericarditis,  peritonitis,  and  meningitis  are  common 
terminal  affections.  The  victim  of  gout  may  show  remarkable  mental 
and  even  bodily  vigor.  Certain  of  the  most  distinguished  members  of  our 
professsion  have  been  terrible  sufferers  from  this  disease,  notably  the  elder 
Scaliger,  Jerome  Cardan,  and  Sydenham,  whose  statement  that  "  more 
wise  men  than  fools  are  victims  of  the  affection  "  still  holds  good. 

Irregular  Gout. — This  is  a  motley,  ill-defined  group  of  symptoms,  mani- 
festations of  a  condition  of  disordered  nutrition,  to  which  the  terms  gouty 
diathesis  or  litlicemic  state  have  been  given.  Cases  are  seen  in  members  of 
gouty  families,  who  may  never  themselves  have  suffered  from  the  acute 
disease,  and  in  persons  who  have  lived  not  wisely  but  too  well,  who  have 
eaten  and  drunk  largely,  lived  sedentary  lives,  and  yet  have  been  fortunate 
enough  to  escape  an  acute  attack.  It  is  interesting  to  note  the  various 
manifestations  of  the  disease  in  a  family  with  marked  hereditary  disposi- 
tion. The  daughters  often  escape,  while  one  son  may  have  gouty  attacks 
of  great  severity,  even  though  he  lives  a  temperate  life  and  tries  in  every 
way  to  avoid  the  conditions  favoring  the  disorder.  Another  son  has,  per- 
haps, only  the  irregular  manifestations  and  never  the  acute  articular  affec- 
tion. While  the  irregular  features  are  perhaps  more  often  met  with  in 
the  hereditary  affection,  they  are  by  no  means  infrequent  in  persons  who 
appear  to  have  acquired  the  disease.  The  tendency  in  some  families  is  to 
call  every  affection  gouty.  Even  infantile  complaints,  such  as  scald-head, 
naso-pharyngeal  vegetations,  and  enuresis,  are  often  regarded,  without  suf- 
ficient grounds,  I  believe,  as  evidences  of  the  family  ailment.  Among  the 
commonest  manifestations  of  irregular  gout  are  the  following: 

(a)  Cutaneous  Eruptions. — Garrod  and  others  have  called  special  atten- 
tion to  the  frequent  association  of  eczema  with  the  gouty  habit.  The 
French  in  particular  insist"  upon  the  special  liability  of  gouty  persons  to 
skin  affections,  the  arthritides,  as  they  call  them. 

(b)  Gastro-intestinal  Disorders. — Attacks  of  what  is  termed  biliousness, 
in  which  the  tongue  is  furred,  the  breath  foul,  the  bowels  constipated,  and 
the  action  of  the  liver  torpid,  are  not  uncommon  in  gouty  persons.  A 
gouty  parotitis  is  described. 

(c)  Cardio-vascular  Symptoms. — With  the  lithgemia,  arterio-sclerosis  is 
frequently  associated.  The  blood  tension  is  persistently  high,  the  vessel 
walls  become  stiff,  and  cardiac  and  renal  changes  gradually  develop.  In 
this  condition  the  manifestations  may  be  renal,  as  when  the  albuminuria 
becomes  more  marked,  or  dropsical  symptoms  supervene.  The  manifesta- 
tions may  be  cardiac,  when  the  hypertrophy  of  the  left  ventricle  fails  and 
there  are  palpitation,  irregular  action,  and  ultimately  a  condition  of  asys- 
tole. Or,  finally,  the  manifestations  may  be  vascular,  and  thrombosis  of 
the  coronary  arteries  may  cause  sudden  death.  Aneurism  may  develop  and 
prove  fatal,  or,  as  most  frequently  happens,  a  blood-vessel  gives  way  in 
the  brain,  and  the  patient  dies  of  apoplexy.    It  makes  but  little  difference 


GOUT.  415 

whether  vre  regard  this  condition  as  primarily  an  arterio-sclerosis,  or  as  a 
gouty  nephritis;  the  point  to  be  remembered  is  that  the  nutritional  dis- 
order with  which  an  excess  of  uric  acid  is  associated  induces  in  time  in- 
creased tension,  arterio-sclerosis,  chronic  interstitial  nephritis,  and  changes 
in  the  myocardium.  Pericarditis  is  not  an  infrequent  terminal  complica- 
tion of  gout. 

(d)  Nervous  Manifestations. — Headache  and  megrim  attacks  are  not 
infrequent.  Haig  attributes  them  to  an  excess  of  uric  acid.  Neuralgias  are 
not  uncommon;  sciatica  and  parEesthesias  may  develop.  A  common  gouty 
manifestation,  upon  which  Duckworth  has  laid  stress,  is  the  occurrence  of 
hot  or  itching  feet  at  night.  Plutarch  mentions  that  Strabo  called  this 
symptom  "  the  lisping  of  the  gout."  Cramps  in  the  legs  may  also  be  very 
troublesome.  Hutchinson  has  called  attention  to  hot  and  itching  eyeballs 
as  a  frequent  sign  of  masked  gout.  Associated  or  alternating  with  this 
symptom  there  may  be  attacks  of  episcleral  congestion.  Apoplexy  is  a 
common  termination  of  gout.    Meningitis  may  develop,  usually  basilar. 

(e)  Urinary  Disorders. — The  urine  is  highly  acid  and  high-colored,  and 
may  deposit  on  standing  crystals  of  lithic  acid.  Transient  and  temporary 
increase  in  this  ingredient  can  not  be  regarded  as  serious.  In  many  cases 
of  chronic  gout  the  amount  may  be  diminished,  and  only  increased  at  cer- 
tain periods,  forming  the  so-called  uric-acid  showers.  The  chart  on  page 
412  illustrates  this  very  well.  Sugar  is  found  intermittently  in  the  urine 
of  gouty  persons — gouty  glycosuria.  It  may  pass  into  true  diabetes,  but  is 
usually  very  amenable  to  treatment.  Oxaluria  may  also  be  present.  Gouty 
persons  are  specially  prone  to  calculi,  Jerome  Cardan  to  the  contrary,  who 
reckoned  freedom  from  stone  among  the  chief  of  the  dona  podagrce.  Minute 
quantities  of  albumin  are  very  common  in  persons  of  gouty  dyscrasia,  and, 
when  the  renal  changes  are  well  established,  tube-casts.  Urethritis,  accom- 
panied with  a  well-marked  purulent  discharge,  may  develop,  so  it  is  stated, 
usually  at  the  end  of  an  attack.  It  may  occur  spontaneously,  or  follow  a 
pure  connection. 

(/)  Pulmonary  Disorders. — There  are  no  characteristic  changes,  but, 
as  Greenhow  has  pointed  out,  chronic  bronchitis  occurs  with  great  fre- 
quency in  persons  of  a  gouty  habit. 

(g)  Of  eye  affections,  iritis,  glaucoma,  htemorrhagic  retinitis,  and  sup- 
purative panopthalmitis  have  been  described. 

Diagnosis. — Recurring  attacks  of  arthritis,  limited  to  the  big  toe  and 
to  the  tarsus,  occurring  in  a  member  of  a  gouty  family,  or  in  a  man  who 
has  lived  too  well,  leave  no  question  as  to  the  nature  of  the  trouble.  There 
are  many  cases  of  gout,  however,  in  which  the  feet  do  not  suffer  most  se- 
verely. After  an  attack  or  two  in  one  toe,  other  joints  may  be  affected, 
and  it  is  just  in  such  cases  of  polyarthritis  that  the  difficulty  in  diagnosis  is 
apt  to  arise.  We  have  had  of  late  years  several  cases  admitted  for  the  third 
or  fourth  time  with  involvement  of  three  or  more  of  the  larger  joints.  The 
presence  of  tophi  has  settled  the  nature  of  a  trouble  which  in  the  previous 
attacks  had  been  regarded  as  rheumatic.  The  following  are  suggestive 
points  in  snch  cases:  (1)  The  patient's  habits  and  occupation.  In  this  coun- 
try the  brewery  men  and  barkeepers  are  often  affected.     (2)  The  presence 


416  CONSTITUTIONAL  DISEASES. 

of  tophi.  The  ears  should  always  he  felt  in  a  case  of  polyarthritis.  The 
diagnosis  may  rest  with  a  small  tophus.  The  student  should  learn  to  recog- 
nize on  the  ear  margin,  Woolner's  tip,  fibroid  nodules,  and  small  sebaceous 
tumors.  The  last  are  easily  recognized  microscopically.  The  sodium 
urate  crystals  are  distinctive  in  the  tophi.  (3)  The  condition  of  the  urine; 
As  shown  in  Chart  XIY,  the  ilric-acid  output  is  usually  very  low  during 
the  intervals  of  the  paroxysm.  There  may,  indeed,  be  no  excretion  what- 
ever. At  the  height  of  the  attack  the  elimination,  as  a  rule,  is  greatly  in- 
creased. The.  ratio  of  the  uric  acid  to  the  urea  excretion  is  disturbed  in 
gouty  cases,  and  may  fall  as  low  as  1  to  100  or  1  to  150.  (4)  The  gouty  poly- 
arthritis may  be  afebrile.  A  patient  with  three  or  four  Joints  red,  swollen, 
and  painful  in  acute  rheumatism  has  fever,  and,  while  pyrexia  may  be  pres- 
ent and  often  is  in  gout,  its  absence  is,  I  think,  a  valuable  diagnostic  sign. 

Treatment. — Hygienic. — Individuals  who  have  inherited  a  tendency 
to  gout,  or  who  have  shown  any  manifestations  of  it,  should  live  temper- 
ately, abstain  from  alcohol,  and  eat  moderately.  An  open-air  life,  with 
plenty  of  exercise  and  regular  hours,  does  much  to  counteract  an  inborn 
tendency  to  the  disease.  The  skin  should  be  kept  active:  if  the  patient  is 
robust,  by  the  morning  cold  bath  with  friction  after  it;  but  if  he  is  weak 
or  debilitated  the  evening  warm  bath  should  be  substituted.  An  occa- 
sional Turkish  bath  with  active  shampooing  is  very  advantageous.  The 
patient  should  dress  warmly,  avoid  rapid  alterations  in  temperature,  and 
be  careful  not  to  have  the  skin  suddenly  chilled. 

Dietetic. — With  few  exceptions,  persons  over  forty  eat  too  much,  and 
the  first  injunction  to  a  gouty  person  is  to  keep  his  appetite  within  reason- 
able bounds,  to  eat  at  stated  hours,  and  to  take  plenty  of  time  at  his  meals. 
In  the  matter  of  food,  quantity  is  a  factor  of  more  importance  than  quality 
with  many  gouty  persons.  As  Sir  William  Eoberts  well  says,  "Nowhere 
perhaps  is  it  more  necessary  than  in  gout  to  consider  the  man  as  well  as 
the  ailment,  and  very  often  more  the  man  than  the  ailment." 

Very  remarkable  differences  of  opinion  exist  as  to  the  most  suitable 
diet  in  this  disease,  some  urging  warmly  a  vegetable  diet,  others  allowing 
a  very  liberal  amount  of  meat.  On  the  one  hand,  the  author  just  quoted 
says:  "  The  most  trustworthy  experiments  indicate  that  fat,  starch,  and 
sugar  have  not  the  least  direct  influence  on  the  production  of  uric  acid; 
but  as  the  free  consumption  of  these  articles  naturally  operates  to  restrict 
the  intake  of  the  nitrogenous  food,  their  use  has  indirectly  the  effect  of 
diminishing  the  average  production  of  uric  acid."  On  the  other  hand, 
W.  H.  Draper  says:  "  The  conversion  of  azotized  food  is  more  complete 
with  a  minimum  of  carbohydrates  than  it  is  with  an  excess  of  them;  in 
other  words,  one  of  the  best  means  of  avoiding  the  accumulation  of  lithic 
acid  in  the  blood  is  to  diminish  the  carbohydrates  rather  than  the  azotized 
foods."  The  weight  of  opinion  leans  to  the  use  of  a  modified  nitrogenous 
diet,  without  excess  in  starchy  and  saccharine  articles  of  food.  Fresh  vege- 
tables and  fruits  may  be  used  freely,  but  among  the  latter  strawberries  and 
bananas  should  be  avoided. 

Ebstein  urges  strongly  the  use  of  fat  in  the  form  of  good  fresh  butter, 
from  2^  to  3^  ounces  in  the  day.     He  says  that  stout  gouty  subjects  not 


GOUT.  417 

only  do  not  increase  in  weight  with  plenty  of  fat  in  the  food,  but  that  they 
actually  become  thin  and  the  general  condition  improves  very  much.  Hot 
bread  of  all  sorts  and  the  various  articles  of  food  prepared  from  Indian 
corn  should,  as  a  rule,  be  avoided.  Eoberts  advises  gouty  patients  to  re- 
strict as  far  as  practicable  the  use  of  common  salt  with  their  meals,  since 
the  sodium  biurate  very  readily  crystallizes  out  in  tissues  with  a  high  per- 
centage of  sodium  salts. 

In  this  matter  of  diet  each  individual  case  must  receive  separate  con- 
sideration. 

There  are  very  few  conditions  in  the  gouty  in  which  stimulants  of  any 
sort  are  required.  Wlienever  indicated,  whisky  will  be  found  perhaps  the 
most  serviceable.  While  all  are  injurious  to  these  patients,  some  are  much 
more  so  than  others,  particularly  malted  liquors,  champagne,  port,  and  a 
very  large  proportion  of  all  the  light  wines. 

Mineral  Waters. — All  forms  may  be  said  to  be  beneficial  in  gout,  as  the 
main  element  is  the  water,  and  the  ingredients  are  usually  indifferent. 
Much  of  the  humbuggery  in  the  profession  still  lingers  about  mineral  waters, 
more  particularly  about  the  so-called  lithia  waters.  For  a  careful  consid- 
eration of  the  question  the  reader  is  referred  to  William  Ewart's  recent 
work  on  Gout  and  Goutiness. 

The  question  of  the  utility  of  alkalies  in  the  treatment  of  gout  is 
closely  connected  with  this  subject  of  mineral  waters.  This  deep-rooted 
belief  in  the  profession  was  rudely  shaken  a  few"  years  ago  by  Sir  William 
Roberts,  who  claims  to  have  shown  conclusively  that  alkalescence  as  such 
has  no  influence  whatever  on  the  sodium  biurate.  The  sodium  salts  are 
believed  by  this  author  to  be  particularly  harmful,  but,  in  spite  of  all  the 
theoretical  denunciation  of  the  use  of  the  sodium  salts  in  gout,  the  gouty 
from  all  parts  of  the  world  flock  to  those  very  Continental  springs  in  which 
these  salts  are  most  predominant.     Bain  urges  the  use  of  potassium  salts. 

Of  the  mineral  springs  best  suited  for  the  gouty  may  be  mentioned, 
in  this  country,  those  of  Saratoga,  Bedford,  and  the  White  Sulphur;  Buxton 
and  Bath,  in  England;  in  France,  Aix-les-Bains  ^nd  Contrexeville;  and  in 
Germany,  Carlsbad,  Wildbad,  and  Homburg. 

The  efficacy  in  reality  is  in  the  water,  in  the  way  it  is  taken,  on  an 
empty  stomach,  and  in  large  quantities;  and,  as  every  one  knows,  the  im- 
portant accessories  in  the  modified  diet,  proper  hours,  regular  exercise, 
with  baths,  douches,  etc.,  play  a  very  important  role  in  the  '"  cure.'^ 

Medicinal  Treatment. — In  an  acute  attack  the  limb  should  be  elevated 
and  the  affected  joint  wrapped  in  cotton-wool.  Warm  fomentations,  or 
Fullers  lotion,  may  be  used.  The  local  hot-air  treatment  may  be  tried. 
A  brisk  mercurial  purge  is  always  advantageous  at  the  outset.  The  wine 
or  tincture  of  colchicum,  in  doses  of  20  to  30  minims,  may  be  given  every 
four  hours  in  combination  with  the  citrate  of  potash  or  the  citrate  of 
lithium.  The  action  of  the  colchicum  should  be  carefully  watched.  It 
has,  in  a  majority  of  the  cases,  a  powerful  influence  over  the  symptoms — 
relieving  the  pain,  and  reducing,  sometimes  with  great  rapidity,  the  swell- 
ing and  redness.  It  should  be  promptly  stopped  so  soon  as  it  has  relieved 
the  pain.    In  cases  in  which  the  pain  and  sleeplessness  arc  distressing  and 


418  CONSTITUTIONAL  DISEASES. 

do  not  yield  to  colchicum,  morphia  is  necessary.  The  patient  should  be 
placed  on  a  diet  chiefly  of  milk  and  barley-water,  but  if  there  is  any  de- 
bility, strong  broths  may  be  given,  or  eggs.  It  is  occasionally  necessary  to 
give  small  quantities  of  stimulants.  During  convalescence  meats  and  fish 
and  game  may  be  taken,  and  gradually  the  patient  may  resume  the  diet 
previously  laid  down. 

In  some  of  the  subacute  intercurrent  attacks  of  arthritis  in  old,  de- 
formed joints,  the  sodium  salicylate  is  occasionally  useful,  but  its  adminis- 
tration must  be  watched  in  cases  of  cardiac  and  renal  insufficiency.  It  is 
also  much  advocated  by  Haig  in  the  uric-acid  habit. 

The  chronic  and  irregular  forms  of  gout  are  best  treated  by  the  dietetic 
and  hygienic  measures  already  referred  to.  Potassium  iodide  is  some- 
times useful,  and  preparations  of  guaiacum,  quinine,  and  the  bitter  tonics 
combined  with  alkalies  are  undoubtedly  of  benefit. 

Piperazin  has  been  much  lauded  as  an  efficient  aid  in  the  solution  of 
uric  acid.  The  clinical  results,  however,  are  very  discordant.  It  may  be 
employed  in  doses  of  from  15  to  30  grains  in  the  day,  and  is  conveniently 
given  in  aerated  water  containing  5  grains  to  the  tumblerful. 


V.    DIABETES    MELLITUS. 

Definition. — A  disorder  of  nutrition,  in  which  sugar  accumulates  in 
the  blood  and  is  ezcreted  in  the  urine,  the  daily  amount  of  which  is  greatly 
increased. 

For  a  case  to  be  considered  one  of  diabetes  mellitus  it  is  necessary,  ac- 
cording to  von  ISToorden,  that  the  form  of  sugar  eliminated  in  the  urine 
be  grape  sugar,  that  it  must  be  eliminated  for  weeks,  months,  or  years,  and 
that  the  excretion  of  sugar  must  take  place  after  the  ingestion  of  moderate 
amounts  of  carbohydrates. 

Etiology. — Hereditary  influences  play  an  important  role,  and  cases 
are  on  record  of  its  occurrence  in  many  members  of  the  same  family. 
Morton  (Phthisiologia,  1689,  pp.  43  and  44)  gives  two  remarkable  family 
cases.  In  one  four  children  were  affected,  one  of  whom  recovered  on  a 
milk  diet  and  diascordium.  An  analysis  of  112  cases  in  my  series  gave  only 
6  cases  with  a  history  of  diabetes  in  relatives  (Pleasants).  Naunyn  ob- 
tained a  family  history  of  diabetes  in  35  out  of  201  private  cases,  but  in 
only  7  of  157  hospital  cases.  There  are  instances  of  the  coexistence  of 
the  disease  in  man  and  wife.  Schmidt  first  drew  attention  to  the  possibility 
of  diabetes  being  contagious.  Out  of  his  series  of  2,320  cases  he  believed 
that  26  instances  were  the  result  of  contagion.  In  the  majority  of  the  cases 
the  wife  contracted  the  disease  later  than  the  husband.  8cx. — Men  are 
more  frequently  affected  than  women,  the  ratio  being  about  three  to  two. 
Up  to  May  15,  1901,  156  cases  of  diabetes  had  been  treated  in  the  medical 
wards  and  medical  dispensary  of  the  Johns  Hopkins  Hospital,  95  of  which 
were  in  males  and  61  in  females.  It  is  a  disease  of  adult  life;  a  majority 
of  the  cases  occur  from  the  third  to  the  sixth  decade.  Of  the  156  cases, 
the  largest  number — 46,  or  23  per  cent — occurred  between  fifty  and  sixty 


DIABETES  MELLITUS.  419 

years  of  age.  These  figures  agree  fairly  closely  with  those  of  Frerichs, 
Seegen,  and  Pavy,  all  of  whom  found  the  largest  number  of  cases  in  the 
sixth  decade,  their  percentages  being  26,  30,  and  30.7  respectively.  It  is 
rare  in  childhood,  but  cases  are  on  record  in  children  under  one  year  of 
age.  Persons  of  a  neurotic  temperament  are  often  affected.  It  is  a  disease 
of  the  higher  classes.  Yon  Noorden  states  that  the  statistics  for  London 
and  Berlin  show  that  the  number  of  cases  in  the  upper  ten  thousand  ex- 
ceeds that  in  the  lower  hundred  thousand  inhabitants.  Race. — Hebrews 
seem  especially  prone  to  it;  one  fourth  of  Frerichs'  patients  were  of  the 
Semitic  race.  I  have  been  much  impressed  with  the  frequency  of  the  dis- 
ease among  them.  Of  the  last  16  cases  which  I  have  had  in  private  practice, 
8  were  in  Hebrews.  Diabetes  is  comparatively  rare  in  the  colored  race,  but 
not  so  uncommon  as  was  formerly  supposed.  Of  the  series  of  156  cases,  15, 
or  9.6  per  cent  were  in  negroes.  The  ratio  of  males  to  females  affected 
is  almost  exactly  the  reverse  of  that  in  the  white  race;  6  of  the  15  cases  were 
in  males  and  9  in  females.  In  a  considerable  proportion  of  the  cases  of 
diabetes  the  subjects  have  been  excessively  fat  at  the  beginning  of,  or  prior 
to,  the  onset  of  the  disease.  A  slight  trace  of  sugar  is  not  very  uncommon 
in  obese  persons.  This  so-called  lipogenic  glycosuria  is  not  of  grave  signifi- 
cance, and  is  only  occasionally  followed  by  true  diabetes.  On  the  other 
hand,  as  von  ISToorden  has  shown,  there  may  be  a  "  diabetogenous  obesity," 
in  which  diabetes  and  obesity  develop  in  early  life,  and  these  cases  are  very 
unfavorable.  There  are  instances  on  record  in  which  obesity  with  diabetes 
has  occurred  in  three  generations.  Diabetes  is  more  common  in  cities  than 
in  country  districts.  Gout,  syphilis,  and  malaria  have  been  regarded  as  pre- 
disposing causes.  Burdel  and  Calmette  think  that  malaria  is  an  important 
predisposing  etiological  factor.  In  only  1  of  the  156  cases  could  malaria 
be  considered  more  than  a  possible  cause  of  the  diabetes  (Futcher).  Mental 
shock,  severe  nervous  strain,  and  worry  precede  many  cases.  In  one  case 
the  symptoms  came  on  suddenly  after  the  patient  had  been  nearly  suffocated 
by  smoke  from  having  been  confined  in  a  cell  of  a  burning  jail.  Shock 
and  the  toxic  effects  of  the  smoke  may  both  have  been  factors  in  this  case. 
The  combination  of  intense  application  to  business,  over-indulgence  in  food 
and  drink,  with  a  sedentary  life,  seems  particularly  prone  to  induce  the  dis- 
ease. Glycosuria  may  set  in  during  pregnancy,  and  in  rare  instances  may 
only  occur  at  this  period.  Trousseau  thought  that  the  offspring  of  phthisi- 
cal parents  were  particularly  prone  to  diabetes.  Injury  to  or  disease  of  the 
spinal  cord  or  brain  has  been  followed  by  diabetes.  In  the  carefully  ana- 
lyzed cases  of  Frerichs  there  were  30  instances  of  organic  disease  of  these 
parts.  The  medulla  is  not  always  involved.  In  only  4  of  his  cases,  which 
showed  organic  disease,  was  there  sclerosis  or  other  anomaly  of  this  part. 
An  irritative  lesion  of  Bernard's  diabetic  centre  in  the  medulla  is  an  occa- 
sional cause.  I  saw  with  Eeiss,  at  the  Friedrichshain,  Berlin,  a  woman  who 
had  anomalous  cerebral  symptoms  and  diabetes,  and  in  whom  there  was 
found  post  mortem  a  cysticercus  in  the  fourth  ventricle.  Ebstein  has  re- 
cently recorded  4  cases  in  which  there  was  a  coincident  occurrence  of  epi- 
lepsy and  diabetes  mcllitus.  He  thinks  that  in  the  majority  of  cases  the 
two  diseases  are  dependent  on  a  common  cause.    He  believes  that  the  asso- 


420  CONSTITUTIONAL  DISEASES. 

elation  would  be  found  much  more  commonly  in  Jacksonian  epilepsy  than 
has  been  the  case  heretofore^  if  more  careful  and  systematic  examinations 
of  the  urine  were  made. 

The  disease  has  occasionally  followed  the  infectious  fevers.  Cases  have 
been  recorded  as  occurring  during  or  immediately  after  diphtheria,  influ- 
enza, rheumatism,  enteric  fever,  and  syphilis.  Again,  a  few  have  followed 
injury  without  implication  of  the  brain  or  cord.  Leo  believes  that  diabetes 
is  due  to  a  toxic  agent.  He  has  produced  glycosuria  in  dogs  by  adminis- 
tering both  fresh  and  fermented  diabetic  urine. 

In  comparison  with  its  incidence  in  European  countries  diabetes  is  a  rare 
disease  in  America.  The  last  census  gave  only  3.8  per  100,000  of  popula- 
tion, against  a  ratio  of  from  5  to  14  in  the  former.  The  death-rate  has  been 
gradually  on  the  increase  in  Paris  during  the  last  three  or  four  decades, 
reaching  14  to  the  100,000  of  population  in  1891.  For  the  same  year  the 
mortality  in  Malta  was  13.1  to  the  100,000  of  population.  The  disease  is 
gradually  on  the  increase  in  the  United  States.  The  statistics  for  1870  gave 
2.1;  for  1880,  2.8;  and  for  1890,  3.8  deaths  to  the  100,000  population.  In 
this  region  the  incidence  of  the  disease  may  be  gathered  from  the  fact  that 
among  239,000  patients  under  treatment  at  the  Johns  Hopkins  Hospital 
and  Dispensary  during  the  twelve  years  since  its  opening  there  have  been 
161  cases.  During  the  twelve  years  76,000  medical  cases  were  treated,  the 
156  diabetic  cases  constituting  only  0.20  per  cent  of  these. 

We  are  ignorant  of  the  nature  of  the  disease.  Normally  the  carbo- 
hydrates taken  with  the  food  are  stored  in  the  liver  and  in  the  muscles  as 
glycogen,  and  then  utilized  as  needed  by  the  system.  Glycogen  can  also 
be  formed  from  the  proteids  of  the  food,  and  under  certain  circumstances 
sugar  may  be  directly  formed  from  the  body  proteids.  "WHienever  the 
sugar  in  the  systemic  blood  exceeds  a  definite  amount  (about  0.2  per  cent) 
it  is  discharged  by  the  kidneys,  producing  glycosuria.  Theoretically  dia- 
betes may  be  supposed  to  be  induced  by: 

(a)  The  ingestion  of  a  larger  quantity  of  carbohydrates  and  peptones 
than  can  be  warehoused,  so  to  speak,  in  the  liver  as  glycogen,  so  that  part 
has  to  pass  over  into  the  hepatic  blood.  Some  of  the  instances  of  lipogenic 
or  dietetic  glycosuria  are  of  this  nature. 

(&)  Disturbances  of  the  liver  function:  (1), Changes  in  the  circulation 
under  nervous  influences.  Puncture  of  the  medulla,  lesions  of  the  cord, 
and  central  irritation  of  various  kinds  are  followed  by  glycosuria,  which 
is  attributed  to  a  vaso-motor  paralysis  (more  rapid  blood-flow)  induced 
by  these  causes.  On  this  view  the  disease  is  a  neurosis.  (2)  Instability  of 
the  glycogen,  owing  either  to  imperfect  formation  or  to  conditions  in  the 
cells  which  render  it  less  stable.  Phloridzin  and  other  substances  which 
cause  diabetes  very  probably  act  in  this  way;  phloridzin  acts  primarily  on 
the  renal  epithelium,  destroying  its  power  of  keeping  back  the  sugar.  As 
to  the  possibility  of  a  renal  form  of  diabetes  in  man,  consult  ISTaunyn, 
page  106. 

(c)  Defective  assimilation  of  the  glucose  in  the  system.  How  and  under 
what  normal  circumstances  the  sugar  is  utilized  we  do  not  yet  know. 
Theoretically  faulty  metabolism  would  explain  the  condition. 


DIABETES  MELLITUS.  421 

Morbid  Anatomy. — Saundby  (Lectures  on  Diabetes,  1891)  has  given 
a  good  summary  of  the  anatomical  changes: 

The  nervous  system  shows  no  constant  lesions.  In  a  few  instances  there 
have  been  tumors  or  sclerosis  in  the  medulla,  or,  as  in  the  case  above  men- 
tioned, a  cysticercus  has  pressed  on  the  floor.  Cysts  have  been  met  with 
in  the  white  matter  of  the  cerebrum  and  perivascular  changes  have  been 
described.  Glycogen  has  been  found  in  the  spinal  cord.  In  the  peripheral 
nervous  system  there  are  instances  in  which  tumors  have  been  found  press- 
ing on  the  vagus.  A  secondary  multiple  neuritis  is  not  rare,  and  to  it  the 
so-called  diabetic  tabes  is  probably  due.  E.  T.  Williamson  has  found 
changes  in  the  posterior  columns  of  the  cord  similar  to  those  which  occur 
in  pernicious  ansemia. 

In  the  sympathetic  system  the  ganglia  have  been  enlarged  and  in  some 
instances  sclerosed,  but  there  is  nothing  peculiar  in  these  changes.  The 
Hood  may  contain  as  high  as  0.4  per  cent  of  sugar  instead  of  0.15  per  cent. 
The  plasma  is  usually  loaded  with  fat,  the  molecules  of  which  may  be  seen 
as  fine  particles.  When  drawn,  a  white  creamy  layer  coats  the  coagulum, 
and  there  may  be  lipsemic  clots  in  the  small  vessels.  There  are  no  special 
changes  in  the  red  or  white  corpuscles.  The  polyhuclear  leucocytes  con- 
tain glycogen.  Glycogen  can  occur  in  normal  blood,  but  it  is  here  extra- 
cellular. It  has  been  also  found  in  the  polynuclear  leucocytes  in  leuksemia. 
The  heart  is  hypertrophied  in  some  cases.  Endocarditis  is  very  rare. 
Arterio-sclerosis  is  common.  The  lungs  show  important  changes.  Acute 
broncho-pneumonia  or  croupous  pneumonia  (either  of  which  may  terminate 
in  gangrene)  and  tuberculosis  are  common.  The  so-called  diabetic  phthisis 
is  always  tuberculous  and  results  from  a  caseating  broncho-pneumonia.  In 
rare  cases  there  is  a  chronic  interstitial  pneumonia,  non-tuberculous.  Fat 
embolism  of  the  pulmonary  vessels  has  been  described  in  connection  with 
diabetic  coma. 

The  liver  is  usually  enlarged;  fatty  degeneration  is  common.  In  the 
so-called  diabetic  cirrhosis — the  cirrhose  pigmentaire — the  liver  is  enlarged 
and  sclerotic,  and  a  cachexia  develops  with  melanoderma.  This  condition 
is  probably  identical  with  haemochromatosis.  Dilatation  of  the  stomach 
is  common. 

The  Pancreas  in  Diabetes. — The  present  status  may  be  thus  sum- 
marized: (a)  Extirpation  of  the  gland  in  dogs  (and  occasionally  in  man 
— W.  T.  Bull)  is  followed  by  glycosuria.  If  a  small  portion  remains,  sugar 
does  not  appear.  (&)  In  a  considerable  percentage  of  cases  of  diabetes 
lesions  of  the  pancreas  are  found;  50  per  cent  (Hansemann,  Williamson) 
show  a  chronic  interstitial  inflammation,  (c)  In  view  of  the  experimental 
work,  it  is  reasonable  to  infer  that  the  diabetes  is  secondary  to  the  pan- 
creatic lesion.  The  organ  has,  like  the  liver,  a  double  secretion — an  ex- 
ternal, which  is  poured  into  the  intestines,  and  an  internal,  of  the  nature 
of  a  ferment,  in  the  presence  of  which  alone  the  normal  assimilative  pro- 
cesses can  take  place  with  the  glycogen.  Disease  of  the  pancreas  causes 
diabetes  by  preventing  the  formation  of  the  glycolytic  ferment.  The  fact 
that  if  a  small  portion  of  the  gland  is  left,  in  the  experiments  upon  dogs, 
diabetes  does  not  occur,  is  analogous  to  the  remarkable  circumstance  that 


422  CONSTITUTIONAL  DISEASES. 

a  small  fragment  of  the  thyroid  is  sufficient  to  prevent  the  development 
of  artificial  myscedema. 

It  is  probable  that  the  observations  of  Opie  from  Dr.  Welch's  laboratory 
give  a  key  to  the  problem.  Imbedded  in  the  gland  are  the  peculiar  bodies 
known  as  the  islands  of  Langerhans^  composed  of  polygonal  cells  arranged 
in  irregular  columns,  between  which  are  wide  anastomosing  capillaries. 
The  lumina  of  the  ducts  do  not  enter  the  islands,  which  are  in  reality  duct- 
less glands,  like  the  para-thyroid,  the  thyroid,  the  pituitary,  etc.  The  in- 
timate relation  of  the  columns  of  cells  to  the  rich  network  of  blood-vessels 
suggest  that  they  furnish  the  internal  secretion  of  the  gland  as  advanced 
by  Schafer.  Experimental  evidence  is  defective,  but  changes  in  the  islands 
have  been  found  in  diabetes.  In  a  diabetic  woman,  aged  twenty-four,  from 
my  wards,  dead  of  tuberculosis  of  the  lungs,  Opie  found  the  glandular  tissue 
of  the  pancreas  well  preserved  and  healthy,  but  the  islands  of  Langerhans 
were  everywhere  "represented  by  a  sharply  circumscribed  hyaline  struc- 
ture composed  of  particles  of  homogeneous  material."  In  two  other  cases 
lesions  of  the  islands  were  found,  but  there  was  also  chronic  pancreatitis 
(Opie,  Jour.  Exper.  Med.,  vol.  v). 

Of  15  autopsies  froin  my  own  27  cases,  in  9  on  gross  examination  the 
pancreas  was  found  to  be  atrophic.  In  one  of  these  fat  necroses,  and  in 
another  calculi,  were  present. 

The  Jcidneys  show  usually  a  diffuse  nephritis  with  fatty  degeneration. 
A  hyaline  change  occurs  in  the  tubal  epithelium,  particularly  of  the  de- 
scending limb  of  the  loop  of  Henle,  and  also  in  the  capillary  vessels  of  the 
tufts. 

Symptoms. — Acute  and  chronic  forms  are  recognized,  but  there  is 
no  essential  difference  between  them,  except  that  in  the  former  the  patients 
are  younger,  the  course  is  more  rapid,  and  the  emaciation  more  marked. 
Acute  cases  may  occur  in  the  aged.  I  saw  with  Sowers  in  "Washington  a 
man  aged  seventy-three  in  whom  the  entire  course  of  the  disease  was  less 
than  three  weeks. 

It  is  also  possible  to  divide  the  cases  into  (1)  lipogenic  or  dietetic,  which 
includes  the  transient  glycosuria  of  stout  persons;  (2)  neurotic,  due  to  in- 
juries or  functional  disorders  of  the  nervous  system;  and  (3)  pancreatic, 
in  which  there  is  a  lesion  of  the  pancreas.  It  is,  however,  by  no  means 
easy  to  discriminate  in  all  cases  between  these  forms.  Attempts  have 
been  made  to  separate  a  clinical  variety  analogous  to  experimental  pan- 
creatic diabetes.  Hirschfeld,  from  G-uttmann's  clinic,  has  described  cases 
running  a  rapid  and  severe  course  usually  in  young  and  middle-aged 
persons.  The  polyuria  is  less  common  or  even  absent,  and  there  is  a  strik- 
ing defect  in  the  assimilation  of  the  albuminoids  and  fats,  as  shown  by 
the  examination  of  the  fasces  and  urine.  In  4  of  7  cases  autopsies  were 
made  and  the  pancreas  was  found  atrophic  in  two,  cancerous  in  one,  and 
in  the  fourth  exceedingly  soft. 

The  onset  of  the  disease  is  gradual  and  either  frequent  micturition  or 
inordinate  thirst  first  attracts  attention.  "Very  rarely  it  sets  in  rapidly, 
after  a  sudden  emotion,  an  injury,  or  after  a  severe  chill.  Wlien  fully 
established  the  disease  is  characterized  by  great  thirst,  the  passage  of  large 


DIABETES  MELLITUS.  423 

quantities  of  saccharine  urine,  a  voracious  appetite,  and,  as  a  rule,  pro- 
gressive emaciation. 

Among  the  general  symptoms  of  the  disease  thii'st  is  one  of  the  most 
distressing.  Large  quantities  of  water  are  required  to  keep  the  sugar 
in  solution  and  for  its  excretion  in  the  urine.  The  amount  of  fluid  con- 
sumed will  be  found  to  bear  a  definite  ratio  to  the  quantity  excreted.  In- 
stances, however,  are  not  uncommon  of  pronounced  diabetes  in  which  the 
thirst  is  not  excessive;  but  in  such  cases  the  amount  of  urine  passed  is 
never  large.  The  thirst  is  most  intense  an  hour  or  two  after  meals.  As 
a  rule,  the  digestion  is  good  and  the  appetite  inordinate.  The  condition 
is  sometimes  termed  bulimia  or  polyphagia.    Lumbar  pain  is  common. 

The  tongue  is  usually  dry,  red,  and  glazed,  and  the  saliva  scanty.  The 
gums  may  become  swollen,  and  in  the  later  stages  aphthous  stomatitis  is 
common.    Constipation  is  the  rule. 

In  spite  of  the  enormous  amount  of  food  consumed  a  patient  may  be- 
come rapidly  emaciated.  This  loss  of  flesh  bears  some  ratio  to  the  poly- 
uria, and  when,  under  suitable  diet,  the  sugar  is  reduced,  the  patient  may 
quickly  gain  in  flesh.  The  skin  is  dry  and  harsh,  and  sweating  rarely  occurs, 
except  when  phthisis  coexists.  Drenching  sweats  have  been  known  to  alter- 
nate with  excessive  polyuria.  The  temperature  is  often  subnormal;  the 
pulse  is  usually  frequent,  and  the  tension  increased.  Many  diabetics,  how- 
ever, do  not  show  marked  emaciation.  Patients  past  the  middle  period 
of  life  may  have  the  disease  for  years  without  much  disturbance  of  the 
health,  and  may  remain  well  nourished.  These  are  the  cases  of  the  diabete 
gras  in  contradistinction  to  diahete  maigre. 

The  Urine. — The  amount  varies  from  6  or  8  pints  in  mild  cases  to  30 
or  40  pints  in  very  severe  cases.  In  rare  instances  the  quantity  of  urine 
is  not  much  increased.  Under  strict  diet  the  amount  is  much  lessened,  and 
in  intercurrent  febrile  affections  it  may  be  reduced  to  normal.  The  specific 
gravity  is  high,  ranging  from  1.025  to  1.045;  but  in  exceptional  cases  it 
may  be  low,  1.013  to  1.020.  The  highest  specific  gravity  recorded,  so  far 
as  I  know,  is  by  Trousseau — 1.074.  Very  high  specific  gravities — 1.070  -|- 
— suggest  fraud.  The  urine  is  pale  in  color,  almost  like  water,  and  has  a 
sweetish  odor  and  a  distinctly  sweetish  taste.  The  reaction  is  acid.  Sugar 
is  present  in  varying  amounts.  In  mild  cases  it  does  not  exceed  1^  or  2  per 
cent,  but  it  may  reach  from  5  to  10  per  cent.  The  total  amount  excreted 
in  the  twenty-four  hours  may  range  from  10  to  20  ounces,  and  in  exceptional 
cases  from  1  to  2  pounds.    The  following  are  the  most  satisfactory  tests: 

Fehling's  Test. — The  solution  consists  of  sulphate  of  copper  (grs.  90^), 
neutral  tartrate  of  potassium  (grs.  364),  solution  of  caustic  soda  (fl.  ozs.  4), 
and  distilled  water  to  make  up  6  ounces.  Put  a  drachm  of  this  in  a  test- 
tube  and  boil  (to  test  the  reagent);  add  an  equal  quantity  of  urine  and  boil 
again,  when,  if  sugar  is  present,  the  yellow  suboxide  of  copper  is  thrown 
down.    The  solution  must  be  freshly  prepared,  as  it  is  apt  to  decompose. 

Trommer's  Test. — To  a  drachm  of  urine  in  a  test-tube  add  a  few  drops 
of  a  dilute  sulphate-of-copper  solution  and  then  as  much  liquor  potasses 
as  urine.  On  boiling,  the  copper  is  reduced  if  sugar  be  present,  forming 
the  yellow  or  orange-red  suboxide.    There  are  certain  fallacies  in  the  copper 


424  CONSTITUTIONAL  DISEASES. 

tests.  Thus,  a  substance  called  glycuronic  acid  is  met  with  in  the  urine 
after  the  use  of  certain  drugs — chloral,  phenacetin,  morphia,  chloroform, 
etc. — which  reduces  copper.  Homogentisinic,  uroleucinic,  and  glycosuric 
acids,  which  are  held  to  be  the  cause  of  alcaptonuria,  may  also  prove  a 
source  of  error  (see  Alcaptonuria,  by  T.  B.  Futcher,  IST.  Y.  Med.  Jour., 
1898,  i). 

Fermentation  Test. — This  is  free  from  all  doubt.  Place  a  small  frag- 
ment of  yeast  in  a  test-tube  full  of  urine,  which  is  then  inverted  over  a 
glass  vessel  containing  the  same  fluid.  If  sugar  is  present,  fermentation 
goes  on  with  the  formation  of  carbon  dioxide,  which  accumulates  in  the 
upper  part  of  the  tube  and  gradually  expels  the  urine.  In  doubtful  cases 
a,  control  test  shotdd  always  be  used.  For  laboratory  work  the  polariscope 
is  of  great  value. 

Of  other  ingredients  in  the  urine,  the  urea  is  increased,  the  uric  acid 
does  not  show  special  changes,  and  the  phosphates  may  be  greatly  in  ex- 
cess. The  calcium  salts  are  markedly  increased.  The  same  holds  true 
for  the  ammonia  in  all  severe  cases,  and  particularly  in  diabetic  coma. 
Ealfe  has  described  a  great  increase  in  the  phosphates,  and  in  some  of 
these  cases,  with  an  excessive  excretion,  the  symptoms  may  be  very  simi- 
lar to  those  of  diabetes,  though  the  sugar  may  not  be  constantly  present. 
The  term  phosphatic  diabetes  has  sometimes  been  applied  to  them. 
Acetone  and  acetone-forming  substances  are  not  infrequently  present. 
Lieben's  test  is  as  follows:  The  urine  is  distilled  and  a  few  cubic  centimetres 
of  the  distillate  are  rendered  alkaline  with  liquor  potassse.  A  few  drops  of 
Lugol's  solution  are  then  added,  when,  if  acetone  be  present,  the  distillate 
assumes  a  turbid  yellow  color,  due  to  the  formation  of  iodoform,  which  is 
recognized  by  its  odor  and  by  the  formation  of  minute  hexagonal  and 
stellate  crystals.  Diacetic  acid  is  sometimes  present,  and  may  be  recognized 
from  the  fact  that  a  solution  of  the  chloride  of  iron  yields  a  beautiful 
Bordeaux-red  color.  Other  substances,  as  formic,  carbolic,  and  salicylic 
acids,  give  the  same  reaction  in  both  fresh  and  previously  boiled  urine, 
while  diacetic  acid  does  not  give  the  reaction  in  urine  previously  boiled. 
In  testing  for  diacetic  acid  perfectly  fresh  urine  should  be  used,  as  it 
rapidly  becomes  broken  up  into  acetone  and  carbonic  acid.  /3-oxybutyric 
acid,  the  recognized  cause  of  coma,  should  be  tested  for  in  all  severe  cases. 
As  it  is  Igevo-rotatory,  its  presence  is  indicated  by  Itevo-rotation  in  com- 
pletely fermented  urine,  as  well  as  by  the  greater  percentage  of  sugar 
demonstrable  with  Fehling^s  than  with  the  polariscopic  method. 

Bremer  finds  that  diabetic  urine  has  the  power  of  dissolving  gentian 
violet,  whereas  normal  urine  fails  to  do  so.  Unfortunately,  the  urine  in 
diabetes  insipidus  and  in  certain  forms  of  polyuria  reacts  similarly.  Froh- 
lich  has  recently  devised  a  test  based  on  the  fact  that  diabetic  urine  has  the 
property  of  decolorizing  solutions  of  methylene  blue. 

Glycogen  has  also  been  described  as  present  in  the  urine. 

Albumin  is  not  infrequent.  It  occurred  in  nearly  37  per  cent  of  the 
examinations  made  by  Lippman  at  Carlsbad. 

Pneumaturia,  the  formation  of  gas  in  the  urine,  due  to  fermentative 
processes  in  the  bladder,  is  occasionally  met  with. 


DIABETES  MELLITUS.  425 

Fat  may  be  passed  in  the  urine  in  the  form  of  a  fine  emulsion  (lipuria). 

Diabetes  in  CMldren. — Stern  has  analyzed  117  cases  in  children.  They 
usually  occur  among  the  better  classes.  Six  were  under  one  year  of  age. 
Hereditary  influences  were  marked.  The  course  of  the  disease  is,  as  a  rule, 
much  more  rapid  than  in  adults.  The  shortest  duration  was  two  days.  In 
7  cases  it  did  not  last  a  month.  One  case  is  mentioned  of  a  child  apparently 
born  with  the  glycosuria,  who  recovered  in  eight  months. 

Complications. — (a)  Cutaneous. — Boils  and  carbuncles  are  extremely 
common.  Painful  onychia  may  occur.  Eczema  is  also  met  with,  and  at 
times  an  intolerable  itching.  In  women  the  irritation  of  the  urine  may 
cause  the  most  intense  pruritus  pudendi,  and  in  men  a  balanitis.  Earer 
affections  are  xanthoma  and  purpura.  Gangrene  is  not  uncommon,  and 
is  associated  usually  with  arterio-sclerosis.  William  Hunt  has  analyzed 
64  cases.  In  50  the  localities  were  as  follows:  Feet  and  legs,  37;  thigh  and 
buttock,  2;  nucha,  2;  external  genitals,  1;  lungs,  3;  fingers,  3;  back,  1; 
eyes,  1.  Perforating  ulcer  of  the  foot  may  occur.  Bronzing  of  the  skin 
(diabete  bronze)  occurs  in  certain  cases  of  diabetes  in  which  the  latter  de- 
velops as  a  late  event  in  the  disease  known  as  hemochromatosis,  which  is 
further  characterized  by  pigmentary  cirrhosis  of  the  liver  and  pancreas. 
With  the  onset  of  severe  complications  the  tolerance  of  the  carbohydrates 
is  much  increased.    Profuse  sweats  may  occur. 

(b)  Pulmonary. — The  patients  are  not  infrequently  carried  off  by  acute 
pneumonia,  which  may  be  lobar  or  lobular.  Gangrene  is  very  apt  to  super- 
vene, but  the  breath  does  not  necessarily  have  the  foul  odor  of  ordinary 
gangrene. 

Tuberculous  hroncho-pneumonia  is  very  common.  It  was  formerly 
thought,  from  its  rapid  course  and  the  limitation  of  the  disease  to  the  lung, 
that  this  was  not  a  true  tuberculous  affection;  but  in  the  cases  which  have 
come  under  my  notice  the  bacilli  have  been  present,  and  the  condition  is 
now  generally  regarded  as  tuberculous. 

(c)  Renal. — Albuminuria  is  a  tolerably  frequent  complication.  The 
amount  varies  greatly,  and,  when  slight,  does  not  seem  to  be  of  much  mo- 
ment. OEdema  of  the  feet  and  anldes  is  not  an  infrequent  symptom.  Gen- 
eral anasarca  is  rare,  however,  owing  to  the  marked  polyuria.  It  was  pres- 
ent in  a  marked  degree  in  one  of  my  156  cases.  It  is  sometimes  associated 
with  arterio-sclerosis.  It  occasionally  precedes  the  development  of  the  dia- 
betic coma.    Occasionally  cystitis  develops. 

(d)  Nervous  System. — (1)  Diabetic  coma,  first  studied  by  Kussmaul, 
comes  on  in  a  considerable  proportion  of  all  cases,  particularly  in  the  young. 
Stephen  Mackenzie  states  that  of  the  fatal  cases  of  diabetes  at  the  London 
Hospital,  all  under  the  age  of  twenty-five,  with  but  one  exception,  had  died 
in  coma.  In  Naunyn's  44  fatal  cases  it  occurred  in  12.  It  preceded  death 
in  28  of  Williamson's  40  cases.  It  occurred  in  15  of  the  27  fatal  cases  in  my 
series.  Frerichs  recognized  three  groups  of  cases:  (a)  Those  in  which  after 
exertion  the  patients  were  suddenly  attacked  with  weakness,  syncope,  som- 
nolence, and  gradually  deepening  unconsciousness;  death  occurring  in  a  few 
hours.  ((3)  Cases  with  preliminary  gastric  disturliance,  such  as  nausea  and 
vomiting,  or  some  local  affection,  as  pharyngitis,  phlegmon,  or  a  pulmonary 


426  CONST  [TUTIONAL  DISEASES. 

complication.  In  such  cases  the  attack  begins  with  headache,  delirium, 
great  distress,  and  dyspnoea,  affecting  both  inspiration  and  expiration,  a 
condition  called  by  Kussmaul  air-hunger.  Cyanosis  may  or  may  not  be 
present.  If  it  is,  the  pulse  becomes  rapid  and  weak  and  the  patient  grad- 
ually sinks  into  coma;  the  attack  lasting  from  one  to  five  days.  There 
may  be  a  very  heavy  sweetish  odor  of  the  breath,  due  to  the  presence  of 
acetone.  (7)  Cases  in  which,  without  any  previous  dyspnoea  or  distress,  the 
patient  is  attacked  with  headache  and  a  feeling  of  intoxication,  and  rapidly 
falls  into  a  deep  and  fatal  coma.  There  are  atypical  cases  in  which  the  coma 
is  due  to  uraemia,  to  apoplexy,  or  to  meningitis. 

There  has  been  much  dispute  as  to  the  nature  of  these  symptoms,  but 
clinical  laboratory  investigations  have  practically  afEorded  a  satisfactory 
explanation.  For  years  the  coma  symptoms  were  ascribed  to  the  toxic 
effects  of  acetone  and  later  to  those  of  diacetic  acid.  Experimental  work, 
however,  showed  that  these  views  were  incorrect.  The  almost  universal 
opinion  now  is  that  the  coma  is  due  to  an  acid  intoxication,  or,  as  ISTaunyn 
terms  it,  an  acidosis.  The  offending  agent  is  believed  to  be  y8-oxybutyric 
acid,  which  accumulates  in  the  tissues  and  circulating  blood  in  enormous 
quantities,  and  is  eliminated  in  the  urine  in  combination  with  various  base- 
forming  elements,  but  never  free.  In  1884  Stadelmann,  Kiilz,  and  Min- 
kowski almost  simultaneously  found  this  acid  in  the  urine  of  patients  with 
diabetic  coma.  Subsequent  researches,  particularly  those  published  from 
Naunyn's  clinic,  have  fully  confirmed  these  results,  and  it  is  now  almost 
universally  accepted  that  ^S-oxybutyric  acid  is  the  cause  of  diabetic  coma. 
The  amount  of  the  acid  excreted  in  the  twenty-four  hours  may  be  enormous. 
Kiilz  found  in  3  cases  67,  100,  and  226  grammes  respectively.  Magnus- 
Levy  has  estimated  that  from  100  to  200  grammes  are  often  contained  in 
the  tissues  of  fatal  cases.  This  author  is  of  the  belief  that  the  /8-oxybu- 
tyric  acid  is  derived  from  the  fats  of  the  body,  whereas  most  observers,  in- 
eluding  N"aunyn,  trace  it  to  the  disintegration  of  the  tissue  albumins.  Ace- 
tone and  diacetic  acid  are  derivative  products  of  the  /3-oxybutyric  acid. 

Saunders  and  Hamilton  have  described  cases  in  which  the  lung  cap- 
illaries were  blocked  with  fat.  They  attributed  the  symptoms  to  fat  em- 
bolism, but  there  are  many  cases  on  record  in  which  this  condition  was  not 
found,  though  lipsemia  is  by  no  means  infrequent  in  diabetes. 

Albuminuria  frequently  precedes  or  accompanies  the  attack,  and  numer- 
ous small,  short,  hyaline,  and  finely  granular  casts  are  demonstrable. 

(2)  Peripheral  Neuritis. — The  neuralgias,  numbness,  and  tingling,  which 
are  not  uncommon  symptoms  in  diabetes,  are  probably  minor  neuritic 
manifestations.  Herpes  zoster  may  occur.  Perforating  ulcer  of  the  foot 
may  develop. 

Diabetic  Tales  (so  called). — This  is  a  peripheral  neuritis,  characterized 
by  lightning  pains  in  the  legs,  loss  of  knee-jerk — whicli  may  occur  with- 
out the  other  symptoms — and  a  loss  of  power  in  the  extensors  of  the  feet. 
The  gait  is  the  characteristic  steppage,  as  in  arsenical,  alcoholic,  and  other 
forms  of  neuritic  paralysis.  Charcot  states  that  there  may  be  atrophy  of 
the  optic  nerves.  Changes  in  the  posterior  columns  of  the  cord  have  been 
found  by  Williamson  and  others. 


DIABETES  MELLITUS.  427 

Diabetic  Paraplegia. — This  is  also  in  all  probability  due  to  neuritis. 
There  are  cases  in  which  power  has  been  lost  in  both  arms  and  legs. 

(3)  Mental  Symptoms. — The  patients  are  often  morose,  and  there  is  a 
strong  tendency  to  become  hypochondriacal.  General  paralysis  has  been 
known  to  develop.  Some  patients  display  an  extraordinary  degree  of  rest- 
lessness and  anxiety. 

(4)  Special  Senses. — Cataract  is  liable  to  occur,  and  may  develop  with 
rapidity  in  young  persons.  Diabetic  retinitis  closely  resembles  the  albu- 
minuric form.  Ha3morrhages  are  common.  Sudden  amaurosis,  similar 
to  that  which  occurs  in  uraemia,  may  occur.  Paralysis  of  the  muscles  of 
accommodation  may  be  present;  and  lastly,  atrophy  of  the  optic  nerves. 
Aural  symptoms  may  come  on  with  great  rapidity,  either  an  otitis  media, 
or  in  some  instances  inflammation  of  the  mastoid  cells. 

(5)  Sexual  Function. — Impotence  is  common,  and  may  be  an  early 
symptom.  Conception  is  rare;  if  it  occurs,  abortion  is  apt  to  follow.  A 
diabetic  mother  may  bear  a  healthy  child;  there  is  no  known  instance  of  a 
diabetic  mother  bearing  a  diabetic  child.  The  course  of  the  disease  is 
usually  aggravated  after  delivery. 

Course. — In  children  the  disease  is  rapidly  progressive,  and  may  prove 
fatal  in  a  few  days.  It  may  be  stated,  as  a  general  rule,  that  the  older  the 
patient  at  the  time  of  onset  the  slower  the  course.  Cases  without  hereditary 
influences  are  the  most  favorable.  In  stout,  elderly  men  diabetes  is  a  much 
more  hopeful  disease  than  it  is  in  thin  persons.  Middle-aged  patients  may 
live  for  many  years,  and  persons  are  met  with  who  have  had  the  disease 
for  ten,  twelve,  or  even  fifteen  years. 

Diagnosis. — As  stated  in  the  definition,  for  a  case  to  be  considered 
diabetes  the  sugar  eliminated  in  the  urine  must  be  grape  sugar,  it  should 
be  present  for  weeks,  months,  or  years,  and  the  excretion  of  sugar  must 
take  place  after  the  ingestion  of  moderate  amounts  of  carbohydrates.  As 
a  rule,  there  is  no  difficulty  in  determining  the  presence  of  diabetes.  The 
urine  tests  already  given  are  distinctive. 

Bremer's  Blood  Test. — This  author  claims  that  he  is  able  to  make  a  diag- 
nosis of  diabetes  from  the  examination  of  a  drop  of  the  patient's  blood,  de- 
pending on  the  fact  that  it  reacts  differently  from  normal  blood  to  various 
aniline  dyes. 

His  latest  published  method  is  briefly  as  follows:  Rather  thick  smears 
of  suspected  and  normal  blood  are  made  on  ordinary  microscopic  slides. 
They  are  then  heated  in  a  thermostat  up  to  135°  C,  and  when  sufficiently 
cooled  are  stained  in  a  one-per-cent  aqueous  solution  of  Congo-red  for  one 
and  a  half  to  two  minutes.  Slides  of  the  non-diabetic  and  diabetic  blood 
are  placed  ba<ik  to  back,  so  that  each  will  be  exposed  to  the  same  conditions. 
The  excess  of  the  stain  is  washed  off,  and  if  the  suspected  patient  has  dia- 
betes the  blood  will  be  unstained,  whereas  the  normal  blood  takes  a  dis- 
tinct Co7igo-red  stain.  Bremer  obtains  this  reaction  in  the  prediabetic 
stage,  and  also  in  the  intervals  when  the  patient's  urine  is  temporarily  free 
from  sugar.  He  thinks  the  reaction  is  due  to  a  qualitative  change  in  the 
haemoglobin  of  the  red  blood-cells,  and  not  to  an  excess  of  grape  sugar  in 
the  blood.     In  a  number  of  cases  in  my  wards,  in  which  the  test  has  been 


428  CONSTITUTIONAL  DISEASES. 

performed,  the  reaction  has  been  repeatedly  obtained,  but  it  was  not  pos- 
sible to  fully  confirm  Bremer's  statement  that  the  reaction  was  also  present 
when  the  urine  was  temporarily  free  from  sugar.  According  to  E.  T.  Wil- 
liamson, diabetic  blood  has  the  power  to  decolorize  weak  alkaline  solutions 
of  methylene  blue  to  a  yellowish-green  or  yellow  color.  He  has  devised  a 
blood  test  for  diabetes,  using  definite  proportions  of  blood  and  the  reagent, 
Williamson  has  obtained  the  reaction  in  every  one  of  11  cases  of  diabetes 
in  which  the  test  was  tried,  but  failed  to  get  it  in  a  single  instance  in  the 
blood  of  100  non-diabetic  cases.  He  is  inclined  to  the  view  that  the  reaction 
is  due  to  an  excess  of  sugar  in  the  blood.  The  reaction  was  obtained  by 
Futcher  in  7  cases  in  which  it  was  tried  in  my  wards  (Phila.  Med.  Journal, 
February  12,  1898). 

Deception  may  be  practised.  A  young  girl  under  my  care  had  urine 
with  a  specific  gravity  of  1.065.  The  reactions  were  for  cane  sugar.  There 
is  one  case  in  the  literature  in  which,  after  the  cane-sugar  fraud  was  de- 
tected, the  woman  bought  grape  sugar  and  put  it  into  her  bladder! 

Prognosis. — In  true  diabetes  instances  of  cure  are  rare.  On  the 
other  hand,  the  transient  or  intermittent  glycosuria,  met  with  in  stout 
overfeeders,  or  in  persons  who  have  undergone  a  severe  mental  strain,  is 
very  amenable  to  treatment.  Not  a  few  of  the  cases  of  reputed  cures  be- 
long to  this  division.  Practically,  in  cases  under  ^forty  years  of  age  the 
outlook  is  bad;  in  older  persons  the  disease  is  less  serious  and  much  more 
amenable  to  treatment.  It  is  a  good  plan  at  the  outset  to  determine  whether 
the  urine  of  a  patient  contains  sugar  or  not  on  a  diet  absolutely  free  from 
carbohydrates.  In  mild  cases  the  sugar  disappears;  in  the  severer  cases  it 
continues  to  be  formed  from  the  proteids. 

Treatment. — In  families  with  a  marked  predisposition  to  the  disease 
the  use  of  starchy  and  saccharine  articles  of  diet  should  be  restricted. 

The  personal  hygiene  of  a  diabetic  patient  is  of  the  first  importance. 
Sources  of  worry  should  be  avoided,  and  he  should  lead  an  even,  quiet  life, 
if  possible  in  an  equable  climate.  Flannel  or  silk  should  be  worn  next  to 
the  skin,  and  the  greatest  care  should  be  taken  to  promote  its  action.  A 
lukewarm,  or  if  tolerably  robust,  a  cold  bath,  should  be  taken  every  day. 
An  occasional  Turkish  bath  is  useful.  Systematic,  moderate  exercise  should 
be  taken.  When  this  is  not  feasible,  massage  should  be  given.  It  is  well 
to  study  accurately  the  dietetic  capabilities  of  each  case. 

Diet. — Our  injunctions  to-day  are  those  of  Sydenham:  "Let  the  pa- 
tient eat  food  of  easy  digestion,  such  as  veal,  mutton,  and  the  like,  and  ab- 
stain from  all  sorts  of  fruit  and  garden  stuff." 

Diabetic  patients  admitted  to  the  medical  wards  of  the  Johns  Hopkins 
Hospital  are  kept  for  three  or  four  days  on  the  ordinary  ward  diet,  which 
contains  moderate  amounts  of  carbohydrates,  in  order  to  ascertain  the 
amount  of  sugar  excretion.  For  two  days  more  the  starches  are  gradually 
cut  off.  They  are  then  placed  on  the  following  standard  non-carbohydrate 
diet,  arranged  from  a  list  recommended  by  von  Noorden: 

Breakfast:  7.30,  200  cc.  (§  vi)  of  tea  or  coffee;  150  grammes  (§  iv)  of 
beefsteak,  mutton-chops  without  bone,  or  boiled  ham;  one  or  two  eggs. 

Lunch:  12.30,  200  grammes  (§vi)  cold  roast  beef;  60  grammes  (§  ij) 


DIABETES  MELLITUS.  429 

celery,  fresh  cucumbers  or  tomatoes  with  vinegar,  olive  oil,  pepper  and  salt 
to  taste;  30  cc.  (3  v)  whisky  with  400  cc.  (5  xiij)  water;  60  cc.  (5  ij)  coffee, 
without  milk  or  sugar. 

Dinner:  6  P.  M.,  200  cc.  clear  bouillon;  250  grammes  (5  viiss)  roast 
beef;  10  grammes  (3  iiss)  butter;  80  grammes  (§  ij)  green  salad,  with  10 
grammes  (3  iiss)  vinegar  and  20  grammes  (5  v)  olive  oil,  or  three  table- 
spoonfuls  of  some  well-cooked  green  vegetable;  three  sardines  a  I'huile; 
20  cc.  (3v)  whisky,  with  400  cc.  (o^iij)  water. 

Supper:  9  p.  m.,  two  eggs  (raw  or  cooked);  400  cc.  (5  xiij)  water. 

This  diet  contains  about  200  grammes  of  albumin  and  about  135 
grammes  of  fat.  The  effect  of  the  diet  on  the  sugar  excretion  is  remark- 
able. In  many  cases  there  is  an  entire  disappearance  of  the  sugar  from 
the  urine  in  three  or  four  days.  Chart  XV  shoAvs  very  graphically  the 
remarkable  drop  in  the  sugar  excretion  for  the  first  twenty-four  hours  in 
a  case  placed  on  the  standard  diet.  The  sugar  failed,  however,  in  this  par- 
ticular case  to  entirely  disappear  from  the  urine  except  on  one  day,  al- 
though he  was  kept  on  the  diet  for  over  two  months.  In  cases  in  which 
the  urine  becomes  free  from  sugar  gradually  increasing  quantities  of  starch 
up  to  20,  50,  and  100  grammes  are  added  daily.  White  bread  contains 
fifty-five  per  cent  of  starch.  The  effect  of  the  non-carbohydrate  diet,  ac- 
cording to  von  jSToorden,  is  to  improve  the  metabolic  fimctions  so  that  the 
system  can  warehouse  considerable  quantities  of  carbohydrates  without 
sugar  appearing  in  the  urine.  He  advises  that  patients  should  return  to 
the  strict  non-carbohydrate  regimen  at  intervals  of  three  or  four  months, 
so  as  to  increase  their  power  of  warehousing  carbohydrates. 

In  cases  in  wdiich  a  standard  diet  is  not  ordered  it  is  well  to  begin  cut- 
ting off  article  by  article  until  the  sugar  disappears  from  the  urine.  Within 
a  month  or  two  the  patient  may  be  allowed  a  more  liberal  diet,  testing  the 
different  kinds  of  food. 

The  following  is  a  list  of  articles  which  diabetic  patients  may  take: 

Liquids:  Soups — ox-tail,  turtle,  bouillon,  and  other  clear  soups.  Lem- 
onade, coffee,  tea,  chocolate,  and  cocoa;  these  to  be  taken  Avithout  sugar, 
but  they  may  be  sweetened  with  saccharin.  Potash  or  soda  Avater,  and 
Apollinaris,  or  the  Saratoga- Vichy,  and  milk  in  moderation,  may  be  used. 

Of  animal  food:  Fish  of  all  sorts,  including  crabs,  lobsters,  and  oysters; 
salt  and  fresh  butcher's  meat  (with  the  exception  of  liver),  poultry,  and 
game.    Eggs,  butter,  buttermilk,  curds,  and  cream  cheese. 

Of  bread:  Gluten  and  bran  bread,  and  almond  and  cocoanut  biscuits. 

Of  A^egetables:  Lettuce,  tomatoes,  spinach,  chicory,  sorrel,  radishes, 
asparagus,  Avater-cress,  mustard  and  cress,  cucumbers,  celery,  and  endives. 
Pickles  of  various  sorts. 

Fruits:  Lemons  and  oranges.  Currants,  plums,  cherries,  pears,  apples 
(tart),  melons,  raspberries  and  straAvborries  may  be  taken  in  moderation. 
•  Nuts  are,  as  a  rule,  alloAvable. 

Among  proliihited  articles  are  the  folloAving:  Thick  soups  and  liver. 

Ordinary  bread  of  all  sorts  (in  quantity),  rye,  wheaten,  brown,  or  white. 
All  farinaceous  preparations,  such  as  hominy,  rice,  tapioca,  semolina,  arrow- 
root, sago,  and  vermicelli. 


430 


CONSTITUTIONAL  DISEASES. 


Of  vegetables:  Potatoes,  turnips,  parsnips,  squashes,  vegetable-mar- 
rows of  all  kinds,  beets,  corn,  artichokes. 

Of  liquids:  Beer,  sparkling  wine  of  all  sorts,  and  the  sweet  aerated 
drinks. 

In  feeding  a  diabetic  patient  one  of  the  greatest  difficulties  is  in 
arranging  a  substitute  for  bread.  Of  the  gluten  foods,  many  are  very 
unpalatable;  others  are  frauds. 


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Chart  XV. — Illustrating  influence  of  diet  on  sugar  and  amount  of  urine. 


A  good  gluten  flour  is  made  by  the  Battle  Creek  Sanitarium  Company, 
Michigan.  Other  substitutes  are  the  almond  food,  the  Aleuronat  bread, 
and  soya  bread,  but  these  and  other  substitutes  are  not  satisfactory  as  a 
rule.  For  sweetening  purposes  saccharin  may  be  used,  of  which  tablets  are 
prepared. 

Medicinal  Treatment. — This  is  most  unsatisfactory,  and  no  one  drug 
appears  to  have  a  directly  curative  influence.  Opium  alone  stands  the 
test  of  experience  as  a  remedy  capable  of  limiting  the  progress  of  the  dis- 
ease.    Diabetic  patients  seem  to  have  a  special  tolerance  for  this  drug. 


DIABETES  MELLITUS.  4,31 

Codeia  is  preferred  by  Pavy,  and  has  the  advantage  of  being  less  consti- 
pating than  morphia.  A  patient  may  begin  with  half  a  grain  three  times 
a  day,  which  may  be  gradually  increased  to  6  or  8  grains  in  the  twenty- 
four  hours.  Not  much  effect  is  noticed  unless  the  patient  is  on  a  rigid  diet. 
When  the  sugar  is  reduced  to  a  minimum,  or  is  absent,  the  opium  should 
be  gradually  withdrawn.  The  patients  not  only  bear  well  these  large  doses 
of  the  drug,  but  they  stand  its  gradual  reduction.  Potassium  bromide  is 
often  a  useful  adjunct.  The  arsenite  of  bromine,  a  solution  of  arsenious 
acid  with  bromine  in  glycerin  (dose,  3  to  5  minims  after  meals),  has  been 
very  highly  recommended,  but  it  is  by  no  means  so  certain  as  opium. 
Arsenic  alone  may  be  used.  Antipyrin  may  be  given  in  doses  of  10  grains 
three  times  a  day,  and  in  cases  with  a  marked  neurotic  constitution  is  some- 
times satisfactory.  The  salicylates,  iodoform,  nitroglycerin,  jambul,  the 
lithium  salts,  strychnine,  creasote,  and  lactic  acid  have  been  employed. 

Preparations  of  the  pancreas  (glycerin  extracts  of  the  dried  and  fresh 
gland)  have  been  used  in  the  hope  that  they  would  supply  the  internal  secre- 
tion necessary  to  normal  sugar  metabolism.  The  success  has  not,  however, 
been  in  any  way  comparable  with  that  obtained  with  the  thyroid  extract  in 
myxoedema.  Lepine  has  isolated  a  glycolytic  ferment  from  the  pancreas 
and  also  from  the  malt  diastase,  and  has  used  it  with  some  success  in  4  cases. 

Of  the  complications,  the  pruritus  and  eczema  are  best  treated  by  cool- 
ing lotions  of  boric  acid  or  hyposulphite  of  soda  (1  ounce;  water,  1  quart), 
or  the  use  of  ichthyol  and  lanolin  ointment.  - 

In  the  thin,  nervous  cases  the  bowels  should  be  kept  open  and  the  urine 
tested  at  short  intervals  for  acetone  and  diaeetic  acid — the  derivatives  of 
/S-oxy-butyric  acid. 

The  co7na  is  an  almost  hopeless  complication.  Inhalations  of  oxygen 
have  been  recommended.  The  use  of  bicarbonate  of  soda  in  very  large  doses 
is  recommended  to  neutralize  the  acid  intoxication.  It  may  be  used  intra- 
venously; as  much  as  80  grammes  have  been  injected.  This  treatment  was 
first  recommended  by  Stadelmann,  and  has  undoubtedly  given  the  best  re- 
sults. Naunyn  and  Magnus-Levy  report  cases  of  recovery  from  coma  by 
its  use.  I  have  had  one  recovery.  The  sodium  bicarbonate  should  be 
pushed  until  the  urine  is  alkaline.  As  much  as  100  grammes  should  be 
given  daily.  All  diabetics  with  a  marked  diaeetic  acid  reaction  in  the  urine 
should  be  placed  on  sodium  bicarbonate.  Next  to  the  antacid  treatment, 
subcutaneous  or  intravenous  injections  of  normal  salt  solution  have  given 
the  best  results.  The  improvement,  unfortunately,  is  only  temporary  with 
this  line  of  treatment.  Eeynolds  published  2  cases  of  recovery  after  the 
administration  of  a  dose  of  castor  oil,  followed  by  30  to  60  grains  of  citrate 
of  potassium  every  hour  in  copious  draughts  of  water.  The  bowels  of  a 
diabetic  patient  should  be  kept  acting  freely,  as  constipation  is  believed 
to  predispose  to  the  development  of  coma. 


27 


432  CONSTITUTIONAL  DISEASES. 


VI.    DIABETES    INSIPIDUS. 

Definition. — A  chronic  affection  characterized  by  the  passage  of  large 
quantities  of  normal  urine  of  low  specific  gravity. 

The  condition  is  to  be  distinguished  from  diuresis  or  polyuria,  which 
is  a  frequent  symptom  in  hysteria,  in  Bright's  disease,  and  occasionally 
in  cerebral  or  other  affections.  Willis,  in  1674,  first  recognized  the  distinc- 
tion between  a  saccharine  and  non-saccharine  form  of  diabetes. 

Etiology. — The  disease  is  most  common  in  young  persons.  Of  the 
85  cases  collected  by  Strauss,  9  were  under  five  years;  12  between  five  and 
ten  years;  36  between  ten  and  twenty-five  years.  Males  are  more  fre- 
quently attacked  than  females.  The  affection  may  be  congenital.  A  hered- 
itary tendency  has  been  noted  in  many  instances,  the  most  extraordinary 
of  which  has  been  reported  by  Weil.  Of  91  members  in  four  generations, 
23  had  persistent  polyuria  without  any  deterioration  in  health.  Injury  to 
the  nervous  system  has  been  present  in  certain  eases,  and  the  disease  has 
followed  sunstroke,  or  a  violent  emotion,  such  as  fright.  Traumatism 
has  occasionally  been  the  exciting  cause.  The  injury  may  have  been  to 
the  head,  but  in  other  cases  it  has  been  to  the  trunk  or  to  the  limbs.  Trous- 
seau stated  that  the  parents  of  children  with  diabetes  insipidus  frequently 
have  glycosuria  or  albuminuria.  Ealfe  stated  that  malnutrition  is  an  im- 
portant predisposing  factor  in  children.  The  disease  has  followed  rapidly 
the  copious  drinking  of  cold  water,  or  a  drinking-bout;  or  has  set  in  during 
the  convalescence  from  an  acute  disease.  Tumors  of  the  brain  and  lesions 
of  the  medulla  have  befen  met  with  in  a  few  instances.  Cases  of  polyuria 
have  been  accompanied  by  paralysis  of  the  sixth  nerve.  An  interesting 
group  of  cases  is  associated  with  cerebral  lues,  three  of  the  series  reported 
by  Futcher,  Bernard,  it  will  be  remembered,  discovered  a  spot  in  the  floor 
of  the  fourth  ventricle  of  animals,  irritation  of  which  produced  polyuria. 
Lesions  of  the  organs  of  the  abdomen  may  be  associated  with  an  excessive 
flow  of  urine,  which,  however,  should  not  be  regarded  as  true  diabetes  in- 
sipidus. Dickenson  mentions  its  occurrence  in  abdominal  tumors;  Ealfe,  in 
abdominal  aneurism.  I  have  noted  it  in  several  cases  of  tuberculous  peri- 
tonitis. There  have  been  six  cases  of  diabetes  insipidus  at  my  clinic  in  the 
past  twelve  years.    (Futcher.  'J.  H.  H.  Eeports,  1902.) 

The  nature  of  the  disease  is  unknown.  It  is,  doubtless,  of  nervous 
origin.  The  most  reasonable  view  is  that  it  results  from  a  vaso-motor  dis- 
turbance of  the  renal  vessels,  due  either  to  local  irritation,  as  in  a  case  of 
abdominal  tumor,  to  central  disturbance  in  cases  of  brain-lesion,  or  to 
functional  irritation  of  the  centre  in  the  medulla,  giving  rise  to  continuous 
renal  congestion. 

Morbid  Anatomy. — There  are  no  constant  anatomical  lesions.  The 
Tcidneys  have  been  found  enlarged  and  congested.  The  Uadder  has  been 
found  hypertrophied.  Dilatation  of  the  ureters  and  of  the  pelves  of  the 
kidneys  has  been  present.  Death  has  not  infrequently  resulted  from  chronic 
pulmonary  disease.  Very  varied  lesions  have  been  met  with  in  the  nervous 
system. 


DIABETES  INSIPIDUS.  '  433 

Symptoms. — The  disease  may  come  on  rapidly,  as  after  a  fright  or 
an  injury.  More  commonly  it  develops  slowly.  According  to  Ralfe,  the 
patients  often  complain  in  the  early  stages  of  severe  racking  pains  in  the 
lumbar  region  shooting  down  the  thighs.  A  copious  secretion  of  urine, 
with  increased  thirst,  are  the  prominent  features  of  the  disease.  The 
amount  of  urine  in  the  twenty-four  hours  may  range  from  20  to  40  pints, 
or  even  more.  Trousseau  speaks  of  a  patient  who  consumed  50  pints  of 
fluid  daily  and  passed  about  56  pints  of  urine  in  the  twenty-four  hours. 
The  specific  gravity  is  low,  1.001  to  1.005;  the  color  is  extremely  pale  and 
watery.  The  total  solid  constituents  may  not  be  reduced.  The  amount  of 
urea  has  sometimes  been  found  in  excess.  Abnormal  ingredients  are  rare. 
Muscle-sugar,  inosite,  has  been  occasionally  found.  Albumin  is  rare. 
Traces  of  sugar  have  been  met  with.  Naturally,  with  the  passage  of  such 
enormous  quantities  of  urine,  there  is  a  proportionate  thirst,  and  the  only 
inconvenience  of  the  disease  is  the  necessity  for  frequent  micturition  and 
frequent  drinking.  The  appetite  is  usually  good,  rarely  excessive  as  in 
diabetes  mellitus;  but  Trousseau  tells  of  the  terror  inspired  by  one  of  his 
patients  in  the  keepers  of  those  eating-houses  where  bread  was  allowed  with- 
out extra  charge  to  the  extent  of  each  customer's  wishes,  and  says  that  he 
was  presented  with  money  to  prevent  him  coming  back  to  dine.  The 
patients  may  be  well  nourished  and  healthy-looking.  The  disease  in  many 
instances  does  not  appear  to  interfere  in  any  way  with  the  general  health. 
The  perspiration  is  naturally  slight  and  the  skin  is  harsh.  The  amount 
of  saliva  is  small  and  the  mouth  usually  dry.  Cases  have  been  described 
in  which  the  tolerance  of  alcohol  has  been  remarkable,  and  patients  have 
been  known  to  take  a  couple  of  pints  of  brandy,  or  a  dozen  or  more  bottles 
of  wine,  in  the  day. 

The  course  depends  entirely  upon  the  nature  of  the  primary  trouble. 
Sometimes,  with  organic  disease,  either  cerebral  or  abdominal,  the  general 
health  is  much  impaired;  the  patient  becomes  thin,  and  rapidly  loses 
strength.  In  the  essential  or  idiopathic  cases,  good  health  may  be  main- 
tained for  an  indefinite  period,  and  the  affection  has  been  known  to  persist 
for  fifty  years.  Death  usually  results  from  some  intercurrent  affection. 
Spontaneous  cure  may  take  place. 

Diagnosis. — A  low  specific  gravity  and  the  absence  of  sugar  in  the 
urine  distinguish  the  disease  from  diabetes  mellitus.  Hysterical  polyuria 
may  sometimes  simulate  it  very  closely.  The  amount  of  urine  excreted 
may  be  enormous,  and  only  the  development  of  other  hysterical  manifesta- 
tions may  enable  the  diagnosis  to  be  made.  This  condition  is,  however, 
always  transitory. 

In  certain  cases  of  chronic  Bright's  disease  a  very  large  amount  of 
urine  of  low  specific  gravity  may  be  passed,  but  the  presence  of  albumin 
and  of  hyaline  casts,  and  the  existence  of  heightened  arterial  tension,  stiff 
vessels,  and  hypertrophied  left  ventricle  make  the  diagnosis  easy. 

Treatm.ent. — The  treatment  is  not  satisfactory.  No  attempt  should 
be  made  to  reduce  the  amount  of  liquid.  Opium  is  highly  recommended, 
but  is  of  doubtful  service.  The  preparations  of  valerian  may  be  tried; 
either  the  powdered  root,  beginning  with  5  grains  three  times  a  day,  and 


434  CONSTITUTIONAL  DISEASES. 

increasing  until  2  drachms  are  taken  in  the  day,  or  the  valerianate  of  zinc, 
in  15 -grain  doses,  gradually  increased  to  30  grains,  three  times  a  day.  Ergot, 
ergotin,  antipyrin,  the  salicylates,  arsenic,  strychnine,  turpentine,  and  the 
bromides  have  been  recommended.     Electricity  may  be  used. 


VII.    RICKETS  {RhacUtis). 

Definition. — A  disease  of  infants,  characterized  by  impaired  nutrition 
of  the  entire  body  and  alterations  in  the  growing  bones. 

Glisson,  the  anatomist  of  the  liver,  accurately  described  tlie  disease  in 
the  seventeenth  century.  The  name  is  derived  from  the  old  English  word 
wrickhen,  to  twist.  Glisson  suggested  to  change  the  name  to  rhachitis,  from 
the  Greek,  pa;)(ts,  the  spine,  as  it  was  one  of  the  first  parts  affected,  and 
also  from  the  similarity  in  the  sound  to  rickets. 

Etiology. — Eickets  exists  in  all  parts  of  the  world,  but  is  particularly 
marked  among  the  poor  of  the  larger  cities,  who  are  badly  housed  and  ill 
fed.  It  is  much  more  common  in  Europe  than  in  America.  In  Vienna  and 
London  from  50  to  80  per  cent  of  all  the  children  at  the  clinics  present 
signs  of  rickets.  It  is  a  comparatively  rare  disease  in  Canada.  In  the  cities 
of  this  continent  it  is  very  prevalent,  particularly  among  the  children  of 
the  negro  and  of  the  Italian  races.  Want  of  sunlight  and  impure  air  are 
important  factors.  Prolonged  lactation  and  suckling  the  child  during  preg- 
nancy are  accessory  influences  in  some  cases. 

There  is  no  evidence  that  the  disease  is  hereditary. 

Eickets  affects  male  and  female  children  equally.  It  is  a  disease  of  the 
first  and  second  years  of  life,  rarely  beginning  before  the  sixth  month. 
Jenner  has  described  a  late  rickets,  in  which  form  the  disease  may  not  ap- 
pear until  the  ninth  or  even  until  the  twelfth  year,  or  later  (the  osteo- 
malacia of  puberty).  Eickets  has  been  regarded  as  a  manifestation  of  con- 
genital syphilis  (Parrot).  Syphilitic  bones  rarely,  if  ever,  present  the 
spongy  tissue  peculiar  to  rickets,  and  rachitic  bones  never  show  the  multiple 
osteophytes  of  syphilis.  "  Syphilis  modifies  rickets;  it  does  not  create  it " 
(Cheadle).  A  faulty  diet  is  the  essential  factor  in  the  production  of  the 
disease.  Like  scurvy,  rickets  may  be  found  in  the  families  of  the  wealthy 
under  perfect  hygienic  conditions.  It  is  most  common  in  children  fed  on 
condensed  milk,  the  various  proprietary  foods,  cow's  milk,  and  food  rich 
in  starches.  "  An  analysis  of  the  foods  on  which  rickets  is  most  frequently 
and  certainly  produced  shows  invariably  a  deficiency  in  two  of  the  chief 
elements  so  plentiful  in  the  standard  food  of  young  animals — namely,  ani- 
mal fat  and  proteid  "  (Cheadle).  Bland  Sutton's  interesting  experiment 
with  the  lion's  cubs  at  the  "  Zoo  "  illustrates  this  point.  When  milk, 
pounded  bones,  and  cod-liver  oil  were  added  to  the  meat  diet  the  rickets 
disappeared,  and  for  the  first  time  in  the  history  of  the  society  the  cubs 
were  reared.  Associated  with  the  defect  in  food  is  a  lack  of  proper  assimila- 
tion of  the  lime  salts. 

Morbid  Anatomy. — The  bones  show  the  most  important  changes, 
particularly  the  ends  of  the  long  bones  and  the  ribs.     Between  the  shaft 


RICKETS.  435 

and  epiphyses  a  slight  bulging  is  apparent,  and  on  section  the  zone  of  pro- 
liferation, which  normally  is  represented  by  two  narrow  bands,  is  greatly 
thickened,  bluish  in  color,  more  irregular  in  outline,  and  very  much  softer. 
The  width  of  this  cushion  of  cartilage  varies  from  5  to  15  mm.  The  line 
of  ossification  is  also  irregular,  and  more  spongy  and  vascular  than  normal. 
The  periosteum  strips  ofE  very  readily  from  the  shaft,  and  beneath  it  there 
may  be  a  spongioid  tissue  not  unlike  decalcified  bone.  The  practical  out- 
come of  these  changes  is  a  delay  in,  and  imperfect  performance  of,  the 
ossification,  so  that  the  bone  has  neither  the  natural  rate  of  growth  nor  the 
normal  firmness.  In  the  cranium  there  may  be  large  areas,  particularly  in 
the  parieto-occipital  region,  in  which  the  ossification  is  delayed,  producing 
the  so-called  cranio-tabes,  so  that  the  bone  yields  readily  to  pressure  with 
the  finger.  There  are  localized  depressed  spots  of  atrophy,  which,  on 
pressure,  give  the  so-called  "  parchment  crackling."  Flat  hyperostoses  de- 
velop from  the  outer  table,  particularly  on  the  frontal  and  parietal  bones, 
and  produce  the  characteristic  broad  forehead  with  prominent  frontal  emi- 
nences, a  condition  sometimes  mistaken  for  hydrocephalus. 

Kassowitz,  the  leading  authority  on  the  anatomy  of  rickets,  regards 
the  hyperasmia  of  the  periosteum,  the  marrow,  the  cartilage,  and  of  the 
bone  itself  as  the  primary  lesion,  out  of  which  all  the  others  develop.  This 
disturbs  the  normal  development  of  the  growing  bone  and  excites  changes 
in  that  already  formed.  The  cartilage  cells  in  consequence  proliferate, 
the  matrix  is  softer,  and  as  a  result  the  bone  which  is  formed  from  this 
unhealthy  cartilage  is  lacking  in  firmness  and  solidity.  In  the  bone  already 
formed  this  excessive  vascularity  exaggerates  the  normal  processes  of  ab- 
sorption, so  that  the  relation  between  removal  and  deposition  is  disturbed, 
absorption  taking  place  too  rapidly.  The  new  material  is  poor  in  lime  salts. 
Kassowitz  has  proved  experimentally  that  hyperemia  of  bone  results  in 
defective  deposition  of  lime  salts.  It  is  interesting  to  note  that  Glisson 
attributed  rickets  to  disturbed  nutrition  by  arterial  blood,  and  believed 
the  changes  in  the  long  bones  to  be  due  to  excessive  vascularity. 

The  chemical  analysis  of  rickety  bones  shows  a  marked  diminution  in 
the  calcareous  salts,  which  may  be  as  low  as  25  or  35  per  cent. 

The  liver  and  spleen  are  usually  enlarged,  and  sometimes  the  mesen- 
teric glands.  As  Gee  suggests,  these  conditions  probably  result  from  the 
general  state  of  the  health  associated  with  rickets.  Beneke  has '  described 
a  relative  increase  in  the  size  of  the  arteries  in  rickets. 

Symptoms. — The  disease  comes  on  insidiously  about  the  period  of 
dentition,  before  the  child  begins  to  walk.  Mild  grades  of  it  are  often  over- 
looked in  the  families  of  the  well-to-do.  In  many  cases  digestive  disturb- 
ances precede  the  appearance  of  the  characteristic  lesions,  and  the  nutrition 
of  the  child  is  markedly  impaired.  There  is  usually  slight  fever,  the  child 
is  irritable  and  restless,  and  sleeps  badly.  If  he  has  already  walked,  he 
now  shows  a  marked  disinclination  to  do  so,  and  seems  feeble  and  unsteady 
in  his  gait.  Sir  William  Jenncr  has  called  attention  to  three  general  symp- 
toms of  great  importance:  First,  a  diffuse  soreness  of  the  body,  so  that 
the  child  cries  when  an  attempt  is  made  to  move  it,  and  prefers  to  keep 
perfectly  still.    This  is  often  a  marked  and  suggestive  symptom.    Secondly, 


436  CONSTITUTIONAL  DISEASES^ 

slight  fever  (100°  to  101.5°),  with,  nocturnal  restlessness,  and  a  tenden- 
cy to  throw  off  the  bedclothes.  This  may  he  partly  due  to  the  fact 
that  the  general  sensitiveness  is  such  that  even  their  weight  may  he  dis- 
tressing. And,  thirdly,  profuse  sweating,  particularly  about  the  head 
and  neck,  so  that  in  the  morning  the  pillow  is  found  soaked  with  perspi- 
ration. 

The  tissues  become  soft  and  flabby;  the  skin  is  pale;  and  from  a 
healthy,  plump  condition,  the  child  becomes  puny  and  feeble.  The  mus- 
cular weakness  may  be  marked,  particularly  in  the  legs,  and  paralysis  may 
be  suspected.  This  so-called  pseudo-paresis  of  rickets  results  in  part  from 
the  flabby,  weak  condition  of  the  legs  and  in  part  from  the  pain  associated 
with  the  movements.  Coincident  with,  or  following  closely  upon,  the  gen- 
eral s}Tnptoms  the  characteristic  skeletal  lesions  are  observed.  Among 
the  first  of  these  to  appear  are  the  changes  in  the  ribs,  at  the  Junction  of 
the  bone  with  the  cartilage,  forming  the  so-called  rickety  rosary.  When 
the  child  is  thin  these  nodules  may  be  distinctly  seen,  and  in  any  case  can 
be  easily  made  out  by  touch.  They  very  rarely  appear  before  the  third 
month.  They  may  increase  in  size  up  to  the  second  year,  and  are  rarely 
seen  after  the  fifth  year.  The  thorax  undergoes  important  changes.  Just 
outside  the  junction  of  the  cartilages  with  the  ribs  there  is  an  oblique, 
shallow  depression  extending  downward  and  outward.  A  transverse  curve, 
sometimes  called  Harrison's  groove,  passes  outward  from  the  level  of  the 
ensiform  cartilage  toward  the  axilla  and  may  be  deepened  at  each  inspira- 
tion. It  is  rendered  more  prominent  by  the  eversion  and  prominence  of 
the  costal  border.  The  sternum  projects,  particularly  in  its  lower  half, 
forming  the  so-called  pigeon  or  chicken  breast.  These  changes  in  the 
thorax  are  not  peculiar,  however,  to  rickets,  and  are  much  more  commonly 
associated  with  hypertrophy  of  the  tonsils,  or  any  trouble  which  interferes 
with  the  free  entrance  of  air  into  the  lungs.  The  spine  is  often  curved 
posteriorly,  the  processes  are  prominent;  lateral  curvature  is  not  so 
common. 

The  head  of  a  rickety  child  usually  looks  large  in  proportion  both  to 
the  body  and  the  face,  and  the  fontanelles  remain  open  for  a  long  time. 
There  are  areas,  particularly  in  the  parieto-occipital  regions,  in  which  ossi- 
fication is  imperfect;  and  the  bone  may  yield  to  the  pressure  of  the  finger, 
a  condition  to  which  the  term  cranio-tabes  has  been  given.  The  relation 
of  this  condition  to  rickets  is  still  somewhat  doubtful,  as  it  is  very  often 
associated  with  syphilis — in  47  of  100  cases  studied  by  George  Carpenter. 
Coincidently  with  this,  hyperplasia  proceeds  in  the  frontal  and  parietal 
eminences,  so  that  these  portions  of  the  skull  increase  in  thickness,  and 
may  form  irregular  bosses.  In  one  type  the  skull  may  be  large  and  elon- 
gated, with  the  top  considerably  flattened.  In  another,  and  perhaps  more 
common  case,  the  shape  of  the  skull,  when  seen  from  above,  is  rectangular 
— the  caput  quadratum.  The  skull  looks  large  in  proportion  to  the  face. 
The  forehead  is  broad  and  square,  and  the  frontal  eminences  marked.  The 
anterior  fontanelle  is  late  in  closing  and  may  remain  open  until  the  third 
or  fourth  year.  The  skin  is  thin,  the  veins  are  full  and  prominent,  and  the 
hair  is  often  rubbed  from  the  back  of  the  skull.    In  contradistinction  to  the 


X  RICKETS.  437 

craiiio-tabes  is  the  condition  of  cranio-sclerosis,  which  has  also  been  ascribed 
to  rickets. 

On  placing  the  ear  over  the  anterior  fontanelle,  or  in  the  temporal 
region,  a  systolic  murmur  may  frequently  be  heard.  This  condition,  first 
described  by  John  D.  Fisher,  of  Boston,  in  1833,  is  heard  with  the  greatest 
frequency  in  rickets,  but  its  presence  and  persistence  in  perfectly  healthy 
infants  have  been  amply  demonstrated.*  The  murmur  is  rarely  heard  after 
the  fifth  year.  A  knowledge  of  the  existence  of  this  systolic  brain  murmur 
may  prevent  errors.  A  case  in  which  it  was  well  marked  was  reported  as  an 
instance  of  supposed  gummy  tumor  of  the  brain,  in  which  the  murmur 
was  thought  to  be  due  to  pressure  on  the  vessels  at  the  base. 

Changes  occur  in  the  bones  of  the  face,  chiefly  in  the  maxilla,  which 
are  reduced  in  size.  The  normal  process  of  dentition  is  much  disturbed; 
indeed,  late  teething  is  one  of  the  marked  features  in  rickets.  The  teeth 
which  appear  may  be  small  and  badly  formed. 

In  the  upper  limbs  changes  in  the  scapulae  are  not  common.  The 
clavicle  may  be  thickened  at  the  sternal  end,  and  there  may  be  thickening 
near  the  attachment  of  the  sterno-cleido  muscle.  The  most  noticeable 
changes  are  at  the  lower  ends  of  the  radius  and  ulna.  The  enlargement 
is  at  the  junction-area  of  the  shaft  and  epiphysis.  Less  evident  enlarge- 
ments may  occur  at  the  lower  end  of  the  humerus.  In  severe  cases  the 
natural  shape  of  the  bones  of  the  arm  may  be  much  altered,  since  they  have 
had  to  support  the  weight  of  the  child  in  crawling  on  the  floor.  The 
changes  in  the  pelvis  are  of  special  importance,  particularly  in  female  chil- 
dren, as  in  extreme  cases  they  lead  to  great  deformity  and  narrowing  of  the 
outlet.  In  the  legs,  the  lower  end  of  the  tibia  first  becomes  enlarged;  and 
in  slight  cases  it  may  alone  be  affected.  In  the  severe  forms  the  upper  end 
of  the  bone,  the  corresponding  parts  of  the  fibula,  and  the  lower  end  of 
the  femur  become  greatly  thickened.  If  the  child  walks,  slight  bowing  of 
the  tibise  inevitably  results.  In  more  advanced  cases  the  tibia  and  even 
the  femora  may  be  arched  forward.  In  other  instances  the  condition  of 
knock-knee  occurs.  Unquestionably  the  chief  cause  of  these,  deformities  is 
the  weight  of  the  body  in  walking,  but  muscular  action  takes  part  in  it. 
The  green-stick  fracture  is  not  uncommon  in  the  soft  bones  of  rickets. 

These  changes  in  the  skeleton  proceed  slowly,  and  the  general  symp- 
toms vary  a  good  deal  with  their  progress.  The  child  becomes  more  or 
less  emaciated,  though  "  fat  rickets  "  is  by  no  means  uncommon,  and  a  child 
may  be  well  nourished  but  "  pasty  "  and  flabby.  Fever  is  not  constant,  but 
in  actively  progressing  changes  in  the  bone  there  is  usually  a  sliglit  pyrexia. 
The  abdomen  is  large,  "pot-bellied,"  due  partly  to  flatulent  distention, 
partly  to  enlargement  of  the  liver,  and  in  severe  cases  to  diminution  of 
the  volume  of  the  thorax.  The  spleen  is  often  enlarged  and  readily  pal- 
pable. The  urine  is  stated  to  contain  an  excess  of  lime  salts,  but  Jacobi 
and  Barlow  say  this  has  not  been  proved.  Ko  special  or  peculiar  changes, 
indeed,  have  as  yet  been  described.     There  is  usually  slight  anamia,  the 

*  Osier.  On  the  Systolic  Brain  Murmur  of  Children,  Boston  Medical  and  Surgical 
Journal,  1880. 


438  CONSTITUTIONAL  DISEASES. 

hsenioglobiii  is  absolutely  and  relatively  decreased;  a  leucocytosis  may  or  may 
not  be  present;  it  is  more  common  with  enlargement  of  the  spleen  (Morse). 
Many  rickety  children  show,  marked  nervous  symptoms;  irritability,  peev- 
ishness, and  sleeplessness  are  constantly  present.  Jenner  called  attention 
to  the  close  relationship  which  existed  between  rickets  and  infantile  con- 
vulsions, particularly  to  the  fits  which  occur  after  the  sixth  month.  Tetany 
is  by  no  means  uncommon.  It  involves  most  frequently  the  arms  and 
hands;  occasionally  the  legs  as  well.  Laryngismus  stridulus  is  a  common 
complication,  and  though  not,  as  some  state,  invariably  associated  with 
this  disease,  yet  it  is  certainly  much  more  frequent  in  rickety  than  in  other 
children.  Severe  rickets  interfere  seriously  with  the  growth  of  a  child. 
Extreme  examples  of  rickety  dwarfs  are  not  uncommon.  The  disease  known 
as  acute  rickets  is  in  reality  a  manifestation  of  scurvy  and  will  be  described 
with  that  disease.      _ 

Prognosis. — The  disease  is  never  in  itself  fatal,  but  the  condition  of 
the  child  is  such  that  it  is  readily  carried  off  by  intercurrent  affections, 
particularly  those  of  the  respiratory  organs.  Spasm  of  the  larynx  and 
convulsions  occasionally  cause  death.  In  females  the  deformity  of  the 
pelvis  is  serious,  as  it  may  lead  to  difficulties  in  parturition. 

Treatment. — The  better  the  condition  of  the  mother  during  preg- 
nancy the  less  likelihood  is  there  of  the  development  of  rickets  in  the 
child.  Eapidly  repeated  pregnancies  and  suckling  a  child  during  preg- 
nancy seem  important  factors  in  the  production  of  the  disease.  Of  the 
general  treatment,  attention  to  the  feeding  of  the  child  is  the  first  con- 
sideration. If  the  mother  is  unhealthy,  or  cannot  from  any  cause  nurse 
the  child,  a  suitable  wet-nurse  should  be  provided,  or  the  child  must  be 
artificially  fed.  Cows'  milk,  diluted  according  to  the  age  of  the  child, 
should  constitute  the  chief  food.  Care  should  be  taken  to  examine  the 
condition  of  the  stools,  and  if  curds  are  present  the  child  is  taking  too 
much,  or  it  is  not  sufficiently  diluted.  Barley-water  or  carefully  strained 
and  well-boiled  oatmeal  gruel  form  excellent  additions  to  the  milk. 

The  child  should  be  warmly  clad  and  should  be  in  the  fresh  air  and 
sunshine  the  greater  part  of  the  day.  It  is  a  "  vulgar  error  "  to  suppose 
that  delicate  children  cannot  stand,  when  carefully  wrapped  up,  an  even 
low  temperature.  The  child  should  be  bathed  daily  in  warm  water.  Care- 
ful friction  with  sweet  oil  is  very  advantageous,  and,  if  properly  performed, 
allays  rather  than  aggravates  the  sensitiveness.  Special  care  should  be 
taken  to  prevent  deformity.  The  child  should  not  be  allowed  to  walk,  and 
for  this  purpose  splints  applied  so  as  to  extend  beyond  the  feet  are  very 
effective.  Of  medicines,  phosphorus  has  been  warmly  recommended  by 
Kassowitz,  and  its  use  is  also  advised  by  Jacobi.  The  child  may  be  given 
gr.  yfg-  two  or  three  times  a  day,  dissolved  in  olive  oil.  The  best  prepara- 
tion in  such  cases  is  the  elixir  phosphori,  six  to  ten  or  twelve  minims  three 
times  a  day  (Jacobi).  Cod-liver  oil,  in  doses  of  from  a  half  to  one  teaspoon- 
ful,  is  very  advantageous.  The  syrup  of  the  iodide  of  iron  may  be  given 
with  the  oil.  The  digestive  disturbances,  together  with  the  respiratory  and 
nervous  complications,  should  receive  appropriate  treatment. 


OBESITY.  439 


VIII.  OBESITY. 

Corpulence,  an  excessive  development  of  the  bodily  fat— an  "  oily 
dropsy/'  in  the  words  of  Lord  Byron — is  a  condition  for  which  we  are 
consulted  in  three  groups  of  cases.  First,  there  are  persons  of  both  sexes 
who  have  an  hereditary  tendency  to  obesity.  Secondly,  in  this  country 
particularly,  there  is  an  increasing  number  of  cases  of  obesity  in  children, 
associated  with  bad  habits  in  eating,  and  usually  carelessness  and  lack  of 
control  on  the  part  of  the  parents.  Thirdly,  and  most  frequently,  we  are 
consulted  by  women  at  the  middle  period  of  life,  who  are  troubled  with 
an  over-growth  of  fat.  While  as  a  rule  fat  is  no  sign  of  health,  and  par- 
ticularly in  children  may  be  associated  with  angemia  and  rickets,  on  the 
other  hand  a  great  many  stout  persons  enjoy  unusual  vigor.  Nor  is  obesity 
always  associated  with  over-eating.  Many  stout  persons  are  light  eaters, 
and  chlorotic  girls  with  depraved  or  poor  appetites  may  be  very  plump. 
After  forty,  as  Sir  James  Paget  remarks,  we  tend  to  become  either  thin  or 
fat,  and  the  former  are  usually  happier  and  live  longer.  Too  much  food 
and  too  little  exercise  are  largely  responsible  in  about  half  of  the  cases, 
but  in  the  hereditary  ones  these  factors  do  not  prevail,  and  this  is  a  point 
to  be  borne  in  mind  very  carefully  in  the  question  of  treatment.  As  Duck- 
worth states,  gout  is  an  important  agent  in  many  instances. 

In  obesity  it  is  now  generally  conceded  that  the  carbohydrates,  which 
were  so  long  blamed,  are  not  at  fault,  since  they  are  themselves  converted 
into  water  and  carbon  dioxide.  On  account,  however,  of  the  facility  with 
which  they  are  utilized  for  the  purposes  of  oxidation,  the  albuminous  ele- 
ments of  the  food  are  less  readily  oxidized  and  not  so  fully  decomposed,  and 
the  fat  is  in  reality  separated  from  them.  So,  too,  the  fats  themselves  are 
not  so  prone  to  cause  obesity  as  the  carbohydrates,  being  less  readily  oxi- 
dized and  interfering  less  with  the  complete  metabolism  of  the  albuminous 
elements. 

An  extraordinary  phenomenon  seen  occasionally  in  excessively  fat  young 
persons  is  an  uncontrollable  tendency  to  sleep. 

Treatment. — We  must  bear  in  mind  at  the  outset  the  injunction  of 
Hippocrates  (Aphorism  III),  speaking  of  a  full  habit  of  body,  that  extreme 
depletions  are  dangerous,  and  that  the  reduction  must  not  be  carried  to 
an  extreme.  The  aphorism  of  the  celebrated  George  Cheyne  (whose  his- 
tory records  one  of  the  most  successful  instances  of  the  treatment  of 
obesity  in  literature),  quoted  at  page  470,  contains  the  essence  of  good 
sense  on  the  subject.  Put  in  other  words,  it  reads — We  eat  too  much  after 
forty  years  of  age. 

We  are  often  consulted  by  persons  in  whose  family  obesity  prevails  to  give 
rules  for  the  prevention  of  the  condition  in  children  or  in  women  approach- 
ing the  climacteric.  In  the  case  of  children  very  much  may  be  done  by 
regulating  the  diet,  reducing  the  starches  and  fats  in  the  food,  not  allow- 
ing the  children  to  eat  sweets,  and  encouraging  systematic  exercises.  In 
the  case  of  women  who  tend  to  grow  stout  after  child-bearing  or  at  the 
climacteric^  in  addition  to  systematic  exercises,  they  should  be  told  to  avoid 


440  CONSTITUTIONAL  DISEASES. 

taking  too  much  food,  and  particularly  to  reduce  the^  starches  and  sugars. 
There  are  a  number  of  methods  or  systems  in  vogue  at  present.  In  the 
celebrated  one  of  Banting,  the  carbohydrates  and  fats  were  excluded  and 
the  amount  of  food  was  greatly  reduced.    Ebstein  allows  more  fat. 

Oertel's  method  is  given  under  the  treatment  of  fatty  heart.  He  re- 
duces the  amount  of  liquid  taken,  and  this  is  practically,  too,  the  so-called 
Schweninger  cure,  in  which  liquids  are  allowed  only  two  hours  after  the 
food. 

Von  Noorden's  dietary,  given  in  his  exhaustive  article  in  ISTothnagel's 
Handbuch,  is  as  follows:  Eight  o'clock,  80  grammes  of  lean,  cold  meat,  25 
grammes  of  bread,  one  cup  of  tea,  with  a  spoonful  of  milk,  no  sugar.  Ten 
o'clock,  one  egg.  Twelve  o'clock,  a  cup  of  strong  meat  broth.  One  o'clock, 
a  small  plate  of  meat  soup  flavored  with  vegetables,  159  grammes  of  lean 
meat  of  one  or  two  sorts,  partly  fish,  partly  flesh,  100  grammes  of  potatoes 
with  salad,  100  grammes  of  fresh  fruit,  or  compote  without  sugar.  Three 
o'clock,  a  cup  of  black  cofi:ee.  Four  o'clock,  200  grammes  of  fresh  fruit. 
Six  o'clock,  a  quarter  of  a  litre  of  milk,  if  desired,  with  tea.  Eight  o'clock, 
125  grammes  of  cold  meat,  or  180  grammes  of  meat  weighed  raw  and 
grilled,  and  eaten  with  pickles  or  radishes  and  salad,  30  grammes  of 
Graham  bread,  and  two  or  three  spoonfuls  of  cooked  fruit  without  sugar. 
He  believes  it  more  satisfactory  to  give  in  addition  to  the  three  meals 
smaller  quantities  of  food  at  shorter  intervals,  so  as  to  obviate  the  tendency 
to  weakness  which  these  patients  often  experience.  In  addition  he  allows 
twice  in  the  day  a  glass  of  wine.  The  use  of  mineral  water,  weak  tea,  or 
lemonade  is  not  limited  at  the  meal  times  or  in  the  intervals. 

In  the  treatment  of  extreme  obesity  it  is  very  much  better  that  the 
patient  should  be  in  hospital,  or  under  the  care  of  a  nurse,  who  will  under- 
take the  proper  weighing  and  administration  of  the  food. 

The  thyroid  extract  should  be  used  only  in  a  systematic  "  cure."  Five 
grains  three  times  a  day  is  a  sufficient  dose.  In  conjunction  with  the  diet 
and  exercises,  it  is  useful,  but  it  should  not  be  ordered  indiscriminately 
to  fat  persons. 

Adiposis  Doloeosa  (Dercum's  Disease). 

"  A  disorder  characterized  by  irregular,  symmetrical  deposits  of  fatty 
masses  in  various  portions  of  the  body,  preceded  by  or  attended  with  pain." 
It  is  an  affection  of  women,  occurring  at  the  middle  period  of  life.  In 
association  with  neuralgic  pains,  fatty  swellings  occur  in  various  parts  of 
the  body.  The  bunches  of  fat  may  form  huge  masses,  pendulous,  and  of 
a  pultaceous  consistence.  They  do  not  occur  on  the  hands,  feet,  or  face. 
It  differs  from  other  forms  of  obesity  in  its  lumpy  distribution,  and  in 
the  nervous  disturbances  in  the  form  of  pains  and  parassthesias.  The 
nature  of  the  trouble  is  unknown. 

In  a  case  of  Burr's,  and  in  one  of  Dercum's,  the  thyroid  gland  showed 
atrophic  changes.  Dercum  tells  me  that  he  has  seen  improvement  from  the 
use  of  the  thyroid  extract,  and  in  one  case  there  was  a  complete  disappear- 
ance of  all  the  neuritis  symptoms,  and  a  great  diminution  in  the  size  of  the 
fatty  deposits. 


SECTION  V. 
DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


I.  DISEASES   OF  THE  MOUTH. 
STOMATITIS. 

(1)  Acute  Stomatitis. — Simple  or  erythematous  stomatitis,  the  com- 
monest form  of  inflammation  of  the  mouth,  results  from  the  action  of 
irritants  of  various  sorts.  It  is  frequent  at  all  ages.  In  children  it  is  often 
associated  with  dentition  and  with  gastro-intestinal  disturbance,  particu- 
larly in  ill-nourished,  unhealthy  subjects.  In  adults  it  may  follow  the  abuse 
of  tobacco  and  the  use  of  too  hot  or  too  highly  seasoned  food.  It  is  a  fre- 
quent concomitant  of  indigestion,  and  is  met  with  in  the  acute  specific 
fevers. 

The  affection  may  be  limited  to  the  gums  and  lips  or  may  extend  over 
the  whole  surface  of  the  mouth  and  include  the  tongue.  There  is  at  first 
superficial  redness  and  dryness  of  the  membrane,  followed  by  increased 
secretion  and  swelling  of  the  tongue,  which  is  furred,  and  indented  by  the 
teeth.  There  is  rarely  any  constitutional  disturbance,  but  in  children  there 
may  be  slight  elevation  of  temperature.  The  condition  is  sufficient  to 
cause  considerable  discomfort,  sometimes  amounting  to  actual  distress  and 
pain,  particularly  in  mastication. 

In  infants  the  mouth  should  be  carefully  sponged  after  each  feeding. 
A  mouth-wash  of  borax  or  the  glycerin  of  borax  may  be  used,  and  in  se- 
vere cases,  which  tend  to  become  chronic,  a  dilute  solution  of  nitrate  of 
silver  (3  or  4  grains  to  the  ounce)  may  be  applied. 

(2)  Aphthous  Stomatitis. — This  form,  also  known  as  follicular  or  vesicu- 
lar stomatitis,  is  characterized  by  the  presence  of  small,  slightly  raised 
spots,  from  2  to  4  mm.  in  diameter,  surrounded  by  reddened  areolae.  The 
spots  appear  first  as  vesicles,  which  rupture,  leaving  small  ulcers  with 
grayish  bases  and  bright-red  margins.  They  are  seen  most  frequently  on 
the  inner  surfaces  of  the  lips,  the  edges  of  the  tongue,  and  the  cheeks. 
They  are  seldom  present  on  the  mucous  membrane  of  the  pharynx.  This 
form  is  met  with  most  often  in  children  under  three  years.  It  may  occur 
either  as  an  independent  affection  or  in  association  with  any  one  of  the 
febrile  diseases  of  childhood  or  with  an  attack  of  indigestion.     The  crop 

441 


442  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  vesicles  comes  out  with  great  rapidity  and  the  little  ulcers  may  be  fully 
formed  within  twenty-four  hours.  The  child  complains  of  soreness  of  the 
mouth  and  takes  food  with  reluctance.  The  buccal  secretions  are  increased, 
and  the  breath  is  heavy,  but  not  foul.  The  constitutional  symptoms  are 
usually  those  of  the  disease  with  which  the  aphthae  are  associated.  The 
disease  must  not  be  confounded  with  thrush.  No  special  parasite  has  been 
found  in  connection  with  it.  It  is  not  a  serious  condition,  and  heals  rapidly 
with  the  improvement  of  the  constitutional  state.  In  severe  cases  it  may 
extend  to  the  pillars  of  the  fauces  and  to  the  pharynx,  and  produce  ulcers 
which  are  irritating  and  difficult  to  heal. 

Each  ulcer  should  be  touched  with  nitrate  of  silver  and  the  mouth 
should  be  thoroughly  cleansed  after  taking  food.  A  wash  of  chlorate  of 
potassium,  or  of  borax  and  glycerin,  may  be  used.  The  constitutional  symp- 
toms should  receive  careful  attention. 

Here  may  be  mentioned  a  curious  affection  which  has  been  ob- 
served chiefly  in  southern  Italy,  and  which  is  characterized  by  a  pearly- 
colored  membrane  with  induration,  immediately  beneath  the  tongue  on 
the  frsenum  (Eiga's  disease).  There  may  be  much  induration  and  ultimately 
ulceration.  It  occurs  in  both  healthy  and  cachetic  children,  usually  about 
the  time  of  the  eruption  of  the  first  teeth.    It  is  sometimes  epidemic. 

(3)  Ulcerative  Stomatitis. — This  form,  which  is  also  known  by  the 
names  of  fetid  stomatitis,  or  futrid  sore  mouth,  occurs  particularly  in  chil- 
dren after  the  first  dentition.  It  may  prevail  as  a  widespread  epidemic  in 
institutions  in  which  the  sanitary  conditions  are  defective.  It  has  been 
met  with  in  jails  and  camps.  Insufficient  and  unwholesome  food,  improper 
ventilation,  and  prolonged  damp,  cold  weather  seem  to  be  special  predis- 
posing causes.  Lack  of  cleanliness  of  the  mouth,  the  presence  of  carious 
teeth,  and  the  collection  of  tartar  around  them  favor  the  development  of 
the  disease.  The  affection  spreads  like  a  specific  disease,  but  the  microbe 
has  not  yet  been  isolated.  It  has  been  held  that  the  disease  is  the  same 
as  the  foot-and-mouth  disease  of  cattle,  and  that  it  is  conveyed  by  the  milk, 
but  there  is  no  positive  evidence  on  these  points.  Payne  suggests  that  the 
virus  is  identical  with  that  of  contagious  impetigo. 

The  morbid  process  begins  at  the  margin  of  the  gums,  which  become 
swollen  and  red,  and  bleed  readily.  Ulcers  form,  the  bases  of  which  are 
covered  with  a  grayish-white,  firmly  adherent  membrane.  In  severe  cases 
the  teeth  may  become  loosened  and  necrosis  of  the  alveolar  process  may 
occur.  The  ulcers  extend  along  the  gum-line  of  the  upper  and  lower 
jaws;  the  tongue,  lips,  and  mucosa  of  the  cheeks  are  usually  swollen,  but 
rarely  ulcerated.  There  is  salivation,  the  breath  is  foul,  and  mastication 
is  painful.  The  submaxillary  lymph-glands  are  enlarged.  An  exanthem 
often  develops  and  may  be  mistaken  for  measles.  The  constitutional  symp- 
toms are  often  severe,  and  in  institutions  death  sometimes  results  in  the 
case  of  debilitated  children. 

In  the  treatment  of  this  form  of  stomatitis  chlorate  of  potassium  has 
been  found  to  be  almost  specific.  It  should  be  given  in  doses  of  10  grains, 
three  times  a  day,  to  a  child,  and  to  an  adult  double  that  amount.  Locally 
it  may  be  used  as  a  mouth-wash,  or  the  powdered  salt  may  be  applied  di- 


STOMATITIS.  443 

rectly  to  the  ulcerated  surfaces.  When  there  is  much  fetor,  a  solution  of 
potassium  permanganate  may  be  used  as  a  wash,  and  an  application  of 
nitrate  of  silver  made  to  the  ulcers. 

There  are  several  other  varieties  of  ulcerative  sore  mouth,  which  differ 
entirely  from  this  form.  Ulcers  of  the  mouth  are  common  in  nursing 
women,  and  are  usually  seen  on  the  mucous  membrane  of  the  lips  and 
cheeks.  They  develop  from  the  mucous  follicles,  and  are  from  3  to  5  mm. 
in  diameter.  They  may  cause  little  or  no  inconvenience;  but  in  some  in- 
stances they  are  very  painful  and  interfere  seriously  with  the  taking  of 
food  and  its  mastication.  As  a  rule  they  heal  readily  after  the  application 
of  nitrate  of  silver,  and  the  condition  is  an  indication  for  tonics,  fresh  air, 
and  a  better  diet. 

Eecurring  outbreaks  of  an  herpetic,  even  pemphigoid,  stomatitis  are 
seen  in  neurotic  individuals  {stomatitis  neurotica  chronica,  Jacobi).  It  may 
precede  or  accompany  the  fatal  form  of  pemphigus  vegetans. 

Parrot  describes  the  occasional  appearance  in  the  new-born  of  small 
ulcers  symmetrically  placed  on  the  hard  palate  on  either  side  of  the  middle 
line.  They  are  met  with  in  very  debilitated  children.  The  ulcers  rarely 
heal;  usually  they  tend  to  increase  in  size,  and  may  involve  the  bone. 

Bednar's  aphthge  consist  of  small  patches  and  ulcers  on  the  hard  palate, 
caused  as  a  rule  in  young  infants  by  the  artificial  nipple  or  the  nurse's 
finger. 

(4)  Parasitic  Stomatitis  {Thrush;  Soor;  Muguet). — This  affection,  most 
commonly  seen  in  children,  is  dependent  upon  a  fungus,  the  saccharomyces 
albicans,  called  by  Kobin  the  oidium  albicans.  It  belongs  to  the  order  of 
yeast  fungi,  and  consists  of  branching  filaments,  from  the  ends  of  which 
ovoid  torula  cells  develop.  The  disease  does  not  arise  apparently  in  a  nor- 
mal mucosa.  The  use  of  an  improper  diet,  uncleanliness  of  the  mouth, 
the  acid  fermentation  of  remnants  of  food,  or  the  development,  from  any 
cause,  of  catarrhal  stomatitis  predispose  to  the  growth  of  the  fungus.  In 
institutions  it  is  frequently  transmitted  by  unclean  feeding-bottles,  spoons, 
etc.  It  is  not  confined  to  children,  but  is  met  with  in  adults  in  the  final 
stages  of  fever,  in  chronic  tuberculosis,  diabetes,  and  in  cachectic  states. 
The  parasite  develops  in  the  upper  layers  of  the  mucosa,  and  the  filaments 
form  a  dense  felt-work  among  the  epithelial  cells.  The  disease  begins  on 
the  tongue  and  is  seen  in  the  form  of  slightly  raised,  pearly-white  spots, 
which  increase  in  size  and  gradually  coalesce.  The  membrane  thus  formed 
can  be  readily  scraped  off,  leaving  an  intact  mucosa,  or,  if  the  process  ex- 
tends deeply,  a  bleeding,  slightly  ulcerated  surface.  The  disease  spreads  to 
the  cheeks,  lips,  and  hard  palate,  and  may  involve  the  tonsils  and  pharynx. 
In  very  severe  cases  the  entire  buccal  mucosa  is  covered  by  the  grayish- 
white  membrane.  It  may  even  extend  into  the  oesophagus  and,  according 
to  Parrot,  to  the  stomach  and  Cfficum.  It  is  occasionally  met  with  on  the 
vocal  cords.  Eobust,  well-nourished  children  are  sometimes  affected,  but 
it  is  usually  met  with  in  enfeebled,  emaciated  infants  with  digestive  or  in- 
testinal troubles.    In  such  cases  the  disease  may  persist  for  months. 

The  affection  is  readily  recognized,  and  must  not  be  confounded  with 


444  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

aplittioTis  stomatitis,  in  whicli  the  ulcers,  preceded  by  the  formation  of 
vesicles,  are  perfectly  distinctive.  In  thrush  the  microscopical  examination 
sho-ws  the  presence  of  the  characteristic  fungus  throughout  the  membrane; 
In  this  condition,  too,  the  mouth  is  usually  dry — a  striking  contrast  to 
the  salivation  accompanying  aphthae. 

Thrush  is  more  readily  prevented  than  removed.  The  child's  mouth 
should  be  kept  scrupulously  clean,  and,  if  artificially  fed,  the  bottles  should 
be  thoroughly  sterilized.  Lime-water  or  any  other  alkaline  tluid,  such  as 
the  bicarbonate  of  soda  (a  drachm  to  a  tumbler  of  water),  may  be  em- 
ployed. When  the  patches  are  present  these  alkaline  mouth-washes  may 
be  continued  after  each  feeding.  A  spray  of  borax  or  of  sulphite  of  soda 
(a  drachm  to  the  ounce)  or  the  black  wash  with  glycerin  may  be  employed. 
The  permanganate  of  potassium  is  also  useful.  The  constitutional  treat- 
ment is  of  equal  importance,  and  it  will  often  be  found  that  the  thrush 
persists,  in  spite  of  all  local  measures,  until  the  general  health  of  the  infant 
is  improved  by  change  of  air  or  the  relief  of  the  diarrhoea,  or,  in  obstinate 
cases,  the  substitution  of  a  natural  for  the  artificial  diet. 

(5)  Gangrenous  Stomatitis  [Cancrum  Oris;  Noma). — An  affection 
characterized  by  a  rapidly  progressing  gangrene,  starting  on  the  gums  or 
cheeks,  and  leading  to  extensive  sloughing  and  destruction.  This  terrible, 
but  fortunately  rare,  disease  is  seen  only  in  children  under  very  insanitary 
conditions  or  during  convalescence  from  the  acute  fevers.  It  is  more 
common  in  girls  than  in  boys.  It  is  met  with  between  the  ages  of  two 
and  five  years.  In  at  least  one  half  of  the  cases  the  disease  has  developed 
during  convalescence  from  measles.  Cases  have  been  seen  also  after  scar- 
let fever  and  typhoid.  The  mucous  membrane  is  first  affected,  usually  of 
the  gums  or  of  one  cheek.  The  process  begins  insidiously,  and  when  first 
seen  there  is  a  sloughing  ulcer  of  the  mucous  membrane,  which  spreads  rap- 
idly and  leads  to  brawny  induration  of  the  skin  and  adjacent  parts.  The 
sloughing  extends,  and  in  severe  cases  the  cheek  is  perforated.  The  disease 
may  spread  to  the  tongue  and  chin;  it  may  invade  the  bones  of  the  jaws  and 
even  involve  the  eyelids  and  ears.  In  mild  cases  an  ulcer  forms  on  the  inner 
surface  of  the  cheek,  which  heals  or  may  perforate  and  leave  a  fistulous  open- 
ing. Naturally  in  such  a  severe  affection  the  constitutional  disturbance 
is  very  great,  the  pulse  is  rapid,  the  prostration  extreme,  and  death  usually 
takes  place  within  a  week  or  ten  days.  The  temperature  may  reach  103°  or 
104°.  Diarrhoea  is  usually  present,  and  aspiration  pneumonia  often  de- 
velops. H.  E.  Wharton  has  described  a  case  in  which  there  was  extensive 
colitis.  Bishop  and  Eyan  have  isolated  an  organism  which  resembles  in 
all  points  the  diphtheria  bacillus  of  reduced  virulence. 

The  treatment  of  the  disease  is  unsatisfactory.  In  many  cases  the 
onset  is  so  insidious  that  there  is  an  extensive  sloughing  sore  when  the  case 
first  comes  under  observation.  Destruction  of  the  sore  by  the  cautery, 
either  the  Paquelin  or  fuming  nitric  acid,  is  the  most  effectual.  Antiseptic 
applications  shoidd  be  made  to  destroy  the  fetor.  The  child  should  be 
carefully  nourished  and  stimulants  given  freely. 

(6)  Mercurial  Stomatitis  (PtyaKsm). — An  inflammation  of  the  mouth 
and  salivary  glands  may  be  caused  by  mercury.     It  occurs  chiefly  in  persons 


STOMATITIS.  445 

who  have  a  special  susceptibility,  and  rarely  now  as  a  result  of  the  excessive 
use  of  the  drug.  It  is  met  with  also  in  persons  whose  occupation  neces- 
sitates the  constant  handling  of  mercury.  It  often  follows  the  adminis- 
tration of  repeated  small  doses.  Thus,  a  patient  with  heart-disease  who 
was  ordered  an  eighth  of  a  grain  of  calomel  every  three  hours  for  diuretic 
purposes  had,  after  taking  eight  or  ten  doses,  a  severe  stomatitis,  which 
persisted  for  several  weeks.  I  have  known  it  to  follow  the  administra- 
tion of  small  doses  of  gray  powder.  The  patient  complains  first  of  a  metallic 
taste  in  the  mouth,  the  gums  become  swollen,  red,  and  sore,  mastication 
is  difficult,  and  soon  there  is  a  great  increase  in  the  secretion  of  the  saliva, 
which  flows  freely  from  the  mouth.  The  tongue  is  swollen,  the  breath  has 
a  foul  odor,  and,  if  the  affection  progresses,  there  may  be  ulceration  of  the 
mucosa,  and,  in  rare  instances,  necrosis  of  the  jaw.  Although  trouble- 
some and  distressing,  the  disease  is  rarely  serious,  and  recovery  usually 
takes  place  in  a  couple  of  weeks.  Instances  in  which  the  teeth  become 
loosened  or  detached  or  in  which  the  inflammation  extends  to  the  pharynx 
and  Eustachian  tubes  are  rarely  seen  now. 

The  administration  of  mercury  should  be  suspended  so  soon  as  the 
gums  are  "  touched.^'  Mild  cases  of  the  affection  subside  within  a  few  days 
and  require  only  a  simple  mouth-wash.  In  severer  cases  the  chlorate  of  po- 
tassium may  be  given  internally,  and  used  to  rinse  the  mouth.  The  bowels 
should  be  freely  opened;  the  patient  should  take  a  hot  bath  every  evening 
and  should  drink  plentifully  of  alkaline  mineral  waters.  Atropine  is  some- 
times serviceable,  and  may  be  given  in  doses  of  j^  of  a  grain  twice  a  day. 
Iodine  is  also  recommended.  When  the  salivation  is  severe  and  protracted, 
the  patient  becomes  much  debilitated,  angemia  develops,  and  a  supporting 
treatment  is  indicated.  The  diet  is  necessarily  liquid,  for  the  patient  finds 
the  chief  difficulty  in  taking  food.  If  the  pain  is  severe  a  Dover  powder 
may  be  given  at  night. 

Here  may  be  appropriately  mentioned  the  influence  of  stomatitis,  par- 
ticularly- the  mercurial  form,  upon  the  developing  teeth  of  children.  The 
condition  known  as  erosion,  in  which  the  teeth  are  honeycombed  or  pitted 
owing  to  defective  formation  of  enamel,  is  indicative,  as  a  rule,  of  infantile 
stomatitis.  Such  teeth  must  be  distinguished  carefully  from  those  of  con- 
genital syphilis,  which  may  of  course  coexist,  but  the  two  conditions  are 
distinct.  The  honeycombing  is  frequently  seen  on  the  incisors;  but,  ac- 
cording to  Jonathan  Hutchinson,  the  test  teeth  of  infantile  stomatitis  are 
the  first  permanent  molars,  then  the  incisors,  "which  are  almost  as  con- 
stantly pitted,  eroded,  and  of  bad  color,  often  showing  the  transverse  fur- 
row which  crosses  all  the  teeth  at  the  same  level."  Magitot  regards  these 
transverse  furrows  as  the  result  of  infantile  convulsions  or  of  severe  illness 
during  early  life.  He  thinks  they  are  analogous  to  the  furrows  on  the 
nails  whicli  so  often  follow  a  serious  disease. 

(7)  Eczema  of  the  Tongue  (Geographical  Tongue). — A  remarkable 
desquamation  of  the  superficial  epithelium  of  the  tongue  in  circinate 
patches,  which  spread  while  the  central  portions  heal.  Fusion  of  patcbcs 
leads  to  areas  with  sinnons  outlines.  When  extensive  the  tongue  may  bo 
covered  with  these  areas,  like  a  geographical  map.     The  affection  causes  a 


446  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

good  deal  of  itching  and  heat,  and  may  be  a  source  of  much  mental  worry 
to  the  patients,  who  often  dread  lest  it  may  be  a  commencing  cancer. 

The  etiology  of  the  disease  is  unknown.  It  occurs  in  infants  and  chil- 
dren, and  it  is  not  very  infrequent  in  adults.  It  has  been  regarded  as  a 
gouty  manifestation,  and  transient  attacks  may  accompany  indigestion. 
It  is  very  liable  to  relapse.  In  adults  it  may  prove  very  obstinate,  and  I 
know  of  one  instance  in  which  the  disease  persisted  in  spite  of  all  treat- 
ment for  more  than  two  years.  Solutions  of  nitrate  of  silver  give  the  most 
satisfactory  results  in  relieving  the  intense  burning. 

(8)  Leukoplakia  buccalis. — Samuel  Plumbe  described  the  condition  as 
idliyosis  lingualce.  It  has  also  been  called  buccal  psoriasis  and  Tceratosis 
mucosce  oris.  There  are  unsymmetrical  patches  of  various  shapes,  whitish 
or  often  pearly  white  in  color,  smooth,  and  without  any  tendency  to  ulcer- 
ate. They  have  been  called  lingual  corns.  The  intensity  of  the  opaque 
white  color  depends  upon  the  thickness  of  the  epidermis.  The  patches 
may  extend  and  become  slightly  papillomatous.  There  are  instances  in 
which  genuine  epithelioma  has  developed  from  them.  The  condition  is 
met  with  most  commonly  in  heavy  smokers,  and  is  sometimes  known  as 
the  smoker's  tongue.  An  interesting  question  is  the  relation  to  syphilis. 
While  somewhat  similar  patches  develop  in  infected  persons,  the  true 
syphilitic  glossitis  rarely  presents  the  same  opaque  white,  smooth  appear- 
ance. It  is  more  commonly  at  the  edge  and  the  point  of  the  tongue  than 
on  the  dorsum,  and  yields  promptly  to  specific  treatment. 

Leukoplakia  is  a  very  obstinate  affection  and  resists  as  a  rule  all  forms 
of  treatment.  All  irritants,  such  as  smoke  and  very  hot  food,  should  be 
avoided.  Local  treatment  with  one-half-per-cent  corrosive  sublimate  or  a 
one-per-cent  chromic-acid  solution  has  been  recommended.  The  propriety 
of  active  local  treatment  is  doubtful.  The  appearance  of  anything  like 
papillomatous  outgrowths  should  be  regarded  as  an  indication  for  surgical 
intervention. 


II.    DISEASES   OF  THE  SALIYAEY  GLAKDS. 

1.  Supersecretion  (Ptyalism). — The  normal  amount  of  saliva  varies 
from  2  to  3  pints  in  the  twenty-four  hours.  The  secretion  is  increased 
during  the  taking  of  food  and  in  the  physiological  processes  of  dentition. 
A  great  increase,  to  which  the  term  ptyalism  is  applied,  is  met  with  under 
many  circumstances.  It  occurs  occasionally  in  mental  and  nervous  affec- 
tions and  in  rabies.  Occasionally  it  is  seen  in  the  acute  fevers,  particularly 
in  small-pox.  It  occurs  sometimes  with  disease  of  the  pancreas.  It  has 
been  met  with  during  gestation,  usually  early,  though  it  may  persist 
throughout  the  entire  course.  It  has  been  known  to  occur  at  each  men- 
strual period;  and,  lastly,  it  is  a  common  effect  of  certain  drugs.  Mercury, 
gold,  copper,  the  iodine  compounds,  and  (among  vegetable  remedies) 
jaborandi,  muscarin,  and  tobacco  excite  the  salivary  secretion.  Of  these 
we  most  frequently  see  the  effect  of  mercury  in  producing  ptyalism.  The 
salivation  may  be  present  without  any  inflammation  of  the  mouth. 


DISEASES  OF  THE  SALIVARY  GLANDS.  447 

2.  Xerostomia  {Arrest  of  the  Salivary  and  Buccal  Secretions;  Dry 
Mouth). — In  this  condition,  first  described  by  Jonathan  Hutchinson,  the 
secretions  of  the  mouth  and  salivary  glands  are  suppressed.  The  tongue 
is  red,  sometimes  cracked,  and  quite  dry;  the  mucous  membrane  of  the 
cheeks  and  of  the  palate  is  smooth,  shining,  and  dry;  and  mastication, 
deglutition,  and  articulation  are  very  difficult.  The  condition  is  not  com- 
mon. A  majority  of  the  cases  are  in  women,  and  in  several  instances  have 
been  associated  with  nervous  phenomena.  The  general  health,  as  a  rule, 
is  unimpaired.  Hadden  suggests  that  it  is  due  to  involvement  of  some 
centre  which  controls  the  secretion  of  the  salivary  and  buccal  glands.  A 
Avell-marked  case  came  under  my  observation  in  a  man  aged  thirty-two, 
who  was  sent  to  me  by  Donald  Baynes  on  account  of  a  peculiar  growth 
in  the  mouth.  This  proved  to  be  the  remnants  of  food  which,  owing  to 
the  absence  of  any  salivary  or  buccal  secretions,  collected  along  the  gums, 
became  hardened,  and  adhered  to  them.  The  condition  lasted  for  three 
weeks,  and  was  cured  by  the  galvanic  current. 

3.  Inflammation  of  the  Salivary  Glands. 
(a)  Specific  Parotitis.    (See  Mumps.) 

(6)  Symptomatic  parotitis  or  parotid  huho  occurs: 

(1)  In  the  course  of  the  infectious  fevers — typhus,  typhoid,  pneumonia, 
pysemia,  etc.  In  ordinary  practice  it  occurs  oftenest,  perhaps,  in  typhoid 
fever.  It  is  the  result  either  of  septic  infection  through  the  blood,  or  the 
inflammation,  in  many  cases,  passes  up  the  salivary  duct,  and  so  reaches 
the  gland.  The  process  is  usually  very  intense  and  leads  rapidly  to  sup- 
puration. It  is,  as  a  rule,  an  unfavorable  indication  in  the  course  of  a  fever. 
Parotitis  may  occur  in  secondary  syphilis. 

(2)  In  connection  with  injury  or  disease  of  the  abdomen  or  pelvis,  a 
condition  to  which  Stephen  Paget  has  called  special  attention.  Of  101 
cases  of  this  kind,  "  10  followed  injury  or  disease  of  the  urinary  tract,  18 
were  due  to  injury  or  disease  of  the  alimentary  canal,  and  23  were  due  to 
injury  or  disease  of  the  abdominal  wall,  the  peritoneum,  or  the  pelvic 
cellular  tissue.  The  remaining  50  were  due  to  injury,  disease,  or  tempo- 
rary derangement  of  the  genital  organs."  By  temporary  derangement  is 
meant  slight  injuries  or  natural  processes — a  slight  blow  on  the  testis,  the 
introduction  of  a  pessary,  menstruation,  or  pregnancy.  The  etiology  of 
this  form  of  parotitis  is  obscure.  We  have  had  3  cases.  Many  of  them 
are  undoubtedly  septic. 

(3)  In  association  with  facial  paralysis,  as  in  a  case  of  fatal  peripheral 
neuritis  described  by  Gowers. 

In  the  treatment  of  parotid  bubo  the  application  of  half  a  dozen  leeches 
will  sometimes  reduce  the  inflammation  and  promote  resolution.  When 
suppuration  seems  inevitable  hot  fomentations  should  be  applied.  A  free 
incision  should  be  made  early. 

(c)  Chronic  parotitis,  a  condition  in  which  the  glands  are  enlarged, 
rarely  painful,  may  follow  inflammation  of  the  throat  or  mumps.  Sali- 
vation may  be  present.  It  may  be  due  to  lead,  mercury,  or  potassium 
iodide.  It  occurs  also  in  chronic  Bright's  disease  and  in  secondary  syphilis. 
Mikulicz  has  described  a  remarkable  condition  of  chronic  symmetrical  en- 
28 


4AS  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

largement  of  the  salivary  and  lachrymal  glands.  The  condition  may  per- 
sist for  years.  The  case  under  my  care  mentioned  in  the  second  edition 
of  this  work  died  subsequently  of  tuberculosis  (Am.  Jr.  Med.  Sci.,  Janu- 
ary, 1898). 

(d)  Gaseous  Tumors  of  Steno's  Duct  and  of  tJie  Parotid  Gland. — In 
glass-blowers  and  musicians  Steno's  duct  may  become  inflated  with  air 
and  form  a  tumor  the  size  of  a  nut  or  of  an  egg.  Some  have  contained  a 
mixture  of  air,  saliva,  and  pus.  In  rare  cases  there  are  gaseous  tumors  of 
the  glands,  which  give  a  sensation  of  crepitation  on  palpation. 


III.    DISEASES   OF  THE  PHAKT:N'X. 

(1)  Circulatory  Disturbances. — (a)  Hypercsmia  is  a  common  condition 
in  acute  and  chronic  affections  of  the  throat,  and  is  frequently  seen  as  a 
result  of  irritation  from  tobacco  smoke.  Venous  stasis  is  seen  in  valvular 
disease  of  the  heart,  and  in  mechanical  obstruction  of  the  superior  vena 
cava  by  tumor  or  aneurism.  In  aortic  insufficiency  the  capillary  pulse  may 
sometimes  be  seen  and  the  intense  throbbing  of  the  internal  carotid  may 
be  mistaken  for  aneurism. 

(h)  HcemorrJiage  is  found  in  association  with  bleeding  from  other  mucous 
surfaces,  or  it  is  due  to  local  causes  in  the  pharynx  itself.  In  the  latter 
ease  it  may  be  mistaken  for  hsemorrhage  from  the  lungs  or  stomach.  The 
bleeding  may  come  from  granulations  or  vegetations  in  the  naso-pharynx. 
Sometimes  the  patient  finds  the  pillow  stained  in  the  morning  with  bloody 
secretion.  The  condition  is  rarely  serious,  and  only  requires  suitable  local 
treatment  of  the  phar5'nx.  Occasionally  a  haemorrhage  takes  place  into 
the  mucosa,  producing  a  pharyngeal  hgematoma.  I  have  thrice  seen  a 
condition  of  the  uvula  resembling  hsemorrhagic  infarction.  One  was  in  a 
patient  with  acute  rheumatism,  to  whom  large  doses  of  salicylic  acid  had 
been  given;  the  other  two  were  instances  of  peliosis  rheumatica,  in  both 
■  of  which  partial  sloughing  of  the  uvula  took  place. 

(c)  (Edema. — An  infiltrated  oedematous  condition  of  the  uvula  and 
adjacent  parts  is  not  very  uncommon  in  conditions  of  debility,  in  profound 
anamia,  and  in  Bright's  disease.  The  uvula  is  sometimes  from  this  cause 
enormously  enlarged,  whence  may  arise  difficulty  in  swallowing  or  in 
breathing. 

(2)  Acute  Pharyngitis  (Sore  Tliroat;  Angina  Simplex). — The  entire 
pharyngeal  structures,  often  with  the  tonsils,  are  involved.  The  condition 
may  follow  cold  or  exposure.  In  other  instances  it  is  associated  with  con- 
stitutional states,  such  as  rheumatism  or  gout,  or  with  digestive  disorders. 
The  patient  complains  of  uneasiness  and  soreness  in  swallowing,  of  a  feel- 
ing of  tickling  and  dryness  in  the  throat,  together  with  a  constant  desire 
to  hawk  and  cough.  Trequently  the  inflammation  extends  into  the  lar3'nx 
and  produces  hoarseness.  Not  uncommonly  it  is  only  part  of  a  general 
naso-pharyngeal  catarrh.  The  process  may  pass  into  the  Eustachian  tubes 
and  cause  slight  deafness.  There  is  stiffness  of  the  neck,  the  Ivmph-glands 
of  which  may  be  enlarged  and  painful.     The  constitutional  symptoms  are 


DISEASES  OP  THE   PHARYNX.  449 

rarely  severe.  The  disease  sets  in  with  a  chilly  feeling  and  slight  fever; 
the  pulse  is  increased  in  frequency.  Occasionally  the  febrile  symptoms 
are  more  severe,  particularly  if  the  tonsils  are  specially  involved.  The  ex- 
amination of  the  throat  shows  general  congestion  of  the  mucous  membrane, 
which  is  dry  and  glistening,  and  in  places  covered  with  sticky  secretion. 
The  uvula  may  be  much  swollen. 

Acute  pharyngitis  lasts  only  a  few  days  ^nd  requires  mild  measures. 
If  the  tonsils  are  involved  and  the  fever  is  high,  aconite  or  sodium  salicylate 
may  be  given.  Guaiacum  also  is  beneficial;  but  in  a  majority  of  the  cases 
a  calomel  purge  or  a  saline  aperient  and  inhalations  with  steam  meet  the 
indications. 

(3)  Chronic  Pharyngitis. — This  may  follow  repeated  acute  attacks.  It 
is  very  common  in  persons  who  smoke  or  drink  to  excess,  and  in  those 
who  use  the  voice  very  much,  such  as  clergymen,  hucksters,  and  others. 
It  is  frequently  met  with  in  chronic  nasal  catarrh.  The  naso-pharynx  and 
the  posterior  wall  are  the  parts  most  frequently  affected.  The  mucous 
membrane  is  relaxed,  the  venules  are  dilated,  and  roundish  bodies,  from 
2  to  4  mm.  in  diameter,  reddish  in  color,  project  to  a  variable  distance 
beyond  the  mucous  membrane.  These  represent  the  proliferations  of  lymph 
tissue  about  the  mucous  glands.  They  may  be  very  abundant,  forming 
elongated  rows  in  the  lateral  walls  of  the  pharynx.  With  this  there  may 
be  a  dry  glistening  state  of  the  pharyngeal  mucosa,  sometimes  known  as 
pharyngitis  sicca.  The  pillars  of  the  fauces  and  the  uvula  are  often  much 
relaxed.  The  secretion  forms  at  the  back  of  the  pharynx  and  the  patient 
may  feel  it  drop  down  from  the  vault,  or  it  is  tenacious  and  adherent,  and 
is  only  removed  by  repeated  efforts  at  hawking. 

In  the  treatment,  special  attention  must  be  paid  to  the  general  health. 
If  possible,  the  cause  should  be  ascertained.  The  condition  is  almost 
constant  in  smokers,  and  cannot  be  cured  without  stopping  the  use  of 
tobacco.  The  use  of  food  either  too  hot  or  too  much  spiced  should  be  for- 
bidden. AYlien  it  depends  upon  excessive  exercise  of  the  voice,  rest  should 
be  enjoined.  In  many  of  these  cases  change  of  air  and  tonics  help  very 
much.  In  the  local  treatment  of  the  throat  gargles,  washes,  and  pastilles 
of  various  sorts  give  temporary  relief,  but  when  the  hypertrophic  condi- 
tion is  marked  the  spots  should  be  thoroughly  destroyed  by  the  galvano- 
cautery.  In  many  instances  this  affords  great  and  permanent  relief,  but 
in  others  the  condition  persists,  and  as  it  is  not  unbearable,  the  patient 
gives  up  all  hope  of  permanent  relief. 

(4)  Ulceration  of  the  Pharynx. — (a)  Follicular.  The  ulcers  are  usually 
small,  superficial,  and  generally  associated  with  chronic  catarrh. 

(h)  Syphilitic  ulcers  are  usually  painless,  and  most  frequently  situated 
on  the  posterior  wall  of  the  pharynx.  They  occur  in  the  secondary  stage 
as  small,  shallow  excavations  with  the  mucous  patches.  In  the  tertiary 
stage  the  ulcers  are  due  to  erosion  of  gummata,  and  in  liealing  they  leave 
whitish  cicatrices. 

(c)  Tuberculous  ulceration  is  not  very  uncommon  in  advanced  cases 
nf  pbthisis,  and,  if  extensive,  is  one  of  the  most  distressing  features  of  the 
later  stages  of  the  disease.    The  ulcers  are  irregular,  with  ill-defined  edges 


450  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  grayish-yellow  bases.  The  posterior  wall  of  the  pharynx  may  have  an 
eroded,  worm-eaten  appearance.  These  ulcers  are,  as  a  rule,  intensely  pain- 
ful. Occasionally  the  primary  disease  is  about  the  tonsils  and  the  pillars 
of  the  fauces. 

(d)  Ulcers  occur  in  connection  with  pseudo-membranous  inflammation, 
particularly  the  diphtheritic.    In  cancer  and  in  lupus  ulcers  are  also  present. 

(e)  Ulcers  are  met  with  in  certain  of  the  fevers,  particularly  in  typhoid. 
In  many  instances  the  diagnosis  of  the  nature  of  pharyngeal  ulcers  is 

very  difficult.  The  tuberculous  and  cancerous  varieties  are  readily  recog- 
nized, but  it  happens  not  infrequently  that  a  doubt  arises  as  to  the  syph- 
ilitic character  of  an  ulcer.  In  many  instances  the  local  conditions  may 
be  uncertain.  Then  other  evidences  of  syphilis  should  be  sought  for, 
and  the  patient  should  be  placed  on  mercury  and  iodide  of  potassium, 
under  which  remedies  syphilitic  ulcers  usually  heal  with  great  rapidity. 

(5)  Acute  Infectious  Phlegmon  of  the  Pharynx. — Under  this  term 
Senator  has  described  cases  in  which,  along  with  difficulty  in  swallowing, 
soreness  of  the  throat,  and  sometimes  hoarseness,  the  neck  enlarges,  the 
pharyngeal  mucosa  becomes  swollen  and  injected,  the  fever  is  high,  the 
constitutional  symptoms  are  severe,  and  the  inflammation  passes  on  rap- 
idly to  suppuration.  The  symptoms  are  very  intense.  The  swelling  of  the 
pharyngeal  tissues  early  reaches  such  a  grade  as  to  impede  respiration.  Very 
similar  symptoms  may  be  produced  by  foreign  bodies  in  the  pharynx. 

(6)  Retro-pharyngeal  abscess  occurs:  (1)  In  healthy  children  between 
six  months  and  two  years  of  age.  The  child  becomes  restless,  the  voice 
changes;  it  becomes  nasal  or  metallic  in  tone,  and  there  are  pain  and  diffi- 
culty in  swallowing.  Inspection  of  the  pharynx  reveals  a  projecting  tumor 
in  the  middle  line,  or  if  it  be  not  visible,  it  is  readily  felt,  on  palpation,  pro- 
jecting from  the  posterior  wall.  This  form  has  been  carefully  described  by 
Koplik.  (2)  As  a  not  infrequent  sequel  of  the  fevers,  particularly  of  scarlet 
fever  and  diphtheria.     (3)  In  caries  of  the  bodies  of  the  cervical  vertebrae. 

The  diagnosis  is  readily  made,  as  the  projecting  tumor  can  be  seen,  or 
felt  with  the  finger  on  the  posterior  wall  of  the  pharynx. 

(7)  Angina  Ludovici  {Ludwig's  Angina;  Cellulitis  of  the  Neck). — In 
medical  practice  this  is  seen  as  a  secondary  inflammation  in  the  specific 
fevers,  particularly  diphtheria  and  scarlet  fever.  It  may,  however,  occur 
idiopathically  or  result  from  trauma.  It  is  probably  always  a  streptococcus 
infection  which  spreads  rapidly  from  the  glands.  The  swelling  at  first  is 
most  marked  in  the  submaxillary  region  of  one  side.  The  symptoms  are, 
as  a  rule,  intense,  and,  unless  early  and  thorough  surgical  measures  are  em- 
ployed, there  is  great  risk  of  systemic  infection.  Felix  Semon  holds  that 
the  various  acute  septic  inflammations  of  the  throat — acute  oedema  of  the 
larynx,  phlegmon  of  the  pharynx  and  larynx,  and  angina  Ludovici — 
"  represent  degrees  varying  in  virulence  of  one  and  the  same  process." 


ACUTE  TONSILLITIS.  451 

lY.   DISEASES   OF  THE  TONSILS. 
ACUTE  TONSILLITIS. 

(1)  Follicular  or  Lacunar  Tonsillitis. — For  practical  purposes,  under 
this  name  may  be  described  the  various  forms  which  have  been  called  ca- 
tarrhal, erythematous,  ulcero-membranous,  and  herpetic. 

Etiology. ^The  disease  is  met  with  most  frequently  in  young  persons, 
but  in  children  under  ten  it  is  less  common  than  the  chronic  form.  It  is 
rare  in  infants.  Sex  has  no  special  influence.  Exposure  to  wet  and  cold, 
and  bad  hygienic  surroundings  appear  to  have  a  direct  etiological  connec- 
tion with  the  disease.  In  so  many  instances  defective  drainage  has  been 
found  associated  with  outbreaks  of  follicular  tonsillitis  that  sewer-gas  is 
regarded  as  a  common  exciting  cause.  One  attack  renders  a  patient  more 
liable  to  subsequent  infection.  The  tonsils  proper  and  the  adjacent 
lymphatic  tissues  undoubtedly  act  as  portals  of  entry  for  micro-organisms, 
not  only  in  acute  rheumatism  but  probably  in  other  affections.  Packard 
has  called  particular  attention  to  acute  tonsillitis  as  a  precursor  of  endo- 
carditis, erythema  nodosum,  and  chorea.  Cheadle  describes  it  as  one  of 
the  phases  of  rheumatism  in  childhood,  with  which  articular  attacks  or 
chorea  may  alternate.  The  existence  of  pains  in  the  limbs  upon  which 
some  lay  stress  is  no  evidence  of  the  connection  of  the  affection  with 
rheumatism.  A  disease  so  common  and  widespread  as  acute  tonsillitis 
necessarily  attacks  many  persons  in  whose  families  rheumatism  prevails 
or  who  may  themselves  have  had  acute  attacks.         , 

Mackenzie  gives  a  table  showing  that  in  four  successive  years  more 
cases  occurred  in  September  than  in  any  other  month;  in  October  nearly 
as  many,  with  July,  August,  and  November  next.  In  this  country  it  seems 
more  prevalent  in  the  spring.  So  many  cases  develop  within  a  short  time 
that  the  disease  may  be  almost  epidemic.  It  spreads  through  a  family  in 
such  a  way  that  it  must  be  re^rded  as  contagious. 

An  old  notion  prevails  that  there  is  a  definite  relation  between  the 
tonsils  and  the  testes  and  ovaries.  F.  J.  Shepherd  has  called  attention  to 
the  circumstance  that  acute  tonsillitis  is  a  very  common  affection  in  newly 
married  persons.  That  view  is  probably  correct  which  regards  tonsillitis 
as  a  local  disease  with  severe  constitutional  manifestations,  although  the 
fever  is  often  out  of  proportion  to  the  local  symptoms.  The  commonest 
organism  found  in  tonsillitis  is  a  streptococcus.  Staphylococci  also  occur. 
In  some  cases  the  bacillus  diphtherice  of  Loefflcr  has  been  found,  but  it 
does  not  always  possess  the  full  virulence  (see  Atypical  Forms  of  Diph- 
theria). 

Morbid  Anatomy. — The  lacunae  of  the  tonsils  become  filled  with 
exudation  products,  which  form  cheesy-lookiug  masses,  projecting  from 
the  orifices  of  the  crypts.  Not  infrequently  the  exudations  from  contiguous 
lacunae  coalesce.  The  intervening  mucosa  is  usually  swollen,  deep-red  in 
color,  and  may  present  herpetic  vesicles  or,  in  some  instances,  even  mem- 
branous exudation,  in  which  case  it  may  be  difficult  to  distinguish  the  con- 


452  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

dition  from  diphtheria.  The  creamy  contents  of  the  crypt  are  made  up  of 
micrococci  and  epithelial  debris. 

Symptoms. — Chilly  feelings,  or  even  a  definite  chill,  and  aching  pains 
in  the  back  and  limbs  may  precede  the  onset.  The  fever  rises  rapidly,  and 
in  the  case  of  a  young  child  may  reach  105°  on  the  evening  of  the  first  day. 
The  patient  complains  of  soreness  of  the  throat  and  difficulty  in  swallow- 
ing. On  examination,  the  tonsils  are  seen  to  be  swollen  and  the  crypts 
present  the  characteristic  creamy  exudate.  The  tongue  is  furred,  the 
breath  is  heavy  and  foul,  and  the  urine  is  highly  colored  and  loaded  with 
urates.  In  children  the  respirations  are  usually  very  hurried,  and  the 
pulse  is  greatly  increased  in  rapidity.  Swallowing  is  painful,  and  the  voice 
often  becomes  nasal.  Slight  swelling  of  the  cervical  glands  is  present.  In 
severe  cases  the  symptoms  increase  and  the  tonsils  become  still  more  swollen. 
The  inflammation  gradually  subsides,  and,  as  a  rule,  within  a  week  the 
fever  departs  and  the  local  condition  greatly  improves.  The  tonsils,  how- 
ever, remain  somewhat  swollen.  The  prostration  and  constitutional  dis- 
turbance are  often  out  of  j)roportion  to  the  intensity  of  the  local  disease. 

There  are  complications  which  occasionally  excite  uneasiness.  Febrile 
albuminuria  is  not  uncommon,  as  Haig-Brown  has  pointed  out.  Cases  of 
endocarditis  or  pericarditis  have  been  found.  It  is  to  be  borne  in  mind 
that  in  children  an  apex  systolic  murmur  is  by  no  means  uncommon  at 
the  height  of  any  fever.  The  disease  may  extend  to  the  middle  ear.  The 
development  of  paralytic  symptoms,  local  or  general,  after  an  attack  which 
has  been  regarded  as  follicular  tonsillitis  indicates  an  error  in  diagnosis. 
A  diffuse  erythema  may  develop,  simulating  that  of  scarlet  fever. 

Diagnosis. — It  may  be  difficult  to  distinguish  follicular  tonsillitis 
from  diphtheria.  It  would  seem,  indeed,  as  if  there  were  intermediate 
forms  between  the  mildest  lacunar  and  the  severer  pseudo-membranous 
tonsillitis.  In  the  follicular  form  the  individual  yellowish-gray  masses, 
separated  by  the  reddish  tonsillar  tissue,  are  very  characteristic;  whereas 
in  diphtheria  the  membrane  is  of  ashy  gray,  and  uniform,  not  patchy.  A 
point  of  the  greatest  importance  in  diphtheria  is  that  the  membrane  is  not 
limited  to  the  tonsils,  but  creeps  up  the  pillars  of  the  fauces  or  appears  on 
the  uvula.  The  diphtheritic  membrane  when  removed  leaves  a  bleeding, 
eroded  surface;  whereas  the  exudation  of  lacunar  tonsillitis  is  easily  sepa- 
rated, and  there  is  no  erosion  beneath  it.  In  all  doubtful  cases  cultures 
should  be  made  to  determine  the  presence  or  absence  of  Loeffler's  bacillus. 

(2)  Suppurative  Tonsillitis. 

Etiology. — This  arises  under  conditions  very  similar  to  those  men- 
tioned in  the  lacunar  form.  It  may  follow  exposure  to  cold  or  wet,  and  is 
particularly  liable  to  recur.  It  is  most  common  in  adolescence.  The  in- 
flammation is  here  more  deeply  seated.  It  involves  the  stroma,  and  tends 
to  go  on  to  suppuration. 

Sym.ptom.s. — The  constitutional  disturbance  is  very  great.  The  tem- 
perature rises  to  104°  or  105°,  and  the  pulse  ranges  from  110  to  130.  Noc- 
turnal delirium  is  not  uncommon.  The  prostration  may  be  extreme.  There 
is  no  local  disease  of  similar  extent  which  so  rapidly  exhausts  the  strength 
of  a  patient.    Soreness  and  dryness  of  the  throat,  with  pain  in  swallowing. 


ACTJTE  TONSILLITIS.  453 

are  the  symptoms  of  which  the  patient  first  complains.  One  or  both  tonsils 
may  be  involved.  They  are  enlarged,  firm  to  the  touch,  dusky  red  and 
cedematous,  and  the  contiguous  parts  are  also  much  swollen.  The  swelling 
of  the  glands  may  be  so  great  that  they  meet  in  the  middle  line,  or  one 
tonsil  may  even  push  the  uvula  aside  and  almost  touch  the  other  gland. 
The  salivary  and  buccal  secretions  are  increased.  The  glands  of  the  neck 
enlarge,  the  lower  jaw  is  fixed,  and  the  patient  is  unable  to  open  his  mouth. 
In  from  two  to  four  days  the  enlarged  gland  becomes  softer,  and  fluctuation 
can  be  distinctly  felt  by  placing  one  finger  on  the  tonsil  and  the  other  at 
the  angle  of  the  jaw.  The  abscess  points  usually  toward  the  mouth,  but  in 
some  cases  toward  the  pharynx.  It  may  burst  spontaneously,  afllording 
instant  and  great  relief.  Suffocation  has  followed  the  rupture  of  a  large 
abscess  and  the  entrance  of  the  pus  into  the  larynx.  ^Tien  the  suppura- 
tion is  peritonsillar  and  extensive,  the  internal  carotid  artery  may  be 
opened;  but  these  are,  fortunately,  very  rare  accidents. 

Treatment. — In  the  follicular  form  aconite  may  be  given  in  full  doses. 
It  acts  very  beneficially  in  children.  The  salicylates,  given  freely  at  the 
outset,  are  regarded  by  some  as  specific,  but  I  have  seen  no  evidence  of 
such  prompt  and  decisive  action.  At  night,  a  full  dose  of  Dover's  powder 
may  be  given.  The  use  of  guaiacum,  in  the  form  of  3-grain  lozenges,  is 
warmly  recommended.  Iron  and  quinine  should  be  reserved  until  the  fever 
has  subsided.  A  pad  of  spongio-piline  or  thick  flannel  dipped  in  ice-cold 
water  may  be  applied  around  the  neck  and  covered  with  oiled  silk.  More 
convenient  still  is  a  small  ice-bag.  Locally  the  tonsils  may  be  treated  with 
the  dry  sodium  bicarbonate.  The  moistened  fingertip  is  dipped  into  the 
soda,  which  is  then  rubbed  gently  on  the  gland  and  repeated  every  hour. 
Astringent  preparations,  such  as  iron  and  glycerin,  alum,  zinc,  and  nitrate 
of  silver,  may  be  tried.  To  cleanse  and  disinfect  the  throat,  solutions  of 
borax  or  thymol  in  glycerin  and  water  may  be  used. 

In  suppurative  tonsillitis  hot  applications  in  the  form  of  poultices  and 
fomentations  are  more  comfortable  and  better  than  the  ice-bag.  The 
gland  should  be  felt — it  cannot  always  be  seen — from  time  to  time,  and 
should  be  opened  when  fluctuation  is  distinct.  The  progress  of  the  dis- 
ease may  be  shortened  and  the  patient  spared  several  days  of  great  suffer- 
ing if  the  gland  is  scarified  early.  The  curved  bistoury,  guarded  nearly 
to  the  point  with  plaster  or  cotton,  is  the  most  satisfactory  instrument. 
The  incision  should  be  made  from  above  downward,  parallel  with  the  an- 
terior pillar.  There  are  cases  in  which,  before  suppuration  takes  place,  the 
parenchymatous  swelling  is  so  great  that  the  patient  is  threatened  with 
suffocation.  In  such  instances  the  tonsil  must  either  be  excised  or  trache- 
otomy or,  possibly,  intubation  performed.  Delavan  refers  to  two  cases  in 
which  he  states  that  tracheotomy  would,  under  these  circumstances,  have 
saved  life.  Patients  with  this  affection  require  a  nourishing  liquid  diet, 
and  during  convalescence  iron  in  full  doses. 

Early  removal  of  the  tonsils  should  be  practiced  when  a  child  suffers 
with  recurring  attacks,  and  thorough  local  treatment  should  be  given  to 
the  naso-pharynx.  Particular  care  should  be  taken  of  the  child's  mouth 
and  throat. 


454  DISEASES  OF  THE  DI&ESTIVE  SYSTEM. 

CHRONIC  TONSILLITIS. 

{Chronic  Naso-pharyngeal  Obstruction  ;  Mouth-Breathing  ;  Aprosexia.) 

Under  this  heading  will  be  considered  also  hypertrophy  of  the  adenoid 
tissue  in  the  yault  of  the  pharynx,  sometimes  known  as  the  pharjTigeal 
tonsil,  as  the  affection  usually  involyes  both  the  tonsils  proper  and  this 
tissue,  and  the  symptoms  are  not  to  be  differentiated. 

Chronic  enlargement  of  the  tonsillar  tissues  is  an  affection  of  great  im- 
portance, and  may  influence  in  an  extraordinary  way  the  mental  and  bodily 
development  of  children. 

Etiology. — Hypertrophy  of  the  tonsillar  structures  is  occasionally  con- 
genital. Cases  are  perhaps  most  frequent  in  children,  during  the  third 
hemi-decade.  The  condition  also  occurs  in  young  adults,  more  rarely  in 
the  middle-aged.  The  enlargement  may  follow  diphtheria  or  the  eruptive 
fevers.  The  frequency  of  the  occurrence  of  adenoid  growths  in  the  naso- 
pharynx has  been  variously  stated.  Meyer,  to  whom  the  profession  is  in- 
debted for  calling  attention  to  the  subject,  found  them  in  about  one  per 
cent  of  the  children  in  Copenhagen,  while  Chappell  found  60  cases  in  the 
examination  of  2,000  children  in  ISTew  York.  These  figures  give  a  very 
moderate  estimate  of  the  prevalence  of  the  trouble.  It  occurs  equally  in 
boys  and  girls,  according  to  some  writers  with  greater  prevalence  in  the 
former. 

Morbid  Anatomy. — The  tonsils  proper  present  a  condition  of 
chronic  hypertrophy,  due  to  multiplication  of  all  the  constituents  of  the 
glands.  The  lymphoid  elements  may  be  chiefly  involved  without  much 
development  of  the  stroma.  In  other  instances  the  fibrous  matrix  is  in- 
creased, and  the  organ  is  then  harder,  smaller,  firmer,  and  is  cut  with  much 
greater  difficulty. 

The  adenoid  growths,  which  spring  from  the  vault  of  the  phar}Tix, 
form  masses  var3dng  in  size  from  a  small  pea  to  an  almond.  They  may 
be  sessile,  with  broad  bases,  or  pedunculated.  They  are  reddish  in  color, 
of  moderate  firmness,  and  contain  numerous  blood-vessels.  "  Abundant, 
as  a  rule,  over  the  vault,  on  a  line  with  the  fossa  of  the  Eustachian  tube, 
the  growths  may  lie  posterior  to  the  fossa — namely,  in  the  depression  known 
as  the  fossa  of  Eosenmiiller,  or  upon  the  parts  which  are  parallel  to  the 
posterior  wall  of  the  pharynx.  The  gro^i;hs  appear  to  spring  in  the  main 
from  the  mucous  membrane  covering  the  localities  where  the  connective 
tissue  fills  in  the  inequalities  of  the  base  of  the  skull"  (Harrison  Allen). 
The  growths  are  most  frequently  papillomatous  with  a  lymphoid  par- 
enchyma. Hypertrophy  of  the  pharyngeal  adenoid  tissue  may  be  present 
without  great  enlargement  of  the  tonsils  proper.  Chronic  catarrh  of  the 
nose  usually  coexists. 

Symptoms. — The  direct  effect  of  chronic  tonsillar  hypertrophy  is 
the  establishment  of  mouth-breathing.  The  indirect  effects  are  deforma- 
tion of  the  thorax,  changes  in  the  facial  expression,  sometimes  marked 
alteration  in  the  mental  condition,  and  in  certain  cases  stunting  of  the 
growth.    Woods  Hutchinson  has  suggested  that  the  embryological  relation 


CHRONIC  TONSILLITIS.  455 

of  these  structures  with  the  pituitary  body  may  account  for  the  interfer- 
ence with  development.  The  establishment  of  mouth-breathing  is  the 
symptom  which  first  attracts  the  attention.  It  is  not  so  noticeable  by  day, 
although  the  child  may  present  the  vacant  expression  characteristic  of  this 
condition.  At  night  the  child's  sleep  is  greatly  disturbed;  the  respirations 
are  loud  and  snorting,  and  there  are  sometimes  prolonged  pauses,  followed 
by  deep,  noisy  inspirations.  The  pulse  may  vary  strangely  during  these 
attacks,  and  in  the  prolonged  intervals  may  be  slow,  to  increase  greatly 
with  the  forced  inspirations.  The  alse  nasi  should  be  observed  during 
the  sleep  of  the  child  as  they  are  sometimes  much  retracted  during  in- 
spiration, due  to  a  laxity  of  the  walls,  a  condition  readily  remedied  by  the 
use  of  a  soft  wire  dilator.  Night  terrors  are  common.  The  child  may  wake 
up  in  a  paroxysm  of  shortness  of  breath.  Sometimes  there  is  a  nocturnal 
paroxysmal  cough  of  a  very  troublesome  character  (Balne's  cough),  usually 
excited  by  lying  down.    The  attacks  may  occur  through  the  day. 

"When  the  mouth-breathing  has  persisted  for  a  long  time  definite  changes 
are  brought  about  in  the  face,  mouth,  and  chest.  The  facies  is  so  peculiar 
and  distinctive  that  the  condition  may  be  evident  at  a  glance.  The  ex- 
pression is  dull,  heavy,  and  apathetic,  due  in  part  to  the  fact  that  the  mouth 
is  habitually  left  open.  In  long-standing  cases  the  child  is  very  stupid- 
looking,  responds  slowly  to  questions,  and  may  be  sullen  and  cross.  The 
lips  are  thick,  the  nasal  orifices  small  and  pinched-in  looking,  the  supe- 
rior dental  arch  is  narrowed  and  the  roof  of  the  mouth  considerably  raised. 

The  remarkable  alterations  in  the  shape  of  the  chest  in  connection 
with  enlarged  tonsils  were  first  carefully  studied  by  Dupuytren  (1828), 
who  evidently  fully  appreciated  the  great  importance  of  the  condition. 
He  noted  "  a  lateral  depression  of  the  parietes  of  the  chest  consisting  of  a 
depression,  more  or  less  great,  of  the  ribs  on  each  side,  and  a  proportionate 
protrusion  of  the  sternum  in  front."  J.  Mason  Warren  (Medical  Exam- 
iner, 1839)  gave  an  admirable  description  of  the  constitutional  symptoms 
and  the  thoracic  deformities  induced  by  enlarged  tonsils.  These,  with 
the  memoir  of  Lambron  (1861),  constitute  the  most  important  contribu- 
tions to  our  knowledge  on  the  subject.  Three  types  of  deformity  may  be 
recognized: 

(a)  The  Pigeon  or  Chicken  Breast,  by  far  the  most  common  form,  in 
which  the  sternum  is  prominent  and  there  is  a  circular  depression  in  the 
lateral  zone  (Harrison's  groove),  corresponding  to  the  attachment  of  the 
diaphragm.  The  ribs  are  prominent  anteriorly  and  the  sternum  is  angu- 
lated  forward  at  the  manubrio-gladiolar  junction.  As  a  mouth-breather 
is  watched  during  sleep,  one  can  see  the  lower  and  lateral  thoracic  regions 
retracted  during  inspiration  by  the  action  of  the  diaphragm. 

(b)  Barrel  Chest. — Some  children,  the  subject  of  chronic  naso-pharyn- 
geal  obstruction,  have  recurring  attacks  of  asthma,  and  the  chest  may  be 
gradually  deformed,  becoming  rounded  and  barrel-shaped,  the  neck  short, 
and  the  shoulders  and  back  bowed.  A  child  of  ten  or  eleven  may  have  the 
thoracic  conformation  of  an  old  man  with  emphysema. 

(c)  The  Funnel  Breast  (Trichterbrust). — This  remarkable  deformity, 
in  which  there  is  a  deep  depression  at  the  lower  sternum,  has  excited  much 


456  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

controversy  as  to  its  mode  of  origin.  I  believe  that  in  some  instances,  at 
least,  it  is  due  to  the  obstructed  breathing  in  connection  with  adenoid 
vegetations.  I  have  seen  two  cases  in  children,  in  which  the  condition  was 
in  process  of  development.  During  inspiration  the  lower  sternum  was 
forcibly  retracted,  so  much  so  that  at  the  height  the  depression  corre- 
sponded to  that  of  a  well-marked  "  TricMerlrust.''  While  in  repose,  the 
lower  sternal  region  was  distinctly  excavated. 

The  voice  is  altered  and  acquires  a  nasal  quality.  The  pronunciation 
of  certain  letters  is  changed,  and  there  is  inability  to  pronounce  the  nasal 
consonants  n  and  m.  Bloeh  lays  great  stress  upon  the  association  of  mouth- 
breathing  with  stuttering. 

The  hearing  is  impaired,  usually  owing  to  the  extension  of  inflamma- 
tion along  the  Eustachian  tubes  and  the  obstruction  with  mucus  or  the 
narrowing  of  their  orifices  by  pressure  of  the  adenoid  vegetations.  In  some 
instances  it  may  be  due  to  retraction  of  the  drums,  as  the  upper  pharynx 
is  insuffleiently  supplied  with  air.  Xaturally  the  senses  of  taste  and  smell 
are  much  impaired.  With  these  symptoms  there  may  be  little  or  no  nasal 
catarrh  or  discharge,  but  the  pharyngeal  secretion  of  mucus  is  always  in- 
creased. Children,  however,  do  not  notice  this,  as  the  mucus  is  usually 
swallowed,  but  older  persons  expectorate  it  with  difiiculty. 

Among  other  sj^mptoms  may  be  mentioned  headache,  which  is  by  no 
means  uncommon,  general  listlessness,  and  an  indisposition  for  physical 
or  mental  exertion.  Habit-spasm  of  the  face  has  been  described  in  con- 
nection with  it.  I  have  known  several  instances  in  which  permanent  relief 
has  been  afforded  by  the  removal  of  the  adenoid  vegetations.  Enuresis 
is  occasionally  an  associated  symptom.  The  influence  upon  the  mental 
development  is  striking.  Mouth-breathers  are  usually  dull,  stupid,  and 
backward.  It  is  impossible  for  them  to  fix  the  attention  for  long  at  a  time, 
and  to  this  impairment  of  the  mental  function  Guye,  of  Amsterdam,  has 
given  the  name  aprosexia.  Headaches,  forgetfulness,  inability  to  study 
without  discomfort,  are  frequent  symptoms  of  this  condition  in  students. 
There  is  more  than  a  grain  of  truth  in  the  aphorism  sl^uf  your  mouth  and 
save  your  life,  which  is  found  on  the  title-page  of  Captain  Catlin's  cele- 
brated pamphlet  on  mouth-breathing. 

A  symptom  specially  associated  with  enlarged  tonsils  is  fetor  of  the 
breath.  In  the  tonsillar  crypts  the  inspissated  secretion  undergoes  de- 
composition and  an  odor  not  unlike  that  of  Eoquefort  or  Limburger  cheese 
is  produced.  The  little  cheesy  masses  may  sometimes  be  squeezed  from 
the  crypts  of  the  tonsils.  Though  the  odor  may  not  apparently  be  very 
strong,  yet  if  the  mass  be  squeezed  between  the  fingers  its  intensity  will  at 
once  be  appreciated.  In  some  cases  of  chronic  enlargement  the  cheesy 
masses  may  be  deep  in  the  tonsillar  crypts;  and  if  they  remain  for  a  pro- 
longed period  lime  salts  are  deposited  and  a  tonsillar  calculus  is  in  this 
way  produced. 

Children  with  enlarged  tonsils  are  especially  prone  to  take  cold  and  to 
recurring  attacks  of  follicular  disease.  They  are  also  more  liable  to  diph- 
theria, and  in  them  the  anginal  features  in  scarlet  fever  are  always  more 
serious.     The  ultimate  results  of  untreated  adenoid  hj-pertrophy  are  itn- 


CHRONIC  TONSILLITIS.  457 

portant.  In  some  cases  the  vegetations  disappear,  leaving  an  atrophic 
condition  of  the  vault  of  the  pharynx.  Neglect  may  also  lead  to  the  so- 
called  Thornwaldt's  disease,  in  which  there  is  a  cystic  condition  of  the 
pharyngeal  tonsil  and  constant  secretion  of  mneo-pus. 

Diagnosis. — The  facial  aspect  is  usually  distinctive.  Enlarged  ton- 
sils are  readily  seen  on  inspection  of  the  pharynx.  There  may  be  no  great 
enlargement  of  the  tonsils  and  nothing  apparent  at  the  back  of  the  throat 
even  when  the  naso-pharynx  is  completely  blocked  with  adenoid  vegeta- 
tions. In  children  the  rhinoscopic  examination  is  rarely  practicable.  Digi- 
tal examination  is  the  most  satisfactory.  The  growths  can  then  be  felt 
either  as  small,  flat  bodies  or,  if  extensive,  as  velvety,  grape-like  papillo- 
mata. 

Treatment. — If  the  tonsils  are  large  and  the  general  state  is  evidently 
influenced  by  them  they  should  be  at  once  removed.  Applications  of 
iodine  and  iron,  or  pencilling  the  crypts  with  nitrate  of  silver,  are  of  service 
in  the  milder  grades,  but  it  is  waste  of  time  to  apply  them  in  very  enlarged 
glands.  There  is  a  condition  in  which  the  tonsils  are  not  much  enlarged, 
but  the  crypts  are  constantly  filled  with  cheesy  secretions  and  cause  a 
very  bad  odor  in  the  breath.  In  such  instances  the  removal  of  the  secre- 
tion and  thorough  pencilling  of  the  crypts  with  chromic  acid  may  be  prac- 
tised. The  galvano-cautery  is  of  great  service  in  many  cases  of  enlarged 
tonsils  when  there  is  any  objection  to  the  more  radical  surgical  procedure. 

The  treatment  of  the  adenoid  growths  in  the  pharynx  is  of  the  great- 
est importance,  and  should  be  thoroughly  carried  out.  Parents  should 
be  frankly  told  that  the  affection  is  serious,  one  which  impairs  the  mental 
not  less  than  the  bodily  development  of  the  child.  In  spite  of  the  thorough 
ventilation  of  this  subject  by  specialists,  practitioners  do  not  appear  to 
have  grasped  as  yet  the  full  importance  of  this  disease.  They  are  far  too 
apt  to  temporize  and  unnecessarily  to  postpone  radical  measures.  The 
child  must  be  etherized,  when  the  growths  can  be  removed  either  with  the 
fing-er-nail,  which  in  most  instances  is  sufficient,  or  with  a  suitable  curette. 
The  dangers  of  the  operation  are  slight.  Haemorrhage  occurs  and  may 
be  severe.  Death  from  chloroform  has  been  somewhat  frequent.  Hinckel 
(N.  Y.  Med.  Jr.,  Oct.  29,  1898)  has  collected  18  cases.  The  good  effects 
of  the  operation  are  often  apparent  within  a  few  days,  and  the  child  begins 
to  breathe  through  the  nose.  In  some  instances  the  habit  of  mouth-breath- 
ing persists.  As  soon  as  the  child  goes  to  sleep  the  lower  jaw  drops  and 
the  air  is  drawn  into  the  mouth.  In  these  cases  a  chin  strap  can  be  readily 
adjusted,  which  the  child  may  wear  at  night.  In  severe  cases  it  may  take 
months  of  careful  training  before  the  child  can  speak  properly.  According 
to  Mr.  Lane,  of  Guy's  Hospital,  an  all-important  point  in  the  treatment 
of  lesions  of  the  naso-pharjnix  (and,  indeed,  in  the  prevention  of  this  un- 
fortunate condition)  is  to  increase  the  breathing  capacity  of  the  chest  by 
making  the  child  perform  systematic  exercises,  which  cause  the  air  to  be 
driven  freely  and  forcibly  in  and  out  through  the  naso-pharj^nx. 

Throughout  the  entire  treatment  attention  should  be  paid  to  h5^giene 
and  diet,  and  cod-liver  oil  and  the  iodide  of  iron  may  be  administered  with 
benefit. 


458  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

Y.    DISEASES   OF  THE   (ESOPHAGUS. 
I.   ACUTE   CESOPHAGITIS. 

Etiology. — Acute  inflammation  occurs  {a)  in  tlie  catarrhal  processes 
of  the  specific  fevers;  more  rarely  as  an  extension  from  catarrh  of  the 
pharynx.  (&)  As  a  result  of  intense  mechanical  or  chemical  irritation, 
produced  by  foreign  bodies,  by  very  hot  liquids,  or  by  strong  corrosives, 
(c)  In  the  form  of  pseudo-membranous  inflammation  in  diphtheria,  and 
occasionally  in  pneumonia,  typhoid  fever,  and  pyaemia,  {d)  As  a  pustular 
inflammation  in  small-pox,  and,  according  to  Laennec,  as  a  result  of  a  pro- 
longed administration  of  tartar  emetic,  (e)  In  connection  with  local  dis- 
ease, particularly  cancer  either  of  the  tube  itself  or  extension  to  it  from 
without.  And,  lastly,  acute  oesophagitis,  occasionally  with  ulceration,  may 
occur  spontaneously  in  sucklings. 

Morbid  Anatomy.- — It  is  extremely  rare  to  see  redness  of  the 
mucosa,  except  when  chemical  irritants  have  been  swallowed.  More  com- 
monly the  epithelium  is  thickened  and  has  desquamated,  so  that  the  sur- 
face is  covered  with  a  fine  granular  substance.  The  mucous  follicles  are 
swollen  and  occasionally  there  may  be  seen  small  erosions.  In  the  pseudo- 
membranous inflammation  there  is  a  grayish  croupous  exudate,  usually  lim- 
ited in  extent,  at  the  upper  portion  of  the  gullet.  This  must  not  be  con- 
founded with  the  grayish-white  deposit  of  thrush  in  children.  The  pus- 
tular disease  is  very  rare  in  small-pox.  In  the  phlegmonous  inflammation 
the  mucous  membrane  is  greatly  swollen,  and  there  is  purulent  infiltration 
in  the  submucosa.  This  may  be  limited  as  about  a  foreign  body,  or  ex- 
tremely diffuse.  It  may  even  extend  throughout  a  large  part  of  the  gullet. 
Gangrene  occasionally  supervenes.  There  is  a  remarkable  fibrinous  or 
membranous  oesophagitis,  which  is  most  frequently  met  with  in  the  fevers, 
sometimes  also  in  hysteria,  in  which  long  casts  of  the  tube  may  be  vomited. 

Symptoms. — Pain  in  deglutition  is  always  present  in  severe  infiam- 
mation  of  the  CESophagus,  and  in  the  form  which  follows  the  swallowing 
of  strong  irritants  may  prevent  the  taking  of  food.  A  dull  pain  beneath 
the  sternum  is  also  present.  In  the  milder  forms  of  catarrhal  infiamma- 
tion  there  are  usually  no  symptoms.  The  presence  of  a  foreign  body  is 
indicated  by  dysphagia  and  spasm  with  the  regurgitation  of  portions  of 
the  food.  Later,  blood  and  pus  may  be  ejected.  It  is  surprising  how  ex- 
tensive the  disease  may  be  in  the  oesophagus  without  producing  much  pain 
or  great  discomfort,  except  in  swallowing.  The  intense  inflammation 
which  follows  the  swallowing  of  corrosives,  when  not  fatal,  gradually  sub- 
sides, and  often  leads  to  cicatricial  contraction  and  stricture. 

The  treatment  of  acute  inflammation  of  the  oesophagus  is  extremely  un- 
satisfactory, particularly  in  the  severer  forms.  The  slight  catarrhal  cases 
require  no  special  treatment.  Wlien  the  dysphagia  is  intense  it  is  best  not 
to  give  food  by  the  mouth,  but  to  feed  entirely  by  enemata.  Fragments  of 
ice  may  be  given,  and  as  the  pain  and  distress  subside,  demulcent  drinks. 
External  applications  of  cold  often  give  relief. 


SPASM  OF  THE  CESOPHAGUS.  459 

A  chronic  form  of  oesophagitis  is  described,  but  this  results  usually  from 
the  prolonged  action  of  the  causes  which  produce  the  acute  form. 

Ulceration  of  the  (Esophagus. — In  many  cachectic  conditions  catarrhal 
ulceration  is  found.  In  a  few  rare  instances  ulcers  of  the  oesophagus  are 
met  with  in  typhoid  fever.  Acute  malignant  ulceration  may  perforate  the 
oesophagus  and  open  into  the  aorta. 

Associated  with  chronic  heart-disease  and  more  frequently  with  the 
senile  and  the  cirrhotic  liver,  the  oesophageal  veins  may  be  enormously 
distended  and  varicose,  particularly  toward  the  stomach.  In  these  cases 
the  mucous  membrane  is  in  a  state  of  chronic  catarrh,  and  the  patient  has 
frequent  eructations  of  mucus.  Eupture  of  these  oesophageal  veins  may 
cause  fatal  haemorrhage.  Two  cases  of  the  kind  have  occurred  in  my  ex- 
perience. The  blood  may  pass  per  rectum  alone,  as  in  a  case  reported  by 
Power,  of  Baltimore,  in  1839. 


II.    SPASM    OF    THE    CESOPHAGUS  (CEsophagismus). 

'  This  so-called  spasmodic  stricture  of  the  gullet  is  met  with  in  hysterical 
patients  and  hypochondriacs,  also  in  chorea,  epilepsy,  and  especially  hydro- 
phobia. It  is  sometimes  associated  also  with  the  lodgment  of  foreign  bodies. 
The  idiopathic  form  is  found  in  females  of  a  marked  neurotic  habit,  but 
may  also  occur  in  elderly  men.  It  may  be  present  only  during  pregnancy. 
Of  4  cases  which  have  come  under  my  observation,  2  were  in  men,  one  a 
hypochondriac  over  sixty  years  of  age  who  for  many  months  had  taken 
only  liquid  food,  and  with  great  difficulty,  owing  to  a  spasm  which  accom- 
panied every  attempt  to  swallow.  The  readiness  with  which  the  bougie 
passed  and  the  subsequent  history  showed  the  true  nature  of  the  case.  The 
patient  complains  of  inability  to  swallow  solid  food,  and  in  extreme  in- 
stances even  liquids  are  rejected.  The  attack  may  come  on  abruptly,  and 
be  associated  with  emotional  disturbances  and  with  substernal  pain.  The 
bougie,  when  passed,  may  be  arrested  temporarily  at  the  seat  of  the  spasm, 
which  gradually  yields,  or  it  may  slip  through  without  the  slightest  effort. 
The  condition  is  rarely  serious.     Death  has,  however,  followed  it. 

The  diagnosis  is  not  difficult,  particularly  in  young  persons  with  marked 
nervous  manifestations.  In  elderly  persons  oesophagismus  is  almost  always 
connected  with  hypochondriasis,  but  great  care  must  be  taken  to  exclude 
cancer. 

In  some  cases  a  cure  is  at  once  effected  by  the  passage  of  a  bougie.  The 
general  neurotic  condition  also  requires  special  attention. 

Paralysis  of  the  oesophagus  scarcely  demands  separate  consideration. 
It  is  a  very  rare  condition,  due  most  often  to  central  disease,  particularly 
bulbar  paralysis.  It  may  be  peripheral  in  origin,  as  in  diplitheritic  paraly- 
sis. Occasionally  it  occurs  also  in  hysteria.  The  essential  symptom  is 
dysphagia. 


460  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 


III.    STRICTURE    OF  THE    CESOPHAGUS. 

This  results  from:  (a)  Congenital  narrowing,  (b)  The  cicatricial  con- 
traction of  healed  ulcers,  usually  due  to  corrosive  poisons,  occasionally 
to  syphilis,  and  in  rare  instances  after  the  fevers. '  (c)  The  growth  of 
tumors  in  the  walls,  as  in  the  so-called  cancerous  stricture.  Eighty-five 
per  cent  of  the  cases  are  of  this  nature  (Kelynack  and  Anderson),  (d) 
External  pressure  by  aneurism,  enlarged  lymph-glands,  enlarged  thyroid, 
other  tumors,  and  sometimes  by  pericardial  effusion. 

The  cicatricial  stricture  may  occur  anj^where  in  the  gullet,  and  in  ex- 
treme cases  may,  indeed,  involve  the  whole  tube,  but  in  a  majority  of  in- 
stances it  is  found  either  high  up  near  the  pharynx  or  low  down  toward 
the  stomach.  The  narrowing  may  be  extreme,  so  that  only  small  quanti- 
ties of  food  can  trickle  through,  or  the  obstruction  may  be  quite  slight. 
There  is  usually  no  difficulty  in  making  a  diagnosis  of  the  cicatricial  strict- 
ure, as  the  history  of  mechanical  injury  or  the  swallowing  of  a  corrosive 
fluid  makes  clear  the  nature  of  the  case.  "WHien  the  stricture  is  low  down 
the  oesophagus  is  dilated  and  the  walls  are  usually  much  hypertrophied. 
When  the  obstruction  is  high  in  the  gullet,  the  food  is  usually  rejected  at 
once,  whereas,  if  it  is  low,  it  may  be  retained  and  a  considerable  quantity 
collects  before  it  is  regurgitated.  Any  doubt  as  to  its  having  reached  the 
stomach  is  removed  by  the  alkalinity  of  the  material  ejected  and  the  absence 
of  the  characteristic  gastric  odor.  Auscultation  of  the  oesophagus  may  be 
practised  and  is  sometimes  of  service.  The  patient  takes  a  mouthful  of 
water  and  the  auscultator  listens  along  the  left  of  the  spine.  The  normal 
oesophageal  iruit  may  be  heard  later  than  seven  seconds,  the  normal  time,  or 
there  may  be  heard  a  loud  splashing,  gurgling  sound.  The  secondary  mur- 
mur, heard  as  the  fluid  enters  the  stomach,  may  be  absent.  The  passage  of 
the  oesophageal  bougie  will  determine  more  accurately  the  locality.  Conical 
bougies  attached  to  a  flexible  whalebone  stem  are  the  most  satisfactory,  but 
the  gum-elastic  stomach  tube  may  be  used;  a  large  one  should  be  tried  first. 
The  patient  should  be  placed  on  a  low  chair  with  the  head  well  thrown 
back.  The  index  finger  of  the  left  hand  is  passed  far  into  the  pharynx, 
and  in  some  instances  this  procedure  alone  may  determine  the  presence  of 
a  new  growth.  The  bougie  is  passed  beside  the  finger  until  it  touches  the 
posterior  wall  of  the  pharynx,  then  along  it,  more  to  one  side  than  in  the 
middle  line,  and  so  gradually  pushed  into  the  gullet.  It  is  to  be  borne 
in  mind  that  in  passing  the  cricoid  cartilage  there  is  often  a  slight  ob- 
struction. Great  gentleness  should  be  used,  as  it  has  happened  more  than 
once  that  the  bdligie  has  been  passed  through  a  cancerous  ulcer  into  the 
mediastinum  or  through  a  diverticulum.  I  have  known  this  accident  to 
happen  twice — once  in  the  case  of  a  distinguished  surgeon,  who  performed 
oesophagotomy  and  passed  the  tube,  as  he  thought,  into  the  stomach.  The 
post  mortem  on  the  next  day  showed  that  the  tube  had  entered  a  diverticu- 
lum and  through  it  the  left  pleura,  in  which  the  milk  injected  through 
the  tube  was  found.  In  the  other  instance  the  tube  passed  through  a  can- 
cerous ulcer  into  the  lung,  which  was  adherent  and  inflamed.     Fortunately 


CANCER  OF  THE  CESOPHAGUS.  4,61 

these  accidents,  sometimes  unavoidable,  are  extremely  rare.  It  is  well 
always,  as  a  precautionary  measure  before  passing  the  bougie,  to  examine 
carefully  for  aneurism,  which  may  produce  all  the  symptoms  of  organic 
stricture.  In  cases  in  which  the  narrowing  is  extreme  there  is  always  ema- 
ciation.   For  treatment,  surgical  works  must  be  consulted. 


IV.    CANCER    OF  THE   CESOPHAGUS. 

This  is  usually  epithelioma.  It  is  not  an  uncommon  disease,  and  occurs 
more  frequently  in  males  than  in  females.  The  middle  and  lower  thirds  are 
most  often  affected^.  At  first  confined  to  the  mucous  membrane,  the  can- 
cer gradually  increases  and  soon  ulcerates.  The  lumen  of  the  tube  is  nar- 
rowed, but  when  ulceration  is  extensive  in  the  later  stages  the  stricture 
may  be  less  marked.  Dilatation  of  the  tube  and  hypertrophy  of  the  walls 
usually  take  place  above  the  cancer.  The  ulcer  may  perforate  the  trachea 
or  a  bronchus,  the  lung,  the  pleura,  the  mediastinum,  the  aorta  or  one  of 
its  larger  branches,  the  pericardium,  or  it  may  erode  the  vertebral  column. 
The  recurrent  laryngeal  nerves  are  not  infrequently  implicated.  Perfora- 
tion of  the  lung  produces,  as  a  rule,  local  gangrene. 

Symptoms. — The  earliest  symptom  is  dysphagia,  which  is  progressive 
and  may  become  extreme,  so  that  the  patient  emaciates  rapidly.  Eegurgita- 
tion  may  take  place  at  once;  or,  if  the  cancer  is  situated  near  the  stomach, 
it  may  be  deferred  for  ten  or  fifteen  minutes,  or  even  longer  if  the  tube 
is  much  dilated.  The  rejected  materials  may  be  mixed  with  blood  and  may 
contain  cancerous  fragments.  In  persons  over  fifty  years  of  age  persistent 
difficulty  in  swallowing  accompanied  by  rapid  emaciation  usually  indicates 
oesophageal  cancer.  The  cervical  lymph-glands  are  frequently  enlarged  and 
may  give  early  indication  of  the  nature  of  the  trouble.  Pain  may  be  per- 
sistent or  be  present  only  when  food  is  taken.  In  certain  instances  the  pain 
is  very  great.  I  saw  an  autopsy  on  a  case  of  cancer  of  the  oesophagus  in 
which  the  patient  gradually  became  emaciated,  but  had  no  special  symp- 
toms to  call  attention  to  the  disease.  These  latent  cases  are,  however,  very 
rare.    Bronchitis  and  broncho-pneumonia  are  common  terminal  events. 

The  prognosis  is  hopeless;  the  patients  usually  become  progressively 
emaciated,  and  die  either  of  asthenia  or  sudden  perforation  of  the  ulcer. 

In  the  diagnosis  of  the  condition  it  is  important,  in  the  first  place,  to 
exclude  pressure  from  without,  as  by  aneurism  or  other  tumor.  The  his- 
tory enables  us  to  exclude  cicatricial  stricture  and  foreign  bodies.  The 
sound  may  be  passed  and  the  presence  of  the  stricture  determined.  As 
mentioned  above,  great  care  should  be  exercised.  Fragments  of  carcinom- 
atous tissue  may  in  some  instances  be  removed  with  the  tube.  On  aus- 
cultation along  the  left  side  of  the  spine  the  primary  oesophageal  murmur 
may  be  much  altered  in  quality. 

Treatment. — In  most  cases  milk  and  liquids  can  be  swallowed,  but  sup- 
plementary nourishment  should  be  given  by  the  rectum.  It  may  be  ad- 
visable in  some  instances  to  pass  a  tube  into  the  stomach  and  introduce 
food  in  this  way.    When  there  is  difficulty  in  feeding  the  patient  it  is  very 


462  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

much  better  to  have  gastrostomy  performed  at  once,  as  it  gives  the  greatest 
comfort  and  ease,  and  prolongs  the  patient's  life. 


V.    RUPTURE    OF  THE    (ESOPHAGUS. 

(1)  In  a  healthy  organ  as  a  result  of  prolonged  vomiting  after  a  full 
meal,  or  when  intoxicated.  Eight  cases  are  on  record  (Virchow's  Archiv, 
vol.  162).  Boerhaave  described  the  first  case  in  Baron  Wassennar,  who 
"  broke  asunder  the  tube  of  the  oesophagus  near  the  diaphragm,  so  that, 
after  the  most  excruciating  pain,  the  elements  which  he  swallowed  passed, 
together  with  the  air,  into  the  cavity  of  the  thorax,  and  he  expired  in 
twenty-four  hours." 

(2)  In  a  few  cases  the  rupture  has  occurred  in  a  diseased  and  weakened 
tube,  near  the  scar  of  an  ulcer,  for  example. 

(3)  Post-mortem  softening — oesophago-malacia — a  not  very  uncommon 
condition,  must  not  be  mistaken  for  it.  In  spontaneous  rupture  the  rent 
is  clean-cut  and  circumferential;  in  malacia  it  is  rounded  and  often  cribri- 
form, and  the  margins  are  softened.  The  contents  of  the  stomach  may  be 
in  the  left  pleura. 


VI.    DILATATIONS    AND    DIVERTICULA. 

Stenosis  of  the  gullet  is  followed  by  secondary  dilatation  of  the  tube 
above  the  constriction  and  great  hypertrophy  of  the  walls.  Primary  dila- 
tation is  extremely  rare.  The  tube  may  attain  extraordinary  dimensions — 
30  cm.  in  circumference  in  Luschka's  case.  Eegurgitation  of  food  is  the 
most  common  symptom.  There  may  also  be  difficulty  in  breathing  from 
pressure. 

Diverticula  are  of  two  forms:  (a)  Pressure  diverticula,  which  are  most 
common  at  the  junction  of  the  pharynx  and  gullet,  on  the  posterior  wall. 
Owing  to  weakness  of  the  muscles  at  this  spot,  local  bulging  occurs,  which 
is  gradually  increased  by  the  pressure  of  food,  and  finally  forms  a  saccular 
pouch.  (&)  The  traction  diverticula  situated  on  the  anterior  wall  near  the 
bifurcation  of  the  trachea,  result,  as  a  rule,  from  the  extension  of  inflam- 
mation from  the  lymph-glands  with  adhesion  and  subsequent  cicatricial 
contraction,  by  which  the  wall  of  the  gullet  is  drawn  out.  Diverticula  have 
been  successfully  extirpated  by  von  Bergmann  and  by  Mixter. 

A  rare  and  remarkable  condition,  of  which  a  case  has  been'  recorded 
by  MacLachlan,  and  of  which  a  second  is  in  attendance  at  my  clinic,  is  the 
cesophago-pleuro-cutaneous  fistula.  In  my  patient  fluids  are  discharged 
at  intervals  through  a  fistula  in  the  right  infra-clavicular  region,  which 
appears  to  communicate  with  a  cavity  in  the  upper  part  of  the  pleura  or 
lung.    The  condition  has  persisted  for  more  than  twenty  years. 


ACUTE  GASTRITIS.  463 

YI.  DISEASES   OE  THE   STOMACH. 
I.    ACUTE  GASTRITIS. 

(Simple  Gastritis;  Acute  Gastric  Catarrh;  Acute  Dyspepsia.) 

Etiology. — Acute  gastric  catarrh,  one  of  the  most  common  of  com- 
plaints, occurs  at  all  ages,  and  is  usually  traceable  to  errors  in  diet.  It  may 
follow  the  ingestion  of  more  food  than  the  stomach  can  digest,  or  it  may 
result  from  taking  unsuitable  articles,  which  either  themselves  irritate  the 
mucosa  or,  remaining  undigested,  decompose,  and  so  excite  an  acute  dys- 
pepsia. A  frequent  cause  is  the  taking  of  food  which  has  begun  to  decom- 
pose, particularly  in  hot  weather.  In  children  these  fermentative  processes 
are  very  apt  to  excite  acute  catarrh  of  the  bowels  as  well.  Another  very 
common  cause  is  the  abuse  of  alcohol,  and  the  acute  gastritis  which  fol- 
lows a  drinking-bout  is  one  of  the  most  typical  forms  of  the  disease.  The 
tendency  to  acute  indigestion  varies  very  much  in  different  individuals, 
and  indeed  in  families.  We  recognize  this  in  using  the  expressions  a  "  deli- 
cate stomach "  and  a  "  strong  stomach."  Gouty  persons  are  generally 
thought  to  be  more  disposed  to  acute  dyspepsia  than  others.  Acute  catarrh 
of  the  stomach  occurs  at  the  outset  of  many  of  the  infectious  fevers. 

Lebert  described  a  special  infectious  form  of  gastric  catarrh,  occurring 
in  epidemic  form,  and  only  to  be  distinguished  from  mild  typhoid  fever  by 
the  absence  of  rose  spots  and  swelling  of  the  spleen.  Many  practitioners 
still  adhere  to  the  belief  that  there  is  a  form  of  gastric  fever,  but  the  evidence 
of  its  existence  is  by  no  means  satisfactory,  and  certainly  a  great  majority 
of  all  cases  in  this  country  are  examples  of  mild  typhoid. 

Morbid  Anatomy. — Beaumont's  study  of  St.  Martin's  stomach 
showed  that  in  acute  catarrh  the  mucous  membrane  is  reddened  and  swol- 
len, less  gastric  juice  is  secreted,  and  mucus  covers  the  surface.  Slight 
haemorrhages  may  occur  or  even  small  erosions.  The  submucosa  may  be 
somewhat  oedematous.  Microscopically  the  changes  are  chiefly  noticeable 
in  the  mucous  and  peptic  cells,  which  are  swollen  and  more  granular,  and 
there  is  an  infiltration  of  the  intertubular  tissue  with  leucocytes. 

Symptoms. — In  mild  cases  the  symptoms  are  those  of  slight  "indi- 
gestion " — an  uncomfortable  feeling  in  the  abdomen,  headache,  depression, 
nausea,  eructations,  and  vomiting,  which  usually  gives  relief.  The  tongue 
is  heavily  coated  and  the  saliva  is  increased.  In  children  there  are  intes- 
tinal symptoms — diarrhoea  and  colicky  pains.  There  is  usually  no  fever. 
The  duration  is  rarely  more  than  twenty-four  hours.  In  the  severer  forms 
the  attack  may  set  in  with  a  chill  and  febrile  reaction,  in  which  the  tem- 
perature rises  to  102°  or  103°.  The  tongue  is  furred,  the  breath  heavy,  and 
vomiting  is  frequent.  The  ejected  substances,  at  first  mixed  with  food, 
subsequently  contain  much  mucus  and  bile-stained  fluids.  There  may  be 
constipation,  but  very  often  there  is  diarrhoea.  The  urine  presents  the 
usual  febrile  characteristics,  and  there  is  a  heavy  deposit  of  urates.  The 
abdomen  may  be  somewhat  distended  and  slightly  tender  in  the  epigastric 
region.  Herpes  may  appear  on  the  lips.  The  attack  may  last  from  one 
29 


464  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

to  three  days,  and  occasionally  longer.  The  examination  of  the  vomitus 
shows,  as  a  rule,  absence  of  the  hydrochloric  acid,  presence  of  lactic  and 
fatty  acids,  and  marked  increase  in  the  mucus. 

Diagnosis. — The  ordinary  afebrile  gastric  catarrh  is  readily  recog- 
nized. The  acute  febrile  form  is  so  similar  to  the  initial  symptoms  of  many 
of  the  infectious  diseases  that  it  is  impossible  for  a  day  or  two  to  make  a 
definite  diagnosis,  particularly  in  the  cases  which  have  come  on,  so  to  speak, 
spontaneously  and  independently  of  an  error  in  diet.  Some  of  these  re- 
semble closely  an  acute  infection;  the  symptoms  may  be  very  intense,  and 
if,  as  sometimes  happens,  the  attack  sets  in  with  severe  headache  and  de- 
lirium the  case  may  be  mistaken  for  meningitis.  "When  the  abdominal 
pains  are  intense  the  attack  may  be  confounded  with  gallstone  colic.  In 
discriminating  between  acute  febrile  gastritis  and  the  abortive  forms  of 
typhoid  fever  it  is  to  be  borne  in  mind  that  in  the  former  the  temperature 
rises  abruptly,  the  remissions  are  slighter  and  the  drop  is  more  sudden. 
The  initial  bronchitis,  the  well-marked  splenic  enlargement,  and  the  rose 
spots  are  not  present.  It  is  a  very  common  error  to  class  under  gastric 
fever  the  mild  forms  of  the  various  infectious  disorders.  The  gastric  crises 
in  locomotor  ataxia  have  in  many  instances  been  confounded  with  a  simple 
acute  gastritis,  and  it  is  always  wise  in  adults  to  test  the  knee- jerks  and 
pupillary  reactions. 

Treatment. — Mild  cases  recover  spontaneously  in  twenty-four  hours, 
and  require  no  treatment  other  than  a  dose  of  castor  oil  in  children  or  of 
blue  mass  in  adults.  In  the  severer  forms,  if  there  is  much  distress  in  the 
region  of  the  stomach,  the  vomiting  should  be  promoted  by  warm  water 
or  the  simple  emetics.  A  full  dose  of  calomel,  8  to  10  grains,  should  be 
given,  and  followed  the  next  morning  by  a  dose  of  Hunyadi-Janos  or  Carls- 
bad water.  If  there  is  eructation  of  acid  fluid,  bicarbonate  of  soda  and 
bismuth  may  be  given.  The  stomach  should  have,  if  possible,  absolute 
rest,  and  it  is  a  good  plan  in  the  case  of  strong  persons,  particularly  in  those 
addicted  to  alcohol,  to  cut  off  all  food  for  a  day  or  two.  The  patient  may 
be  allowed  soda  water  and  ice  freely.  It  is  well  not  to  attempt  to  check 
the  vomiting  unless  it  is  excessive  and  protracted.  Eecovery  is  usually 
complete,  though  repeated  attacks  may  lead  to  subacute  gastritis  or  to  the 
establishment  of  chronic  dyspepsia. 

Phlegmonous  Gastritis ;  Acute  Suppurative  Gastritis. — This  is  an  ex- 
cessively rare  disease,  characterized  by  the  occurrence  of  suppurative  pro- 
cesses in  the  submucosa.  The  affection  is  more  common  in  men  than  in 
women.  Leith  has  collected  85  cases,  and  has  given  the  best  account  in 
the  literature  (Edinburgh  Hospital  Reports,  vol.  iv).  The  cause  is  seldom 
obvious.  It  has  been  met  with  as  an  idiopathic  affection,  but  it  has  occurred 
also  in  puerperal  fever  and  other  septic  processes,  and  has  occasionally 
followed  trauma.  Anatomically  there  appear  to  be  two  forms,  a  diffuse 
purulent  infiltration  and  a  localized  abscess  formation,  in  which  case  the 
tumor  may  reach  the  size  of  an  egg,  and  may  burst  into  the  stomach  or 
into  the  peritoneal  cavity.  In  two  of  the  cases  I  have  seen,  the  abscess  was 
in  connection  with  cancer  of  the  stomach,  and  it  is  interesting  to  note 
that  in  both  there  were  recurrinsr  chills.    In  a  third  case,  in  a  diffuse  car- 


ACUTE  GASTRITIS.  465 

cinoma,  there  was  extensive  phlegmonous  inflammation  with  vomiting  of  a 
horribly  fetid  material. 

The  symptoms  are  variable.  There  are  usually  pain  in  the  abdomen, 
fever,  dry  tongue,  and  symptoms  of  a  severe  infective  process,  deliriimi 
and  coma  preceding  death.  Jaundice  has  been  met  with  in  some  instaneea. 
Occasionally,  when  the  abscess  tumor  is  large,  it  has  been  felt  externally, 
in  one  case  forming  a  mass  as  large  as  two  fists.  There  are  instances  which 
run  a  more  chronic  course,  with  pains  in  the  abdomen,  fever,  and  chills. 

The  diagnosis  is  rarely  possible,  even  when  with  abscess  rupture  occurs, 
and  the  pus  is  vomited,  as  it  is  not  possible  to  differentiate  this  condition 
from  an  abscess  perforating  into  the  stomach  from  without.  It  is  stated, 
however,  that  Chvostek  made  the  diagnosis  in  one  of  his  cases. 

Toxic  Gastritis. — This  most  intense  form  of  inflammation  of  the  stom- 
ach is  excited  by  the  swallowing  of  concentrated  mineral  acids  or  strong 
alkalies,  or  by  such  poisons  as  phosphorus,  corrosive  sublimate,  ammonia, 
arsenic,  etc.  In  the  non-corrosive  poisons,  such  as  phosphorus,  arsenic, 
and  antimony,  the  process  consists  of  an  acute  degeneration  of  the  glandular 
elements,  and  hsemorrhage.  In  the  powerful  concentrated  poisons  the 
mucous  membrane  is  extensively  destroyed,  and  may  be  converted  into  a 
brownish-black  eschar.  In  the  less  severe  grades  there  may  be  areas  of 
necrosis  surrounded  by  inflammatory  reaction,  while  the  submucosa  is  hsem- 
orrhagic  and  infiltrated.  The  process  is  of  course  more  intense  at  the 
fundus,  but  the  active  peristalsis  may  drive  the  poison  through  the  pylorus 
into  the  intestine. 

The  symptoms  are  intense  pain  in  the  mouth,  throat,  and  stomach, 
salivation,  great  difficulty  in  swallowing,  and  constant  vomiting,  the  vom- 
ited materials  being  bloody  and  sometimes  containing  portions  of  the 
mucous  membrane.  The  abdomen  is  tender,  distended,  and  painful  on 
pressure.  In  the  most  acute  cases  symptoms  of  collapse  supervene;  the 
pulse  is  weak,  the  skin  pale  and  covered  with  sweat;  there  is  restlessness, 
and  sometimes  convulsions.  There  may  be  albumin  or  blood  in  the  urine, 
and  petechias  may  develop  on  the  skin.  T\Tien  the  poison  is  less  intense, 
the  sloughs  may  separate,  leaving  ulcers,  which  too  often  lead,  in  the 
oesophagus  to  stricture,  in  the  stomach  to  chronic  atrophy,  and  finally  to 
death  from  exhaustion. 

The  diagnosis  of  toxic  gastritis  is  usually  easy,  as  inspection  of  the 
mouth  and  pharynx  shows,  in  many  instances,  corrosive  effects,  while  the 
examination  of  the  vomit  may  indicate  the  nature  of  the  poison. 

In  poisoning  by  acids,  magnesia  should  be  administered  in  milk  or 
with  egg  albumen.  Wlien  strong  alkalies  have  been  taken,  the  dilute  acids 
should  be  administered.  If  the  case  is  seen  early,  lavage  should  be  used. 
For  the  severe  inflammation  which  follows  the  swallowing  of  the  stronger 
poisons  palliative  treatment  is  alone  available,  and  morphia  may  be  freely 
employed  to  allay  the  pain. 

Diphtheritic  or  Membranous  Gastritis. — This  condition  is  met  with 
occasionally  in  diphtheria, -^jut  more  commonly  as  a  secondary  process  in 
typhus  or  typhoid  fever,  pneumonia,  pysemia,  small-pox,  and  occasionally 
in  debilitated  children.    An  instance  of  it  came  under  my  notice  in  pneu- 


466  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

monia.  The  exudation  may  be  extensive  and  uniform  or  in  patches.  The 
condition  is  not  recognizable  during  life,  unless,  as  in  a  case  of  John  Thom- 
son's, the  membranes  are  vomited. 

Mycotic  and  Parasitic  Gastritis. — It  occasionally  happens  that  fungi 
develop  in  the  stomach  and  excite  inflammation.  One  of  the  most  remark- 
able cases  of  the  kind  is  that  reported  by  Kundrat,  in  which  the  favus 
fungus  developed  in  the  stomach  and  intestine. 

In  cancer  and  in  dilatation  of  the  stomach  the  sarcinae  and  yeast  fungi 
probably  aid  in  maintaining  the  chronic  gastritis.  As  a  rule,  the  gastric 
juice  is  capable  of  killing  the  ordinary  bacteria.  Orth  states  that  the 
anthrax  bacilli,  in  certain  cases,  produce  swelling  of  the  mucosa  and  ulcera- 
tion. Eug.  Fraenkel  has  reported  a  case  of  acute  emphysematous  gastritis 
probably  of  mycotic  origin.  The  larvas  of  certain  insects  may  excite  gas- 
tritis, as  in  the  cases  reported  by  Gerhardt,  Meschede,  and  others.  In  rare 
instances  tuberculosis  and  syphilis  attack  the  gastric  mucosa. 


II.    CHRONIC  GASTRITIS. 

{Chronic  Catarrh  of  the  Stomach;  Chronic  Dyspepsia) 

Definition. — A  condition  of  disturbed  digestion  associated  with  in- 
creased mucous  formation,  qualitative  or  quantitative  changes  in  the  gastric 
juice,  enfeeblement  of  the  muscular  coats,  so  that  the  food  is  retained  for 
an  abnormal  time  in  the  stomach;  and,  finally,  with  alterations  in  the 
structure  of  the  mucosa. 

Etiology.— The  causes  of  chronic  gastritis  may  be  classified  as  fol- 
lows: (1)  Dietetic.  The  use  of  unsuitable  or  improperly  prepared  food. 
The  persistent  use  of  certain  articles  of  diet,  such  as  very  fat  substances 
or  foods  containing  too  much  of  the  carbohydrates.  New  England  pie  and 
the  hot  breads  of  the  Southern  States  are  responsible  for  many  cases  of 
chronic  dyspepsia.  The  use  in  excess  of  tea  or  coffee,  and,  above  all,  of  alco- 
hol in  its  various  forms.  Under  this  heading,  too,  may  be  mentioned  the 
habits  of  eating  at  irregular  hours  or  too  rapidly  and  imperfectly  chewing 
the  food.  In  this  country  excess  in  eating  does  more  damage  than  excess  in 
drinking.  A  common  cause  of  chronic  catarrh  is  drinking  too  freely  of  ice- 
water  during  meals,  a  practice  which  plays  no  small  part  in  the  prevalence  of 
dyspepsia  in  America.  Another  frequent  cause  is  the  abuse  of  tobacco,  par- 
ticularly chewing.  (2)  Constitutional  causes.  Anaemia,  chlorosis,  chronic 
tuberculosis,  gout,  diabetes,  and  Bright's  disease  are  often  associated  with 
chronic  gastric  catarrh.  (3)  Local  conditions:  (a)  of  the  stomach,  as  in  can- 
cer, ulcer,  and  dilatation,  which  are  invariably  accompanied  by  catarrh;  (&) 
conditions  of  the  portal  circulation,  causing  chronic  engorgement  of  the 
mucous  membrane,  as  in  cirrhosis,  chronic  heart-disease,  and  certain  chronic 
lung  affections. 

Morbid  Anatomy. — Anatomically  two  forms  of  chronic  gastritis 
may  be  recognized,  the  simple  and  the  sclerotic. 

{a)  Simple  Chronic  Gastritis. — The  organ  is  usually  enlarged,  the 
mucous  membrane  pale  gray  in  color,  and  covered  with  closely  adherent, 


CHRONIC  GASTRITIS.  467 

tenacious  mucus.  The  veins  are  large,  patches  of  ecchymosis  are  not  in- 
frequently seen,  and  in  the  chronic  catarrh  of  portal  obstruction  and  of 
chronic  heart-disease  small  hsemorrhagic  erosions.  Toward  the  pylorus  the 
mucosa  is  not  infrequently  irregularly  pigmented,  and  presents  a  rough, 
wrinkled,  mammillated  surface,  the  Hat  mammelone  of  the  French,  a  con- 
dition which  may  sometimes  be  so  prominent  that  writers  have  described 
it  as  gastritis  polyposa.  The  membrane  may  be  thinner  than  normal,  and 
much  firmer,  tearing  less  readily  with  the  finger-nail.  Ewald  thus  de- 
scribes the  histological  changes:  The  minute  anatomy  shows  the  picture 
of  a  parenchymatous  and  an  interstitial  inflammation.  The  gland  cells 
are  in  part  eroded  or  show  cloudy  granular  swelling  or  atrophy.  The  dis- 
tinction between  the  principal  and  marginal  cells  cannot  be  recognized, 
and  in  many  places,  particularly  in  the  pyloric  region,  the  tubes  have  lost 
their  regular  form  and  show  in  many  places  an  atypical  branching,  like 
the  fingers  of  a  glove.  Individual  glands  are  cut  ofE  toward  the  fundus, 
but  appear  at  the  border  of  the  submucosa  as  cysts,  partly  empty,  with  a 
smooth  membrane,  partly  filled  with  remnants  of  hyaline  and  refractile 
epithelium.  An  abundant  small-celled  infiltration  presses  apart  the  tubules 
being  particularly  marked  toward  the  surface  of  the  mucosa,  and  from 
the  submucosa  extensions  of  the  connective  tissue  may  be  seen  passing 
between  the  glands.  The  mucoid  transformation  of  the  cells  of  the  tubules 
is  a  striking  feature  in  the  process  and  may  extend  to  the  very  fundus  of 
the  glands. 

(i)  Sclerotic  Gastritis. — As  a  final  result  of  the  parenchymatous  and 
interstitial  changes  the  mucous  membrane  may  undergo  complete  atrophy, 
so  that  but  few  traces  of  secreting  substance  remain.  There  appear  to 
be  two  forms  of  this  sclerotic  atrophy — one  with  thinning  of  the  coats  of 
the  stomach,  phthisis  ventriculi,  and  a  retention  or  even  increase  of  the 
size  of  the  organ;  the  other  with  enormous  thickening  of  the  coats  and 
great  reduction  in  the  volume  of  the  organ,  the  condition  which  is  usually 
described  as  cirrhosis  ventriculi.  Extreme  atrophy  of  the  mucous  mem- 
brane of  the  stomach  has  been  carefully  studied  by  Fenwick,  Ewald,  and 
others,  and  we  now  recognize  the  fact  that  there  may  be  such  destruction 
and  degeneration  of  the  glandular  elements  by  a  progressive  development 
of  interstitial  tissue  that  ultimately  scarcely  a  trace  of  secreting  tissue  re- 
mains. In  a  characteristic  case,  studied  by  Henry  and  myself,  the  greater 
portion  of  the  lining  membrane  of  the  stomach  was  converted  into  a  per- 
fectly smooth,  cuticular  structure,  showing  no  trace  whatever  of  glandular 
elements,  with  enormous  hypertrophy  of  the  muscularis  mucosse,  and  here 
and  there  formation  of  cysts.  In  the  other  form,  with  identical  atrophy 
and  cyst  formation,  there  is  enormous  increase  in  the  connective  tissue,  and 
the  stomach  may  be  so  contracted  that  it  does  not  hold  more  than  a  couple 
of  ounces.  The  walls  may  measure  from  2  to  3  cm.;  the  greatest  increase 
in  thickness  is  in  the  submucosa,  but  the  hypertrophy  also  extends  to  the 
muscular  layers.  A  similar  afl^ection  may  coexist  in  the  caecum  and  colon. 
The  condition  may  be  difficult  to  distinguish  from  diffuse  carcinoma.  There 
may  be  also  proliferative  peritonitis,  with  perihepatitis,  perisplenitis,  and 
ascites.     While  one  is  not  justified  in  saying  that  all  cases  of  cirrhosis  of 


4,68  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

the  stomacli  represent  a  final  stage  in  the  history  of  a  chronic  catarrh,  it  is 
true  that  in  most  cases  the  process  is  associated  with  atrophy  of  the  gastric 
mucosa,  while  the  history  indicates  the  existence  of  chronic  dyspepsia. 

Erosions  of  the  Stomach. — Small  superficial  losses  of  substance  are  met 
with  in  the  stomach  under  a  great  variety  of  conditions,  usually  in  connec- 
tion with  chronic,  gastritis,  diseases  of  the  liver,  particularly  cirrhosis,  and 
chronic  diseases  of  the  heart.  Einhorn  has  described,  too,  a  special  con- 
dition in  which  in  the  washings  from  the  fasting  stomach  little  shreds  of 
gastric  mucous  membrane  are  found,  and  there  is  tenderness  and  soreness  on 
passing  the  tube  and  a  little  staining  of  the  water.  These  are  probably  the 
result  of  passing  the  tube.  True  erosions  are  usually  multiple,  more  com- 
mon, I  think,  in  the  pyloric  region,  and  are  usually  without  any  symptoms. 
The  mucosa  in  the  neighborhood  of  the  erosion  may  be  deeply  hsemor- 
rhagic.  When  one  sees  a  large  number  of  erosions,  which  may  be  present 
in  some  cases,  it  is  difficult  to  understand  why  larger  ulcers  do  not  form 
at  their  site.  The  only  ill  effect  I  know  of  is  the  occurrence  of  profuse  or 
even  fatal  haemorrhage. 

Symptoms. — The  affection  persists  for  an  indefinite  period,  and,  as 
is  the  case  with  most  chronic  diseases,  changes  from  time  to  time.  The 
appetite  is  variable,  sometimes  greatly  impaired,  at  others  very  good. 
Among  early  symptoms  are  feelings  of  distress  or  oppression  after  eating, 
which  may  become  aggravated  and  amount  to  actual  pain.  When  the 
stomach  is  empty  there  may  also  be  a  painful  feeling.  The  pain  differs  in 
different  cases,  and  may  be  trifling  or  of  extreme  severity.  Wlien  localized 
and  felt  beneath  the  sternum  or  in  the  prsecordial  region  it  is  known  as 
heart-burn  or  sometimes  cardialgia.  There  is  pain  on  pressure  over  the 
stomach,  usually  diffuse  and  not  severe.  The  tongue  is  coated,  and  the 
patient  complains  of  a  bad  taste  in  the  mouth.  The  tip  and  margin  of  the 
tongue  are  very  often  red.  Associated  with  this  catarrhal  stomatitis  there 
may  be  an  increase  in  the  salivary  and  pharyngeal  secretions.  Nausea  is  an 
early  symptom,  and  is  particularly  apt  to  occur  in  the  morning  hours.  It 
is  not,  however,  nearly  so  constant  a  symptom  in  chronic  gastritis  as  in 
cancer  of  the  stomach,  and  in  mild  grades  of  the  affection  it  may  not  occur 
at  all.  Eructation  of  gas,  which  may  continue  for  some  hours  after  taking 
food,  is  a  very  prominent  feature  in  cases  of  so-called  flatulent  dyspepsia, 
and  there  may  be  marked  distention  of  the  intestines.  With  the  gas,  bitter 
fluids  may  be  brought  up.  Vomiting,  which  is  not  very  frequent,  occurs 
either  immediately  after  eating  or  an  hour  or  two  later.  In  the  chronic 
catarrh  of  old  topers  a  bout  of  morning  vomiting  is  common,  in  which  a 
slimy  mucus  is  brought  up.  The  vomitus  consists  of  food  in  various  stages 
of  digestion  and  slimy  mucus,  and  the  chemical  examination  shows  the 
presence  of  abnormal  acids,  such  as  butyric,  or  even  acetic,  in  addition  to 
lactic  acid,  while  the  hydrochloric  acid,  if  indeed  it  is  present,  is  much  re- 
duced in  quantity.  The  digestion  may  be  much  delayed,  and  on  washing 
out  the  stomach  as  late  as  seven  hours  after  eating,  portions  of  food  are 
still  present.  The  prolonged  retention  favors  decomposition,  the  stomach 
becomes  distended  with  gas,  and  this,  with  the  chronic  catarrh,  may  induce 
gradually  an  atony  of  the  muscular  walls.     The  absorption  is  slow,  and 


CHRONIC  GASTRITIS. 

469 

iodide  of  potassium,  given  in  capsules.^  -  ^^.^^  ^^^.^^^^  normally  reach  the 
saliva  within  fifteen  minutes,  may^  ^^^  ^  ^^.^^^^  ^^^  ^^^^  ^^^^  ^^^^  ^^ 
hour. 

Constipation  is  usual^;^  pj^^^t,  but  in  some  instances  there  is  diarrhoea, 
and  undigested  f 00^;^  jmm^  rapidly  through  the  bowels.  The  urine  is  often 
scanty,  high-Cuimtg^,  and  deposits  a  heavy  sediment  of  urates. 

Of  qVh^?- §i^«ffii"|)toms  headache  is  common,  and  the  patient  feels  Cdiis'tantly 
out  %l  '^mM^  indisposed  for  exertion,  and  low-spirited.  la  (aggravated  cases 
Jffieflalifc^olia  may  develop.  Trousseau  called  atteati'b'ii  to  the  occurrence 
kk  "^^-ertigo,  a  marked  feature  in  certain  cases-.  The  pulse  is  small,  some- 
times slow,  and.  there  may  be  palpitati?*L  of  the  heart.  Fever  does  not 
occur.  Congh  is  sometimes  present,  ^but  the  so-called  stomach  cough  of 
chrojafe  dyspeptics  is  in  all  jM^bability  dependent  upon  pharyngeal  irri- 
taiiom. 

The  Gastric  C'&HfS^ls. — The  fasting  stomach  may  be  empty  or  it  may 
contain  mu<dk  ^ii^Mus — gastritis  mucipara  of  Boas.  In  the  test  breakfast, 
witJid?awi6.  i^^  an  hour,  the  HCl  is  usually  diminished,  though  it  may  be 
M^rm^h^'-gastritis  acida.  In  other  cases  the  free  HCl  may  be  absent — • 
(^^Htis  anacida.  While  in  the  advanced  forms  of  atrophy  of  the  mucosa 
■^iiere  may  be  neither  acids  nor  ferments — gastritis  atrophicans. 

The  motor  function  of  the  stomach  is  not  usually  much  impaired. 

The  symptoms  ol  a'ttophy  of  the  mucous  membrane  of  the  stomach,  with 
or  without  iCGiiiitr>a<ietion  of  the  organ,  are  very  complex,  and  cannot  be  said 
to  p!reQeiil<t  a  liftif orm  picture.  The  majority  of  the  cases  present  the  symp- 
tjoM's  0$  al.  Aggravated  chronic  dyspepsia,  often  of  such  severity  that  cancer 
iis  s'uslf^1;ed.  In  one  of  the  cases  which  I  examined,  the  persistent  distress 
•aft*  feating,  the  vomiting,  and  the  gradual  loss  of  flesh  and  strength,  very 
iQf^turally  led  to  this  diagnosis,  but  the  duration  of  the  disease  far  ex- 
ceeded that  of  ordinary  carcinoma.  In  the  cirrhotic  form  the  tumor  mass 
may  sometimes  be  felt.  In  atrophy  of  the  stomach,  whether  associated 
with  cirrhosis  or  not,  the  clinical  picture  may  be  that  of  pernicious  anaemia. 
As  early  as  1860,  Flint  called  attention  to  this  connection  between  atrophy 
of  the  gastric  tubules  and  anaemia,  an  observation  which  Fenwick  and 
others  have  amply  confirmed. 

Did^nosis. — Ewald  distinguishes  three  forms  of  chronic  gastritis:  (1) 
^i-mip^^  gastritis;  (2)  mucous  (schleimige)  gastritis;  (3)  atrophic  gastritis. 

In  (1)  the  fasting  stomach  contains  only  a  small  quantity  of  a  slimy 
fluid,  while  after  the  test  breakfast  the  HCl  is  diminished  in  quantity  or 
may  be  absent.  Lactic  acid  and  the  fatty  acids  may  be  present.  After  Boas's 
more  rigid  test  meal  the  organic  acids  are  rarely  found.  The  pepsin  and 
rennet  are  always  present. 

In  (2)  the  acidity  is  always  slight  and  the  condition  is  distinguished 
from  (1)  chiefly  by  the  large  amount  of  mucus  present. 

In  (3)  the  fasting  stomach  is  generally  empty,  while  after  the  test 
breakfast  HCl,  pepsin,  aud  the  curdling  ferment  are  wholly  wanting. 

The  diagnosis  of  cancer  of  the  stomach  from  chronic  gastritis  may  be 
very  difficult  when  a  tumor  is  not  present.  The  cases  require  most  careful 
study,  and  it  may  take  several  months  before  a  decision  can  be  reached. 


470  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

Treatment. — When  possible  the  cause  in  each  case  should  be  ascer- 
tained and  an  attempt  made  to  determine  the  special  form  of  indigestion. 
Usually  there  is  no  difficulty  in  differentiating  the  ordinary  catarrhal  and 
the  nervous  varieties.  A  careful  study  of  the  phenomena  of  digestion  in 
the  way  already  laid  down,  though  not  essential  in  every  instance,  should 
certainly  be  carried  out  in  the  more  obstinate  and  obscure  forms.  Two  im- 
portant questions  should  be  asked  of  every  dyspeptic — first,  as  to  the  time 
taken  at  his  meals;  and,  second,  as  to  the  quantity  he  eats.  Practically 
a  large  majority  of  all  cases  of  disturbed  digestion  come  from  hasty  and 
imperfect  mastication  of  the  food  and  from  overeating.  Especial  stress 
should  be  laid  upon  the  former  point.  In  some  instances  it  will  alone  suf- 
fice to  cure  dyspepsia  if  the  patient  will  count  a  certain  number  before 
swallowing  each  mouthful.  The  second  point  is  of  even  greater  impor- 
tance. People  habitually  eat  too  much,  and  it  is  probably  true  that  a 
greater  number  of  maladies  arise  from  excess  in  eating  than  from  excess 
in  drinking.  George  Cheyne's  thirteenth  aphorism  contains  a  volume  of 
dietetic  wisdom:  "Every  wise  man,  after  Fifty,  ought  to  begin  to  lessen 
at  least  the  quantity  of  his  Aliment,  and  if  he  would  continue  free  of 
great  and  dangerous  Distempers  and  preserve  his  Senses  and  Faculties  clear 
to  the  last  he  ought  every  seven  years  go  on  abateing  gradually  and  sensibly, 
and  at  last  descend  out  of  Life  as  he  ascended  into  it,  even  into  the  Child's 
Diet." 

(a)  General  and  Dietetic. — A  careful  and  systematically  arranged  di- 
etary is  the  first,  sometimes  the  only,  essential  in  the  treatment  of  a  case  of 
chronic  dyspepsia.  It  is  impossible  to  lay  down  rules  applicable  to  all  cases. 
Individuals  differ  extraordinarily  in  their  capability  of  digesting  different 
articles  of  food,  and  there  is  much  truth  in  the  old  adage,  "  One  man's  food 
is  another  man's  poison."  The  individual  preferences  for  different  articles 
of  food  should  be  permitted  in  the  milder  forms.  Physicians  have  probably 
been  too  arbitrary  in  this  direction,  and  have  not  yielded  sufficiently  to  the 
intimations  given  by  the  appetite  and  desires  of  the  patient. 

A  rigid  milk  diet  may  be  tried.  "  Milk  and  sweet  sound  Blood  differ 
in  nothing  but  in  Color:  Milh  is  Blood"  (George  Cheyne).  In  the  forms 
associated  with  Bright's  disease  and  chronic  portal  congestion,  as  well  as  in 
many  instances  in  which  the  dyspepsia  is  part  of  a  neurasthenic  or  hysterical 
trouble,  this  plan  in  conjunction  with  rest  is  most  efficacious.  If  milk 
is  not  digested  well  it  may  be  diluted  one  third  with  soda  water  or  Vichy, 
or  5  to  10  grains  of  carbonate  of  soda,  or  a  pinch  of  salt  may  be  added  to 
each  tumblerful.  In  many  cases  the  milk  from  which  the  cream  has  been 
taken  is  better  borne.  Buttermilk  is  particularly  suitable,  but  can  rarely 
be  taken  for  so  long  a  time  alone,  as  patients  tire  of  it  much  more  readily 
than  they  do  of  ordinary  milk.  Not  only  can  the  general  nutrition  be 
maintained  on  this  diet,  but  patients  sometimes  increase  in  weight,  and  the 
unpleasant  gastric  symptoms  disappear  entirely.  It  should  be  given  at 
fixed  hours  and  in  definite  quantities.  A  patient  may  take  6  or  8  ounces 
every  three  hours.  The  amount  necessary  varies  a  good  deal,  but  at  least 
3  to  5  pints  should  be  given  in  the  twenty-four  hours.  This  form  of  diet  is 
not,  as  a  rule,  well  borne  when  there  is  a  tendency  to  dilatation  of  the 


CHRONIC  GASTRITIS.  471 

stomach.  The  milk  may  be  previously  peptonized,  but  it  is  impossible  to 
feed  a  chronic  dyspeptic  in  this  way.  The  stools  should  be  carefully 
watched,  and  if  more  milk  is  taken  than  can  be  digested  it  is  well  to  supple- 
ment the  diet  with  eggs  and  dry  toast  or  biscuits. 

In  a  large  proportion  of  the  cases  of  chronic  indigestion  it  is  not  neoes- 
sary  to  annoy  the  patient  with  such  strict  dietaries.  It  may  be  quite  suf- 
ficient to  cut  off  certain  articles  of  food.  Thus,  if  there  are  acid  eructations 
or  flatulency,  the  farinaceous  foods  should  be  restricted,  particularly  pota- 
toes and  the  boarser  vegetables.  A  fruitful  source  of  indigestion  is  the 
hot  bread  which,  in  different  forms,  is  regarded  as  an  essential  part  of  an 
American  breakfast.  This,  as  well  as  the  various  forms  of  pancakes,  pies 
and  tarts,  with  heavy  pastry,  and  fried  articles  of  all  sorts,  should  be  strictly 
forbidden.  As  a  rule,  white  bread,  toasted,  is  more  readily  digested  than 
bread  made  from  the  whole  meal.  Persons,  however,  differ  very  much  in 
this  respect,  and  the  Graham  or  brown  bread  is  for  many  people  most 
digestible.  Sugar  and  very  sweet  articles  of  food  should  be  taken  in  great 
moderation  or  avoided  altogether  by  persons  with  chronic  dyspepsia.  Many 
instances  of  aggravated  indigestion  have  come  to  my  notice  due  to  the 
prevalent  practice  of  eating  largely  of  ice-cream.  One  of  the  most  powerful 
enemies  of  the  American  stomach  in  the  present  day  is  the  soda-water 
fountain,  which  has  usurped  so  important  a  place  in  the  apothecary  shop. 

Fats,  with  the  exception  of  a  moderate  amount  of  good  butter,  very 
fat  meats,  and  thick,  greasy  soups  should  be  avoided.  Kipe  fruit  in  modera- 
tion is  often  advantageous,  particularly  when  cooked.  Bananas  are  not,  as 
a  rule,  well  borne.  Strawberries  are  to  many  persons  a  cause  of  an  annual 
attack  of  indigestion  and  sore  throat  in  the  spring  months. 

As  stated,  in  the  matter  of  special  articles  of  food  it  is  impossible  to 
lay  down  rigid  rules,  and  it  is  the  common  experience  that  one  patient 
with  indigestion  will  take  with  impunity  the  very  articles  which  cause  the 
greatest  distress  to  another. 

Another  detail  of  importance  which  may  be  mentioned  in  this  con- 
nection is  the  general  hygienic  management  of  dyspeptics.  These  pa- 
tients are  often  introspective,  dwelling  in  a  morbid  manner  on  their  symp- 
toms, and  much  inclined  to  take  a  despondent  view  of  their  condition. 
Very  little  progress  can  be  made  unless  the  physician  gains  their  confidence 
from  the  outset.  Their  fears  and  whims  should  not  be  made  too  light  of 
or  ridiculed.  Systematic  exercise,  carefully  regulated,  particularly  when, 
as  at  watering  places,  it  is  combined  with  a  restricted  diet,  is  of  special 
service.  Change  of  air  and  occupation,  a  prolonged  sea  voyage,  or  a  summer 
in  the  mountains  will  sometimes  cure  the  most  obstinate  dyspepsia. 

(b)  Medicinal. — The  special  therapeutic  measures  may  be  divided  into 
those  which  attempt  to  replace  in  the  digestive  Juices  important  elements 
which  are  lacking  and  those  which  stimulate  the  weakened  action  of  the 
organ.  In  the  first  group  come  the  hydrochloric  acid  and  ferments,  which 
are  so  freely  employed  in  dyspepsia.  The  former  is  the  most  important. 
It  is  the  ingredient  in  the  gastric  juice  most  commonly  deficient.  It  is  not 
only  necessary  for  its  own  important  actions,  but  its  presence  is  intimately 
associated  with  that  of  the  pepsin,  as  it  is  only  in  the  presence  of  a  suffi- 


472  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cient  quantity  that  the  pepsinogen  is  converted  into  the  active  digestive 
ferment.  It  is  best  given  as  the  dilute  acid  taken  in  somewhat  larger  quan- 
tities than  are  usually  advised.  Ewald  recommends  large  doses — of  from 
90  to  100  drops — at  intervals  of  fifteen  minutes  after  the  meals.  Leube 
and  Eiegel  advise  smaller  doses.  Probably  from  15  to  20  drops  is  sufficient. 
The  prolonged  use  of  it  does  not  appear  to  be  in  any  way  hurtful.  The  use, 
however,  should  be  restricted  to  cases  of  neurosis  and  atrophy  of  the  mucous 
membrane.    In  actual  gastritis  its  value  is  doubtful. 

Nitrate  of  silver  is  a  good  remedy  in  some  cases,  used  in  solution  in 
the  lavage  (1  to  1,500  or  1  to  2,000),  or  in  pill  form,  one  eighth  to  one 
fourth  of  a  grain  three  times  a  day.  For  many  years  Pepper  has  advocated 
the  more  extended  use  of  this  drug  in  chronic  gastritis.  I  have  seen  an 
instance  of  argyria  after  its  protracted  use. 

The  digestive  ferments:  These  are  extensively  employed  to  strengthen 
the  weakened  gastric  and  intestinal  secretions.  The  use  of  pepsin,  ac- 
cording to  Ewald,  may  be  limited  to  the  cases  of  advanced  mucous  catarrh 
and  the  instances  of  atrophy  of  the  stomach,  in  which  it  should  be  given, 
in  doses  of  from  10  to  15  grains,  with  dilute  hydrochloric  acid  a  quarter 
of  an  hour  after  meals.  It  may  be  used  in  various  different  forms,  either 
as  a  powder  or  in  solution  or  given  with  the  acid.  The  powder,  is  much 
more  certain.  Pepsin  wine  is  generally  inert,  as  there  is  little  of  the  fer- 
ment taken  up  by  alcohol.  It  is  important  to  use  a  reliable  article.  Much 
that  is  in  the  market  is  valueless. 

Pancreatin  is  of  equal  or  even  greater  value  than  the  pepsin.  Pains 
should  be  taken  to  use  a  good  article,  such  as  that  prepared  by  Merck.  It 
should  be  given  in  doses  of  from  15  to  20  grains,  in  combination  with 
bicarbonate  of  soda.  It  is  conveniently  administered  in  tablets,  each  of 
which  contains  5  grains  of  the  pancreatin  and  the  soda,  and  of  these  two 
or  three  may  be  taken  fifteen  or  twenty  minutes  after  each  meal.  Ptyalin 
and  diastase  are  particularly  indicated  when  the  acid  is  excessive.  The 
action  of  the  former  continues  in  the  stomach  during  normal  digestion. 
The  malt  diastase  is  often  very  serviceable  given  with  alkalies. 

Of  measures  which  stimulate  the  glandular  activity  in  chronic  dys- 
pepsia lavage  is  by  far  the  most  important,  particularly  in  the  forms  char- 
acterized by  the  secretion  of  a  large  quantity  of  mucus.  Luke-warm  water 
should  be  used,  or,  if  there  is  much  mucus,  a  1-per-cent  salt  solution,  or 
a  3-  to  5-per-cent  solution  of  bicarbonate  of  soda.  If  there  is  much  fer- 
mentation the  3-per-cent  solution  of  boric  acid  may  be  used,  or  a  dilute 
solution  of  carbolic  acid.  It  is  best  employed  in  the  morning  on  an  empty 
stomach,  or  in  the  evening  some  hours  after  the  last  meal.  It  is  perhaps 
preferable  in  the  morning,  except  in  those  cases  in  which  there  is  much 
nocturnal  distress  and  flatulency.  Once  a  day  is,  as  a  rule,  sufficient,  or, 
in  the  case  of  delicate  persons,  every  second  day.  The  irrigation  may  be 
continued  until  the  water  which  comes  away  is  quite  clear.  It  is  not  neces- 
sary to  remove  all  the  fluid  after  the  irrigation. 

Wliile  perhaps  in  some  hands  this  measure  has  been  carried  to  ex- 
tremes, it  is  one  of  such  extraordinary  value  in  certain  cases  that  it  should 
be  more  widely  employed  by  practitioners.    When  there  is  an  insuperable 


CHRONIC   GASTRITIS.  473 

objection  to  lavage  a  substitute  may  be  used  in  the  form  of  warm  alka- 
line drinks,  taken  slowly  in  the  early  morning  or  the  last  thing  at 
night. 

Of  medicines  which  stimulate  the  gastric  secretion  the  most  important 
are  the  bitter  tonics,  such  as  quassia,  gentian,  calumba,  cundurango,  ipecacu- 
anha, strychnia,  and  cardamoms.  These  are  probably  of  more  value  in 
chronic  gastritis  than  the  hydrochloric  acid.  Of  these  strychnia  is  the  most 
powerful,  though  none  of  them  have  probably  any  very  great  stimulating 
action  on  the  secretion,  and  influence  rather  the  appetite  than  the  diges- 
tion. Of  stomachics  which  are  believed  to  favorably  influence  digestion 
the  most  important  are  alcohol  and  common  salt.  The  former  would  appear 
to  act  in  moderate  quantities  by  increasing  the  acid  in  the  gastric  juice,  and 
with  it  probably  the  pepsin  formation.  Others  hold  that  it  is  not  so  much 
the  secretory  as-  the  motor  function  of  the  stomach  which  the  alcohol 
stimulates.  In  moderate  quantities  it  has  certainly  no  directly  injurious 
influence  on  the  digestive  processes.  Special  care  should  be  taken,  how- 
ever, in  ordering  alcohol  to  dyspeptics.  If  a  patient  has  been  in  the  habit 
of  taking  beer  or  light  wines  or  stimulants  with  his  meals,  the  practice 
may  be  continued  if  moderate  quantities  are  taken.  Beer,  as  a  rule,  is  not 
well  borne.  A  dry  sherry  or  a  glass  of  claret  is  preferable.  In  the  case  of 
women  with  any  form  of  dyspepsia  stimulants  should  be  employed  with 
the  greatest  caution,  and  the  practitioner  should  know  his  patient  well 
before  ordering  alcohol. 

The  importance  of  salt  in  gastric  digestion  rests  upon  the  fact  that  its 
presence  is  essential  in  the  formation  of  the  hydrochloric  acid.  An  in- 
crease in  its  use  may  be  advised  in  all  cases  of  chronic  dyspepsia  in  which 
the  acid  is  defective. 

Treatment  of  Special  Conditions. — Fermentation  and  flatu- 
lency. When  the  digestion  is  slow  or  imperfect,  fermentation  goes  on  in 
the  contents,  with  the  formation  of  gas  and  the  production  of  lactic,  butyric, 
and  acetic  acids.  For  the  treatment  of  this  condition  careful  dieting  may 
suffice,  particularly  forbidding  such  articles  as  tea,  pastry,  and  the  coarser 
vegetables.  It  is  usually  combined  with  pyrosis,  in  which  the  acid  fluids 
are  brought  into  the  mouth.  Bismuth  and  carbonate  of  soda  sometimes 
suffice  to  relieve  the  condition.  Thymol,  creasote,  and  carbolic  acid  may 
be  employed.  For  acid  dyspepsia  Sir  William  Eoberts  recommends  the 
bismuth  lozenge  of  the  British  Pharmacopoeia,  the  antacid  properties  of 
which  depend  on  chalk  and  bicarbonate  of  soda.  It  should  be  taken  an 
hour  or  two  after  meals,  and  only  when  the  pain  and  uneasiness  are  pres- 
ent. The  burnt  magnesia  is  also  a  good  remedy.  Glycerin  in  from  20-  to 
60-minim  doses,  the  essential  oils,  animal  charcoal  alone  or  in  combination 
with  compound  cinnamon  powder,  may  be  tried.  If  there  is  much  pain, 
chloroform  in  20-minim  doses  or  a  teasjioonful  of  Hoffman's  anodyne  may 
be  used.  In  obstinate  cases  lavage  is  indicated  and  is  sometimes  striking  in 
its  effects.     Alkaline  solutions  may  be  used. 

Vomiting  is  not  a  feature  which  often  calls  for  treatment  in  chronic 
dyspepsia;  sometimes  in  children  it  is  a  persistent  symptom.  Creasote  and 
carbolic  acid  in  drop  doses,  a  few  drops  of  chloroform  or  of  dilute  hydro- 


4Y4  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

cyanic  acid,  cocaine,  bismuth,  and  oxalate  of  cerium  may  be  used.  If 
obstinate,  the  stomach  sliould  be  washed  out  daily. 

Constipation  is  a  frequent  and  troublesome  feature  of  most  forms  of 
indigestion.  Occasionally  small  doses  of  mercury,  podophyllin,  the  laxative 
mineral  waters,  sulphur,  and  cascara  may  be  employed.  Glycerin  sup- 
positories or  the  injection  of  from  half  a  teaspoonful  to  a  teaspoonful  of 
glycerin  is  very  efficacious. 

Many  cases  of  chronic  dyspepsia  are  greatly  benefited  by  the  use  of 
mineral  waters,  particularly  a  residence  at  the  springs  with  a  careful  super- 
vision of  the  diet  and  systematic  exercise.  The  strict  regime  of  certain 
German  Spas  is  particularly  advantageous  in  the  cases  in  which  the  chronic 
dyspepsia  has  resulted  from  excess  in  eating  and  in  drinking.  Kissingen, 
Carlsbad,  Ems,  and  Wiesbaden  are  to  be  specially  recommended. 


III.     DILATATION   OF  THE   STOMACH   (Gastrectasis). 

Etiology. — This  may  occur  either  as  an  acute  or  a  chronic  condition. 

Acute  dilatation  is  rarely  seen,  though  it  occurs  whenever  enormous 
quantities  of  food  and  drink  are  quickly  ingested.  Occasionally  this  leads 
to  extreme  paralytic  dilatation,  and  Fagge  has  described  two  cases  which 
came  on  in  this  way,  one  of  which  proved  fatal.  AUbutt  mentions  a  re- 
markable instance  of  acute  dilatation  of  the  stomach  under  the  care  of 
Broadbent,  in  which  8  pints  of  fluid  were  siphoned  from  the  stomach.  "  jSTo 
sooner,  however,  was  this  volume  of  fluid  removed  than  the  stomach  began 
to  refill,  and  was  rapidly  distended  again  to  its  former  dimensions." 

Clironic  dilatation  results  from:  (a)  ISTarrowing  of  the  pylorus  or  of  the 
duodenum  by  the  cicatrization  of  an  ulcer,  hypertrophic  stenosis  of  the 
pylorus  (whether  cancerous  or  simple),  congenital  stricture,  or  occasionally 
by  pressure  from  without  of  a  tumor  or  of  a  floating  kidney.  Without  any 
organic  disease  the  pylorus  may  be  tilted  up  by  adhesion  to  the  liver  or 
gall-bladder,  or  the  stomach  may  be  so  dilated  that  the  pylorus  is  dragged 
down  and  kinked,  (b)  Eelative  or  absolute  insufficiency  of  the  muscular 
power  of  the  stomach,  due  on  the  one  hand  to  repeated  overfilling  of  the 
organ  with  food  and  drink  {TJeljeranstrengung  des  Magens,  Striimpell), 
and  on  the  other  to  atony  of  the  coats  induced  by  chronic  inflammation  or 
degeneration  of  impaired  nutrition,  the  result  of  constitutional  affections, 
as  cancer,  tuberculosis,  ansemia,  etc. 

It  is  important  to  distinguish  between  a  dilated  stomach  and  a  dis- 
placed organ,  which  will  be  considered  under  the  section  on  enteroptosis. 

The  most  extreme  forms  are  met  with  in  the  first  group,  and  most 
commonly  as  a  sequence  of  the  cicatricial  contraction  of  an  ulcer.  There 
may  be  considerable  stenosis  without  much  dilatation,  the  obstruction  being 
compensated  by  hypertrophy  of  the  muscular  coats.  Considerable  atten- 
tion has  been  directed  in  Germany  by  Litten,  ^Ewald,  and  others  to  the 
association  of  dilatation  with  dislocation  of  the  right  kidney. 

In  the  second  group,  due  to  atony  of  the  muscular  coats,  we  must  dis- 
tinguish between  instances  in  which  the  stomach  is  simply  enlarged  and 


DILATATION  OF  THE  STOMACH.  475 

those  with  actual  dilatation,  the  conditions  which  Ewald  characterized  as 
megastrie  and  gastredasis  respectively.  The  size  of  the  stomach  varies 
greatly  in  different  individuals,  and  the  maximum  capacity  of  a  normal 
organ  Ewald  places  at  about  1,600  cc.  Measurements  above  this  point  in- 
dicate absolute  dilatation. 

Atonic  dilatation  of  the  stomach  may  result  from  weakness  of  the  coats, 
due  to  repeated  overdistention  or  to  chronic  catarrh  of  the  mucous  mem- 
brane, or  to  the  general  muscular  debility  which  is  associated  with  chronic 
wasting  disorders  of  all  sorts.  The  combination  of  chronic  gastric  catarrh 
with  overfeeding  and  excessive  drinking  is  one  of  the  most  fruitful  sources 
of  atonic  dilatation,  as  pointed  out  by  Naunyn.  The  condition  is  fre- 
quently seen  in  diabetics,  in  the  insane,  and  in  beer-drinkers.  In  Germany 
this  form  is  very  common  in  men  employed  in  the  breweries.  Possibly 
muscular  weakness  of  the  coats  may  result  in  some  cases  from  disturbed 
innervation.  Dilatation  of  the  stomach  is  most  frequent  in  middle-aged 
or  elderly  persons,  but  the  condition  is  not  uncommon  in  children,  espe- 
cially in  association  with  rickets. 

Symptoms. — These  are  very  variable  and  depend  upon  the  cause  and 
the  degree  of  dilatation.  Naturally  the  features  in  cancer  of  the  pylorus 
would  be  very  different  from  those  met  with  in  an  excessive  drinker.  Dys- 
pepsia is  present  in  nearly  all  cases,  and  there  are  feelings  of  distress  and 
uneasiness  in  the  region  of  the  stomach.  The  patient  may  complain  much 
of  hunger  and  thirst  and  eat  and  drink  freely.  The  most  characteristic 
symptom  is  the  vomiting  at  intervals  of  enormous  quantities  of  liquid  and 
of  food,  amounting  sometimes  to  four  or  more  litres.  The  material  is  often 
of  a  dark-grayish  color,  with  a  characteristic  sour  odor  due  to  the  organic 
acids  present,  and  contains  mucus  and  remnants  of  food.  On  standing  it 
separates  into  three  layers,  the  lowest  consisting  of  food,  the  middle  of 
a  turbid,  dark-gray  fluid,  and  the  uppermost  of  a  brownish  froth.  The 
microscopical  examination  shows  a  large  variety  of  bacteria,  yeast  fungi, 
and  the  sarcina  ventriculi.  There  may  also  be  cherry  stones,  plum  stones, 
and  grape  seeds. 

The  hydrochloric  acid  may  be  absent,  diminished,  normal,  or  in  excess, 
depending  upon  the  cause  of  the  dilatation.  The  fermentation  produces 
lactic,  butyric,  and,  possibly,  acetic  acid  and  various  gases. 

In  consequence  of  the  small  amount  of  fluid  which  passes  from  the 
stomach  or  is  absorbed  there  are  constipation,  scanty  urine,  and  extreme 
dryness  of  the  skin.  The  general  nutrition  of  the  patient  suffers  greatly; 
there  is  loss  of  flesh  and  strength,  and  in  some  cases  the  most  extreme 
emaciation.  A  very  remarkable  symptom  which  occurs  occasionally  is 
tetany,  first  described  by  Kussmaul. 

Physical  Signs. — Inspection. — The  abdomen  may  be  large  and  promi- 
nent, the  greatest  projection  occurring  below  the  navel  in  the  standing 
posture.  In  some  instances  the  outline  of  the  distended  stomach  can  be 
plainly  seen,  the  small  curvature  a  couple  of  inches  below  the  ensiform 
cartilage,  and  the  greater  curvature  passing  obliquely  from  the  tip  of  the 
tenth  rib  on  the  left  side,  toward  the  pubes,  and  then  curving  upward  to 
the  right  costal  margin.    Too  much  stress  cannot  be  laid  on  the  importance 


476  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  inspection.  In  10  of  13  cases  of  dilated  stomach  in  my  wards  during 
one  year  the  diagnosis  was  made  de  visu.  Active  peristalsis  may  be  seen 
in  the  dilated  organ,  the  waves  passing  from  left  to  right.  Occasionally 
anti-peristalsis  may  be  seen.  In  cases  of  stricture,  particularly  of  hyper- 
trophic stenosis,  as  the  peristaltic  wave  reaches  the  pylorus,  the  tumor- 
like thickening  can  sometimes  be  distinctly  seen  through  the  thin  ab- 
dominal wall.  To  stimulate  the  peristalsis  the  abdomen  may  be  flipped 
with  a  wet  towel.  Inflation  may  be  practised  with  carbonic-acid  gas. 
A  small  teaspoonful  of  tartaric  acid  dissolved  in  an  ounce  of  water  is 
first  given,  then  a  rather  larger  quantity  of  bicarbonate  of  soda.  In 
many  cases,  particularly  in  thin  persons,  the  outline  of  the  dilated  stom- 
ach stands  out  with  great  distinctness,  and  waves  of  peristalsis  are  seen 
in  it. 

Palpation. — The  peristalsis  may  be  felt,  and  usually  in  stenosis  the 
tumor  is  evident  at  the  pylorus.  The  resistance  of  a  dilated  stomach  is 
peculiar,  and  has  been  aptly  compared  to  that  of  an  air  cushion.  Biman- 
ual palpation  elicits  a  splashing  sound — clapotage — which  is,  of  course,  not 
distinctive,  as  it  can  be  obtained  whenever  there  is  much  liquid  and  air 
in  the  organ,  but  which  cannot  be  elicited  in  a  healthy  person  two  or  three 
hours  after  eating.  The  splashing  may  be  very  loud,  and  the  patient  may 
produce  it  himself  by  suddenly  depressing  the  diaphragm,  or  it  may  be 
readily  obtained  by  shaking  him.  A  tube  passed  into  the  stomach  may 
be  felt  externally  through  the  skin,  a  procedure  no  longer  recommended  by 
Leube,  who  suggested  it.  The  gurgling  of  gas  through  the  pylorus  may 
be  felt. 

Percussion. — The  note  is  tympanitic  over  the  greater  portion  of  a 
dilated  stomach;  in  the  dependent  part  the  note  is  dull.  In  the  upright 
position  the  percussion  should  be  made  from  above  downward,  in  the  left 
parasternal  line,  until  a  change  in  resonance  is  reached.  The  line  of  this 
should  be  marked,  and  the  patient  examined  in  the  recumbent  position, 
when  it  will  be  found  to  have  altered  its  level.  When  this  is  on  a  line  with 
the  navel  or  below  it,  dilatation  of  the  stomach  may  generally  be  assumed 
to  exist.  The  fluid  may  be  withdrawn  from  the  stomach  with  a  tube,  and 
the  dulness  so  made  to  disappear,  or  it  may  be  increased  by  pouring  in  more 
fluid.  In  cases  of  doubt  the  organ  should  be  artificially  distended  with 
carbonic-acid  gas  in  the  manner  described  above.  The  most  accurate 
method  of  determining  the  size  of  the  stomach  is  by  inflation  through  a 
stomach-tube  with  a  Davidson's  syringe.  Pacanowski  has  shown  that  the 
greatest  vertical  diameter  of  gastric  resonance  in  the  normal  stomach  varies 
from  10  to  14  cm.  in  the  male  and  is  about  10  cm.  in  the  female. 

Auscultation. — The  clapotement  or  succussion  can  be  obtained  readily. 
Frequently  a  curious  sizzling  sound  is  present,  not  unlike  that  heard  when 
the  ear  is  placed  over  a  soda-water  bottle  when  flrst  opened.  It  can  be 
heard  naturally,  and  is  usually  evident  when  the  artificial  gas  is  being 
generated.  The  heart  sounds  may  sometimes  be  transmitted  with  great 
clearness  and  Avith  a  metallic  quality. 

Mensuration  may  be  used  by  passing  a  hard  sound  into  the  stomach 
until  the  greater  curvature  is  reached.     Normally  it  rarely  passes  more 


DILATATION  OF  THE  STOMACH.  477 

than  60  cm.,  measured  from  the  teeth,  but  in  cases  of  dilatation  it  may 
pass  as  much  as  70  cm. 

Diagnosis, — Tlie  diagnosis  can  usually  be  m^de  without  much  diffi- 
culty. I  would  like  to  emphasize  again  the  great  value  of  inspection,  partic- 
ularly in  combination  with  inflation  of  the  stomach  with  carbonic-acid  gas. 
Curious  errors,  however,  are  on  record,  one  of  the  most  remarkable  of  which 
was  the  confounding  of  dilated  stomach  with  an  ovarian  cyst;  even  after 
tapping  and  the  removal  of  portions  of  food  and  fruit  seeds,  abdominal 
section  was  performed  and  the  dilated  stomach  opened.  I  notice  the  report 
of  a  recent  case  in  which  the  diagnosis  of  ascites  Avas  made  and  the  abdomen 
was  opened.  The  prognosis  is  bad  in  cases  in  which  there  is  stenosis  of  the 
pylorus,  either  simple  or  cancerous. 

Treatment. — In  the  cases  due  to  atony  careful  regulation  of  the 
diet  and  proper  treatment  of.  the  associated  catarrh  will  suffice  to  effect  a 
cure.  Strychnine,  ergot,  and  iron  are  recommended.  Washing  out  the 
stomach  is  of  great  service,  though  we  do  not  see  such  striking  and  imme- 
diate results  in  this  form.  In  cases  of  mechanical  obstruction  the  stomach 
should  be  emptied  and  thoroughly  washed,  either  with  warm  water  or  with 
an  antiseptic  solution.  We  accomplish  in  this  way  three  important  things: 
We  remove  the  weight,  which  helps  to  distend  the  organ;  we  remove  the 
mucus  and  the  stagnating  and  fermenting  material  which  irritates  and  in- 
flames the  stomach  and  impedes  digestion;  and  we  cleanse  the  inner  sur- 
face of  the  organ  by  the  application  of  water  and  medicinal  substances. 
The  patient  can  usually  be  taught  to  wash  out  his  own  stomach,  and  in  a 
case  of  dilatation  from  simple  stricture  I  have  known  the  practice  to  be 
followed  daily  for  three  years  with  great  benefit.  The  rapid  reduction  in 
the  size  of  the  stomach  is  often  remarkable,  the  vomiting  ceases,  the  food 
is  taken  readily,  and  in  many  cases  the  general  nutrition  improves  rapidly. 
As  a  rule,  once  a  day  is  sufficient,  and  it  may  be  practised  either  the  first 
thing  in  the  morning  or  before  going  to  bed.  So  soon  as  the  fermentative 
processes  have  been  checked  lukewarm  water  alone  should  be  used. 

The  food  should  be  taken  in  small  quantities  at  frequent  intervals,  and 
should  consist  of  scraped  beef,  Leube's  beef  solution,  and  tender  meats 
of  all  sorts.  Fatty  and  starchy  articles  of  diet  are  to  be  avoided.  Liquids 
should  be  taken  sparingly. 

When  the  condition  becomes  aggravated  a  resort  to  surgery  is  justifi- 
aj^le.  Here  may  be  mentioned  the  recent  statistics  of  gastric  surgery. 
Pyloric  stenosis  is  the  common  condition.  Dreydorff  has  collected  442 
cases — 188  cases  of  pylorectomy,  mortality  57.4  per  cent;  215  gastro-enter- 
ostomies,  mortality  43.3  per  cent;  pyloroplasty,  29  cases,  mortality  20.7 
per  cent.  On  an  average,  after  pylorectomy  the  patient  remained  free  from 
recurrence  for  a  little  over  a  year. 


478  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 


IV.   THE   PEPTIC   ULCER— GASTRIC  AND  DUODENAL. 

The  round,  perforating,  or  simple  ulcer  is  usually  single,  and  occurs 
in  the  stomach  and  in  the  duodenum  as  far  as  the  papilla  biliaria.  It  fol- 
lows nutritional  disturbance  in  a  limited  region  of  the  mucosa,  which  re- 
sults in  the  gradual  destruction  of  this  area  by  the  gastric  juice.  The  con- 
dition is  usually  associated  with  superacidity. 

Etiology. — Incidence  in  the  Post-mortem  Room. — The  statistics  of 
W.  H.  Welch  give  5  per  cent  of  ulcer,  open  or  cicatrized,  a  figure  which 
Bramwell  thinks  high  for  the  general  population  in  Great  Britain.  Others 
give  percentages  as  high  as  10,  The  scars  are  more  frequent  than  the 
open  ulcers.  Among  the  first  thousand  autopsies  at  the  Johns  Hopkins 
Hospital  there  were  9  cases  of  ulcer  of  the  stomach. 

Incidence  Clinically. — The  disease  is  much  less  common  in  some  coun- 
tries than  in  others,  and  in  some  parts  of  this  country.  It  is  certainly  less 
frequently  seen  in  Baltimore  than  in  Massachusetts  or  in  Canada.  In  nine 
years  there  were  in  my  wards  only  25  instances  with  a  diagnosis  of  ulcer. 

Sex. — Of  1,699  cases  collected  from  hospital  statistics  by  W.  H.  Welch 
and  examined  post  mortem,  40  per  cent  were  in  males  and  60  per  cent  were 
in  females. 

Age. — In  females  the  largest  number  of  cases  occurs  between  twenty 
and  thirty;  in  males  between  thirty  and  forty.  It  is  by  no  means  uncom- 
mon in  old  people.  On  the  other  hand,  it  is  not  very  rare  in  children. 
Goodhart  reported  a  case  in  an  infant  thirty  hours  old;  indeed,  ulcers  of 
the  stomach  have  been  found  in  the  foetus  and  in  the  new-born  shortly 
after  birth.  In  390  autopsies  at  the  Baby's  Hospital  in  Kew  York,  Martha 
Wollstein  found  5  eases. 

Heredity  appears  to  play  a  part  in  some  eases  (Dreschfeld). 

Occupation. — Servant  girls  seem  particularly  prone  to  the  disease.  This 
is  to  be  explained  partly  by  their  careless  habits  in  eating,  partly  in  connec- 
tion with  the  associated  anaemia.  The  special  liability  of  shoemakers,  weav- 
ers, and  tailors  to  ulcer  is  probably  connected,  as  Habershon  suggested,  with 
pressure  on  the  stomach. 

Trauma. — Ulcers  have  been  known  to  follow  a  blow  in  the  region  of 
the  stomach.  Easmussen  holds  that  pressure  of  the  costal  margin  from 
various  causes  induces  anaemia  and  atrophy  of  the  mucous  membrane,  par- 
ticularly in  the  region  of  the  smaller  curvature. 

Associated  Diseases. — Anaemia  and  chlorosis  predispose  strongly  to  gas- 
tric ulcer,  particularly  in  women  and  in  association  with  menstrual  dis- 
orders. A  very  considerable  number  of  all  eases  of  gastric  ulcer  occur  in 
chlorotic  girls.  It  has  been  found  also  in  connection  with  disease  of  the 
heart,  arterio-sclerosis,  and  disease  of  the  liver.  The  tuberculous  and  syph- 
ilitic ulcers  of  the  stomach  have  already  been  considered. 

The  duodenal  ulcer  is  less  common  than  the  gastric  ulcer,  and  occurs 
most  frequently  in  males.  The  combined  statistics  of  Krauss,  Chvostek, 
Lebert,  and  Trier  give  171  cases  in  males  and  39  in  females.  In  9  of  my 
cases  7  were  in  males  and  2  in  females;  one  of  these  was  in  a  lad  of  twelve. 


THE  PEPTIC  ULCER— GASTRIC  AND  DUODENAL.  479 

It  has  been  found  in  association  with  tuberculosis,  and  may  follow  large 
superficial  burns.  Perry  and  Shaw  found  it  five  times  in  149  autopsies  in 
cases  of  burns. 

Morbid  Anatomy. — Though  usually  single,  the  ulcers  may  be  mul- 
tiple. In  none  of  my  cases  were  there  more  than  five,  but  there  is  an  in- 
stance on  record  of  thirty-four.  The  ulcer  is  situated  most  commonly  on 
the  posterior  wall  of  the  pyloric  portion  at  or  near  the  lesser  curvature.  It 
is  not  nearly  so  frequent  on  the  anterior  wall.  Of  793  cases  collected  by 
Welch  from  hospital  statistics,  288  were  on  the  lesser  curvature,  235  on 
the  posterior  wall,  95  at  the  pylorus,  69  on  the  anterior  wall,  50  at  the 
cardia,  29  at  the  fundus,  27  on  the  greater  curvature.  The  duodenal  ulcer 
is  usually  situated  just  outside  the  ring  in  the  first  portion  of  the  gut. 

Acute  and  chronic  forms  of  gastric  ulcer  may  be  described.  The  former 
is  usually  small,  punched  out,  the  edges  clean-cut,  the  floor  smooth,  and 
the  peritoneal  surface  not  thickened.  The  chronic  ulcer  is  of  larger  size, 
the  margins  are  no  longer  sharp,  the  edges  are  indurated,  and  the  border 
is  sinuous.  The  gastric  ulcer  sometimes  reaches  an  enormous  size.  The 
largest  of  which  I  have  any  knowledge  is  one  reported  by  Peabody,  which 
measured  19  by  10  cm.  and  involved  all  of  the  lesser  curvature  and  spread 
over  a  large  part  of  the  anterior  and  posterior  walls.  The  sides  are  often 
terraced.  The  floor  is  formed  either  by  the  submucosa,  by  the  muscular 
layers,  or,  not  infrequently,  by  the  neighboring  organs,  to  which  the  stom- 
ach has  become  attached.  In  the  healing  of  the  ulcer,  if  the  mucosa  is 
alone  involved,  the  granulation  tissue  develops  from  the  edges  and  the 
floor  and  the  newly  formed  tissue  gradually  contracts  and  unites  the  mar- 
gins, leaving  a  smooth  scar.  In  larger  ulcers  which  have  become  deep  and 
involved  the  muscular  coat  the  cicatricial  contraction  may  cause  serious 
changes,  the  most  important  of  which  is  narrowing  of  the  pyloric  orifice 
and  consequent  dilatation  of  the  stomach.  In  the  case  of  a  girdle  ulcer, 
hour-glass  contraction  of  the  stomach  may  be  produced.  It  is  probable 
that  large  ulcers  persist  for  years  without  any  attempt  at  healing. 

Among  the  more  serious  changes  which  may  proceed  in  an  ulcer  are 
the  following: 

Perforation. — Fortunately,  in  a  majority  of  the  cases,  adhesions  form 
between  the  stomach  and  adjacent  organs,  particularly  with  the  pancreas, 
the  left  lobe  of  the  liver,  and  the  omental  tissues.  On  the  anterior  surface 
of  the  stomach  adhesions  do  not  so  readily  form,  hence  the  great  danger 
of  tlie  ulcer  in  this  situation,  which  more  readily  perforates  and  excites  a 
diffuse  and  fatal  peritonitis.  On  the  posterior  wall  the  ulcer  penetrates 
directly  into  the  lesser  peritoneal  cavity,  in  which  case  it  may  produce  an 
air-containing  abscess  with  the  symptoms  of  the  condition  known  as  sub- 
phrenic pyo-pneumothorax.  In  rare  instances  adhesions  and  a  gastro- 
cutaneous  fistula  form,  usually  in  the  umbilical  region.  Fistulous  com- 
munication with  the  colon  may  also  occur,  or  a  gastro-duodenal  fistula. 
The  pericardium  may  be  perforated,  and  even  the  left  ventricle.  Perfora- 
tion into  the  pleura  may  also  occur.  It  is  to  be  noted  that  general  em- 
physema of  the  subcutaneous  tissues  occasionally  follows  perforation  of  a 
gastric  ulcer. 

SO 


480  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Erosion  of  Blood-vessels. — The  hsemorrhage  may  occur  in  the  acutely 
formed  ulcer  or  in  the  ulceration  which  takes  place  at  the  base  of  the  chronic 
form;  it  is  in  the  latter  condition  that  the  bleeding  is  most  common.  Ulcers 
on  the  posterior  wall  may  erode  the  splenic  artery,  but  perhaps  more  fre- 
quently the  bleeding  proceeds  from  the  artery  of  the  lesser  curve.  In  the 
case  of  duodenal  ulcer  the  pancreatico-duodenal  artery  may  be  eroded  or 
(as  in  one  of  my  cases)  fatal  haemorrhage  may  result  from  the  opening  of 
the  hepatic  artery,  or  more  rarely  the  portal  vein.  Interesting  changes  occur 
in  the  vessels.  Embolism  of  the  artery  supplying  the  ulcerated  region  has 
been  met  with  in  several  cases;  in  others  diffuse  endarteritis.  Small 
aneurisms  have  been  found  in  the  floor  of  the  ulcers  by  Douglas  Powell, 
Welch,  and  others. 

Cicatrization. — Superficial  ulcers  often  heal  without  leaving  any  seri- 
ous damage.  Stenosis  of  the  pyloric  orifice  not  infrequently  follows  the 
healing  of  an  ulcer  in  its  neighborhood.  In  other  instances  the  large  an- 
nular ulcer  may  cause  in  its  cicatrization  an  hour-glass  contraction  of  the 
stomach.  The  adhesion  of  the  ulcer  to  neighboring  parts  may  subsequently 
be  the  cause  of  much  pain.  The  parts  of  the  mucosa  in  the  neighborhood  of 
the  ulcer  frequently  show  signs  of  chronic  gastritis. 

The  origin  of  the  peptic  ulcer  is  still  obscure.  Ulcers  have  been  pro- 
duced in  animals  in  many  ways,  both  by  artificial  emboli  and  by  direct 
chemical  and  mechanical  irritants  applied  to  the  mucosa.  The  ulcers  thus 
produced  heal  with  great  rapidity  unless  the  animals  have  been  rendered 
anaemic  by  repeated  abstraction  of  blood.  Virchow's  view  that  the  process 
may  result  from  plugging  the  nutrient  artery  of  the  part,  either  by  an 
embolus  or  by  a  thrombus,  and  that  the  infarct  so  produced  is  destroyed  by 
the  gastric  Juice,  has  gained  general  acceptance.  It  is  in  conformity  with 
Pavy's  well-known  experiments  and  with  the  anatomical  facts  already  men- 
tioned, particularly  with  the  funnel-like  shape  of  the  ulcer,  and  the  actual 
demonstration,  in  some  cases,  of  the  plugged  vessels;  but  this  view  scarcely 
meets  all  the  cases,  in  many  of  which  the  etiology  is  still  obscure.  Mere 
mechanical  injury  to  the  mucous  membrane  is,  however,  in  most  cases,  in- 
sufficient cause  for  an  ulcer,  for  normally  the  stomach  is  perfectly  able 
to  withstand  such  insults.  Ewald  concludes  that  certain  predisposing 
causes  play  an  important  role  in  its  development.  He  points  to  its  fre- 
quency in  conditions  of  amenorrhcea,  chlorosis,  anaemia  after  confinements, 
etc.,  where  one  may  assume  that  the  condition  of  the  blood  is  not  wholly 
normal,  and  also  to  the  fact  that  in  the  majority  of  cases  of  this  affection 
there  is  a  superacidity  of  the  gastric  juice.  One  or  both  of  these  predis- 
posing factors  seem  to  be  present  in  most  cases,  and  it  has  been  recently 
shown  that  in  the  various  anaemias  there  is  an  appreciable  diminution  in 
the  normal  alkalinity  of  the  blood,  a  fact  which  tends  to  explain  one  of 
the  predisposing  causes  in  these  affections,  and  which  is  in  accord  with  the 
"  alkalescence  theory  "  of  Cohnheim.  Of  late  the  view  has  been  advanced, 
particularly  by  Letulle  and  by  Sydney  Martin,  that  the  ulceration  is  clue 
to  a  bacterial  necrosis  of  the  gastric  mucosa,  and  the  latter  suggests  that  the 
frequency  of  the  ulcer  at  the  pyloric  region  is  associated  with  the  absence 
of  the  glands  at  this  part,  which  form  the  hydrochloric  acid.     The  duo- 


THE  PEPTIC   ULCER— GASTRIC  AND  DUODENAL.  481 

denal  ulcer  has  an  identical  origin,  but  a  few  cases  of  acute  ulcer,  as 
already  mentioned,  have  a  curious  relation  with  superficial  burns.  Bar- 
deen's  researches  upon  the  necroses  in  the  viscera  following  extensive  burns 
throw  an  important  light  upon  these  cases,  showing  especially  how  the 
gastro-intestinal  mucous  membrane  is  implicated  in  the  toxic  effects.  In 
one  of  my  cases  there  was  an  ulcer  in  the  posterior  wall  of  the  duodenum, 
1.5  cm.  in  diameter,  with  overlapping  edges,  and  not  far  from  it  was  a 
cyst-like  cavity  in  the  submucosa  associated  with  Brunner's  glands,  and  it 
is  possible  that  the  open  ulcer,  with  undermined  edges,  resulted  from  the 
rupture  of  one  of  these  cysts. 

Symptoms. — The  condition  may  be  met  with  accidentally,  post  mor- 
tem. The  first  symptoms  may  be  those  of  perforation.  In  other  cases  again, 
for  months  and  years,  the  patient  has  had  dyspepsia,  and  the  ulcer  may 
not  have  been  suspected  until  the  occurrence  of  a  sudden  haemorrhage. 

The  symptoms  suggestive  of  peptic  ulcer  are:  (a)  Dyspepsia,  which  may 
be  slight  and  trifling  or  of  a  most  aggravated  character.  In  a  considerable 
proportion  of  all  cases  nausea  and  vomiting  occur,  the  latter  not  for  two 
or  more  hours  after  eating.  The  vomitus  usually  contains  a  large  amount 
of  HCl. 

(h)  Hcemorrhage  is  present  in  at  least  one  half  of  all  cases.  It  may  be 
slight,  but  more  commonly  is  profuse,  and  may  be  in  such  quantities  and 
brought  up  so  quickly  that  it  is  fluid,  bright  red  in  color,  and  quite  un- 
altered. When  the  blood  remains  for  some  time  in  the  stomach  and  is 
mixed  with  food  it  may  be  greatly  changed,  but  the  vomiting  of  a  large 
quantity  of  unaltered  blood  is  very  characteristic  of  idcer.  Syncope  or  con- 
vulsions may  follow;  death  rarely  results  directly  from  the  haemorrhage.  A 
most  extreme  grade  of  ansemia  may  be  produced.  Hemiplegia  and  amau- 
rosis with  optic  atrophy  may  follow  the  profuse  haemorrhage.  In  either 
the  gastric  or  duodenal  ulcer,  more  commonly  in  the  latter,  the  blood  may  be 
passed  in  the  stools  and  not  be  vomited.  This  may  occur  when  the  haem- 
orrhage is  slight,  but  also  when  it  is  profuse  enough  to  produce  collapse 
and  extreme  anaemia.  Profuse,  even  fatal,  haemorrhage  may  come  from 
small,  superficial  ulcers,  or  even  from  the  haemorrhagic  erosions.  Prob- 
ably it  is  from  such  that  in  elderly  persons  profuse  haemorrhage  occurs 
without  previous  gastric  symptoms. 

(c)  Pain  is  perhaps  the  most  constant  and  distinctive  feature  of  ulcer. 
It  varies  greatly  in  character;  it  may  be  only  a  gnawing  or  burning  sensa- 
tion, which  is  particularly  felt  when  the  stomach  is  empty,  and  is  relieved 
by  taking  food,  but  the  more  characteristic  form  comes  on  in  paroxysms 
of  the  most  intense  gastralgia,  in  which  the  pain  is  not  only  felt  in  the 
epigastrium,  but  radiates  to  the  back  and  to  the  sides.  In  many  cases  the 
two  points  of  epigastric  pain  and  dorsal  pain,  about  the  level  of  the  teiith 
dorsal  vertebra,  are  very  well  marked.  These  attacks  are  most  frequently 
induced  by  taking  food,  and  they  may  recur  at  a  variable  period  after  eat- 
ing, sometimes  within  fifteen  or  twenty  minutes,  at  others  as  late  as  two 
or  three  hours.  It  is  usually  stated  that  when  the  ulcer  is  near  the  cardia 
the  pain  is  apt  to  set  in  earlier,  but  there  is  no  certainty  on  this  point.  In 
some  cases  it  comes  on  in  the  early  morning  hours.      The  attacks  may 


482  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

occur  at  intervals  with  great  intensity  for  weeks  or  months  at  a  time,  so  that 
the  patient  constantly  requires  morphia,  then  again  they  may  disappear 
entirely  for  a  prolonged  period.  In  the  attack  the  patient  is  usually  bent- 
forward,  and  finds  relief  from  pressure  over  the  epigastric  region;  one 
patient  during  the  attack  would  lean  over  the  back  of  a  chair;  another 
would  lie  flat  on  the  floor,  with  a  hard  pillow  under  the  abdomen.  Pres- 
sure is,  as  a  rule,  grateful.  It  has  been  thought  that  the  posture  assumed 
during  the  attack  would  indicate  the  site  of  the  ulcer,  but  this  is  very 
doubtful. 

(d)  Tenderness  on  pressure  is  a  common  symptom  in  ulcer,  and  patients 
wear  the  waist-band  very  low.  Pressure  should  be  made  with  great  care, 
as  rupture  of  an  ulcer  is  said  to  have  been  induced  by  careless  manipulation. 

(e)  In  old  ulcers  with  thickened  bases  an  indurated  mass  can  usually  be 
felt  in  the  neighborhood  of  the  pylorus. 

(/)  Of  general  symptoms,  loss  of  iveigJit  results  from  the  prolonged  dys- 
pepsia, but  it  rarely,  except  in  association  with  cicatricial  stenosis  of  the 
pylorus,  reaches  the  high  grade  met  with  in  cancer.  The  ancBmia  may  be 
extreme,  and  in  one  case  of  duodenal  ulcer,  which  I  examined,  the  blood- 
count  was  as  low  as  700,000  per  c.  mm.  There  are  instances,  such  as  the 
one  reported  by  Pepper  and  Griffith,  in  which  the  extreme  anasmia  can  not 
be  explained  by  the  occurrence  of  hasmorrhage.  In  a  few  cases  parotitis 
occurs.  In  one  of  my  cases  there  was  a  remarkable  pigmentation  of  the 
face  and  of  the  axillary  folds. 

{g)  Perforation. — This  occurs  in  about  6^  per  cent  of  all  cases.  The 
acute,  perforating  form  is  much  more  common  in  women  than  in  men. 
The  symptoms  are  those  of  perforative  peritonitis.  Particular  attention 
must  be  given  to  this  accident  since  it  has  come  so  successfully  within  the 
sphere  of  the  surgeon.  As  already  mentioned,  perforation  may  take  place 
either  into  the  lesser  peritonseum  or  into  the  general  peritoneal  cavity,  in 
both  of  which  cases  operation  is  indicated;  in  rare  instances  the  ulcer  may 
perforate  the  pericardium.  This  was  the  case  in  10  of  28  eases  in  which  the 
diaphragm  was  perforated  (Pick). 

Localized,  more  frequently  subphrenic,  abscess  may  follow  perforation. 

The  course  of  the  disease  is,  in  the  majority  of  cases,  chronic.  Only  a 
few  instances  run  a  very  acute  course.  The  following  group  of  clinical 
forms,  described  by  "Welch,  indicate  the  diversity  of  this  affection: 

"  1.  Latent  ulcers,  with  entire  absence  of  symptoms,  and  revealed  aa 
open  ulcers  or  as  cicatrices  at  the  autopsy. 

"  2.  Acute  perforating  ulcers.  With  or  without  a  period  of  brief  gas- 
tric disturbance,  perforation  occurs  and  causes  speedy  death. 

"  3.  Acute  hemorrhagic  form  of  gastric  ulcer.  After  a  latent  or  a 
brief  course  of  the  ulcer,  profuse  gastrorrhagia  occurs,  which  may  termi- 
nate fatally  or  may  be  followed  by  the  symptoms  of  chronic  ulcer. 

"  4.  Gastralgic-dyspeptic  form.  In  this,  which  is  the  most  common 
form  of  gastric  ulcer,  gastralgia,  dyspepsia,  and  vomiting  are  the  symptoms. 
Sometimes  one  of  the  symptoms  predominates  greatly  over  the  others,  so 
that  Lebert  distinguishes  separately  a  gastralgic,  a  dyspeptic,  and  a  vomit- 
ive variety.     Gastralgia  is  the  most  frequent  symptom. 


THE  PEPTIC  ULCER— GASTRIC  AND  DUODENAL.  483 

"  5.  Chronic  hsemorrhagic  form.  Gastrorrhagia  is  a  marked  symptom, 
and  occurs  usually  in  combination  with  the  symptoms  Just  mentioned. 

"  6.  Cachectic  form.  This  usually  corresponds  only  to  the  final  stage 
of  one  of  the  preceding  forms,  hut  the  cachexia  may  develop  so  rapidly 
and  become  so  marked  that  the  course  of  the  disease  closely  resembles  that 
of  gastric  cancer. 

"  7.  Eecurrent  form.  In  this  the  symptoms  of  gastric  ulcer  disappear, 
and  then  follow  intervals,  often  of  considerable  duration,  in  which  there 
is  apparent  cure,  but  the  symptoms  return,  especially  after  some  indiscre- 
tion in  the  mode  of  living.  This  intermittent  course  may  continue  for 
many  years.  In  these  cases  it  is  probable  either  that  fresh  ulcers  form  or 
that  the  cicatrix  of  an  old  ulcer  becomes  ulcerated. 

"  8.  Stenotic  form.  By  the  formation  of  cicatricial  tissue  in  and  around 
the  ulcer,  the  pyloric  orifice  becomes  obstructed  and  the  symptoms  of  dila- 
tation of  the  stomach  develop."  And  to  this  may  be  added  the  form  in 
which  cancer  develops,  which  will  be  referred  to  later. 

The  course  may  be  very  protracted,  and  there  are  cases  in  which  the 
disease  has  persisted  for  over  twenty  years.  I  have  reported  two  instances 
of  peptic  ulcer,  probably  duodenal,  in  which  well-marked  symptoms  were 
present,  in  one  case  for  eighteen,  and  in  the  other  for  twelve  years.  Both 
were  of  the  chronic  hasmorrhagic  form. 

Diagnosis. — The  recognition  of  gastric  ulcer  is  in  many  cases  easy, 
as  the  combination  of  dyspepsia,  gastralgic  attacks,  and  hfematemesis  is 
very  characteristic.  Of  the  symptoms,  hgemorrhage  with  the  gastralgic 
attack  is  the  most  characteristic.  The  distinctions  between  ulcer  and  can- 
cer will  be  given  later.  The  greatest  difficulty  is  offered  by  certain  cases 
of  gastralgia,  M^hich  may  resemble  ulcer  very  closely,  as,  with  the  exception 
of  the  hemorrhage,  there  is  no  single  symptom  which  may  not  be  present. 
A  difficulty  also  results  from  the  fact  that  in  many  instances  gastralgia  is 
one  of  the  symptoms  of  nervous  dyspepsia,  and  may  exist  with  marked 
emaciation. 

The  following  points  are  of  value  in  discriminating  between  these  two 
conditions: 

(a)  In  ulcer  the  pain  is  more  definitely  connected  with  taking  food, 
though  this  is  not  always  the  case,  as  in  the  duodenal  form  the  gastralgic 
attacks  may  occur  at  night  when  the  stomach  is  empty.  Relief  of  pain 
after  eating  is  certainly  less  common  in  ulcer  than  in  gastralgia,  though  it 
is  a  very  uncertain  feature,  and  in  certain  cases  the  pain  in  ulcer  is  always 
relieved  by  taking  food. 

(&)  In  ulcer  dyspeptic  symptoms  are  almost  invariably  present  in  the 
intervals  between  the  attacks,  and  even  when  pain  is  absent  there  is  slight 
distress. 

(c)  Local  sensitiveness  over  a  particular  spot  in  the  epigastrium  is  sug- 
gestive of  ulcer.  External  pressure  usually  aggravates  the  pain  in  ulcer, 
and  often  relieves  it  in  gastralgia.  This  is,  however,  a  very  uncertain  fea- 
ture, as  patients  writhing  with  the  pains  of  ulcer  may  press  the  abdomen 
over  the  back  of  a  chair  or  place  a  hard  pillow  under  it. 

{d)  The  general  condition  and  history  of  the  patient  often  give  the 


484  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

most  trustworthy  information.  The  nutrition  is  impaired  more  frequent- 
ly in  ulcer  than  in  gastralgia.  The  latter  is  common  in  neurasthenia 
with  superacidity,  and  may  be  completely  relieved  by  burnt  magnesia 
or  soda.  Pain  may  also  be  associated  in  this  class  of  cases  with  sub- 
acidity. 

(e)  On  examination  of  the  abdomen,  not  only  is  pain  on  pressure  much 
more  common  in  ulcer,  but  there  may  also  be  thickening  about  the  pylorus 
and,  in  many  cases,  signs  of  dilatation  of  the  stomach. 

(f)  Superacidity  and  often  supersecretion  of  the  gastric  juice  exists  with 

ulcer. 

The  gastric  crises  which  occur  in  affections  of  the  spinal  cord,  particu- 
larly in  locomotor  ataxia,  may  simulate  very  closely  the  gastralgic  attacks 
of  ulcer,  and  as  they  so  often  exist  in  the  preataxic  stage  their  true  nature 
may  be  overlooked;  but  the  occurrence  of  lightning  pains,  the  ocular  symp- 
toms, and  the  absence  of  the  knee  reflex  are  indications  usually  sufficient 
to  render  the  diagnosis  clear. 

Can  the  gastric  and  duodenal  ulcer  be  distinguished  clinically?  As 
already  stated,  they  originate  in  the  same  way  and  present  the  same  ana- 
tomical characters.  In  the  great  majority  of  cases  they  cannot  be  sepa- 
rated during  life,  as  the  symptoms  produced  are  identical.  Bucquoy  has 
suggested  that  the  duodenal  ulcer  can  be  distinguished  by  the  following 
definite  characters:  (a)  Sudden  intestinal  hsemorrhage  in  an  apparently 
healthy  person,  which  tends  to  recur  and  produce  a  profound  ansemia. 
Hsemorrliage  from  the  stomach  may  precede  or  accompany  the  meltena. 
(&)  Pain  in  the  right  hypochondriac  region,  coming  on  two  or  three  hours 
after  enting.  (c)  Gastric  crises  of  extreme  .violence,  during  which  the 
haemorrhage  is  more  apt  to  occur.  Certainly  the  occurrence  of  sudden 
intestinal  hgemorrhage  with  gastralgic  attacks  is  extremely  suggestive  of 
duodenal  ulcer.  W.  W.  Johnston  has  reported  an  instance  in  which 
he  made  the  diagnosis  on  these  symptoms,  and  in  one  of  the  Montreal 
eases  Palmer  Howard  suggested  correctly  the  presence  of  a  duodenal 
ulcer  on  similar  grounds.  A  patient  under  my  care  who  had,  during 
eighteen  years,  frequent  attacks  of  hsematemesis  with  gastralgia  had 
melgena  repeatedly  without  vomiting  blood;  but  as  a  rule  in  the  at- 
tacks the  blood  was  vomited  first,  and  did  not  appear  in  the  stools  un- 
til later.  Occasionally  this  symptom  will  be  found  an  important  aid 
in  diagnosis.  The  situation  of  the  pain  is  too  uncertain  a  factor  on 
which  to  lay  much  stress,  and  the  character  of  the  crises  is  usually 
identical. 

Gall-stone  colic  may  occasionally  simulate  the  pains  of  gastric  ulcer. 
The  sudden  onset  and  as  sudden  termination,  the  swelling  and  tenderness 
of  the  liver,  the  enlargement  of  the  gall-bladder,  if  present,  and  the  occur- 
rence of  jaimdice  are  points  to  be  considered.  The  experience  of  surgeons 
has  taught  us  that  a  number  of  cases  in  which  the  pains  were  regarded  as 
gastralgia  have  in  reality  been  due  to  gall-stones,  with  which,  as  is  now  well 
known,  jaundice  is  not  necessarily  connected. 

Treatment. — Post-mortem  observations  show  that  a  very  large  num- 
ber of  ulcers  heal  completely,  but  the  process  is  slow  and  tedious,  often 


THE  PEPTIC  ULCER— GASTRIC  AND  DUODENAL.  485 

requiring  months,  or,  in  severe  cases,  years.     The  following  are  the  im- 
portant points  in  treatment: 

(a)  Absolute  rest  in  bed. 

(b)  A  carefully  and  systematically  regulated  diet.  While  theoretically 
it  is  better  to  give  the  stomach  complete  rest  by  rectal  feeding,  yet  in  prac- 
tice this  strict  limitation  is  not  found  satisfactory.  The  food  should  be 
bland,  easily  digested,  and  given  at  stated  intervals.  The  following  dietary 
will  be  found  useful:  At  8  a.  m.  give  200  cc.  of  Leube's  beef  solution;  at 
12  M.,  300  cc.  of  milk  gruel  or  peptonized  milk.  The  gruel  should  be  made 
with  ordinary  flour  or  arrowroot,  and  is  mixed  with  an  equal  quantity  of 
milk.  If  necessary  it  may  be  peptonized.  Buttermilk  is  very  well  borne 
by  these  patients.  At  4  p.  m.  the  beef  solution  again,  and  at  8  p.  m.  the 
milk  gruel  or  the  buttermilk. 

The  stomach  in  some  cases  is  so  irritable  that  the  smallest  amount  of 
food  is  not  well  borne.  In  such  cases  lavage  may  be  practised,  if  necessary, 
every  morning,  with  mildly  alkaline  water,  after  which  the  beef  solution 
is  given  and  the  feeding  supplemented  by  the  rectal  injections.  Ill  effects 
rarely  follow  the  careful  use  of  the  stomach  tube  in  gastric  ulcer.  There 
are  some  cases  which  do  well  from  the  outset  on  a  milk  diet,  given  at  regu- 
lar intervals,  3  or  4  ounces  every  two  hours.  When  milk  is  not  well  borne 
egg  albumen  may  be  substituted,  or  the  whites  of  eight  eggs  may  be  alter- 
nated with  Leube's  beef  solution.  At  the  end  of  a  month,  if  the  condition 
has  improved,  the  patient  may  be  allowed  scraped  beef  or  young  chicken, 
perfectly  fresh  sweet-bread,  and  farinaceous  puddings  made  with  milk  and 
eggs.  Local  applications,  such  as  warm  fomentations,  over  the  abdomen 
are  very  useful.  The  patient  should  be  told  that  the  treatment  will  take 
at  least  three  months,  and  for  the  greater  portion  of  the  time  he  should 
be  in  bed. 

(c)  Medicinal  measures- are  of  very  litle  value  in  gastric  ulcer,  and  the 
remedies  employed  do  not  probably  benefit  the  ulcer,  but  the  gastric  ca- 
tarrh. The  Carlsbad  salts  are  warmly  recommended  by  von  Ziemssen.  The 
artificial  preparation  (sulphate  of  sodium,  50;  bicarbonate  of  sodium,  6; 
chloride  of  sodium,  3)  may  be  substituted,  of  which  a  teaspoonful  is  taken 
every  morning.  Bismuth,  in  doses  of  30  to  60  grains  three  times  a  day, 
and  nitrate  of  silver  may  be  given,  but  they  influence  the  associated  con- 
ditions rather  than  the  ulcer. 

The  pain,  if  severe,  requires  opium.  Unless  the  gastralgia  is  intense 
morphia  should  not  be  given  hypodermically,  as  there  is  a  very  serious 
danger  in  these  cases  of  establishing  the  morphia  habit.  Doses  of  an 
eiglith  of  a  grain,  with  the  bicarbonate  of  soda  and  bismuth,  will  allay  the 
mild  attacks,  but  the  very  severe  ones  require  the  hyj)odermic  injection  of 
a  quarter  or  often  half  a  grain.  Antipyrin  and  antifebrin  may  be  tried, 
but,  as  a  rule,  are  quite  ineffectual.  In  the  milder  attacks  Hoffman's  ano- 
dyne, or  20  or  30  drops  of  chloroform,  or  the  spirits  of  camphor  will  give 
relief.  Counter-irritation  over  the  stomach  with  mustard  or  cantharides  is 
often  useful. 

When  the  stomach  is  intractable,  the  patient  should  be  fed  per  rectum. 
He  will  sometimes  retain  food  which  is  passed  into  the  stomach  througli  the 


486  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tube,  and  Leube's  beef  solution  or  milk  may  be  given  in  this  way.  Cracked 
ice,  chloroform,  oxalate  of  cerium,  bismuth,  hydrocyanic  acid,  and  ingluvin 
may  be  tried.  When  hasmorrhage  occurs  the  patient  should  be  put  under 
the  influence  of  opium  as  rapidly  as  possible.  No  attempt  should  be  made 
to  check  the  hemorrhage  by  administering  medicines  by  the  mouth;  as 
the  profuse  bleeding  is  always  from  an  eroded  artery,  frequently  from 
one  of  considerable  size,  it  is  doubtful  if  acetate  of  lead,  tannic  and  gallic 
acids,  and  the  usual  remedies  have  the  slightest  influence.  The  essential 
point  is  to  give  rest,  which  is  best  obtained  by  opium.  Ergotin  may  be 
administered  hypodermically  in  two-grain  doses.  Nothing  should  be 
given  by  the  mouth  except  small  quantities  of  ice.  In  profuse  bleeding 
a  ligature  may  be  applied  around  a  leg,  or  a  leg  and  arm.  ISTot  infrequently 
the  loss  of  blood  is  so  great  that  the  patient  faints.  A  fatal  result  is  not, 
however,  very  common  from  haemorrhage.  Transfusion  may  be  necessary, 
or,  still  better,  the  subcutaneous  infusion  of  saline  solution. 

The  patients  usually  recover  rapidly  from  the  hgemorrhage  and  require 
iron  in  full  doses,  which  may,  if  necessary,  be  given  hypodermically. 

Surgical  interference  in  ulcer  of  the  stomach  is  indicated:  (a)  When 
perforation  has  taken  place.  The  statistics  collected  by  Eodman  and  by 
Eobson  indicate  how  successful  this  operation  has  become,  (h)  In  very  in- 
tractable cases  which  have  resisted  all  treatment,  and  which  are  accom- 
panied by  attacks  of  very  severe  pain  and  recurring,  almost  fatal  haemor- 
rhage, the  ulcer  may  be  excised,  (c)  For  hamatemesis.  A  number  of  cases 
have  now  been  successfully  operated  upon  for  the  recurring  bleeding.  The 
surgeon  must  bear  in  mind  that  the  very  severe,  profuse  haemorrhage  does 
not  always  come  from  the  large  round  ulcers,  but,  as  Dieulafoy  has  recently 
pointed  out,  from  quite  small  erosions.  In  a  case  of  this  kind  the  operation 
was  performed  successfully.  Eobson  (Lancet,  1901,  i)  and  Eodman  (Jr. 
Am.  Med.  Assn.,  vol.  i,  1900)  have  dealt  fully  with  the  surgical  aspects 
of  the  subject.  (For  discussion  on  the  Statistics  of  Ulcer  see  Bramwell, 
Lancet,  i,  1901.) 

V.    CANCER   OF  THE  STOMACH. 

Etiology. — Incidence. — In  an  analysis  of  30,000  cases  of  cancer,  W, 
H.  Welch  found  the  stomach  involved  in  21.4  per  cent,  this  organ  thus 
standing  next  to  the  uterus  in  order  of  frequency.  Among  8,46-1  cases  ad- 
mitted to  my  wards,  there  were  150  cases  of  cancer  of  the  stomach.  There 
were  39  cases  among  the  first  1,000  autopsies  in  the  post-mortem  room  of 
the  Johns  Hopkins  Hospital.  The  disease  is  more  common  in  some  coun- 
tries. Figures  indicate  that  cancer  of  the  stomach,  as  of  other  organs,  is 
increasing  in  frequency. 

Sex. — T.  McCrae  has  analyzed  150  cases  from  my  wards  and  found  that 
there  were  126  males  and  24  females.    Welch  gives  the  ratio  as  5  to  4. 

Age. — Of  our  150  cases  the  ages  were  as  follows:  Between  twenty  and 
thirty,  6;  from  thirty  to  forty,  17;  forty  to  fifty,  38;  fifty  to  sixty,  49; 
sixty  to  seventy,  36;  seventy  to  eighty,  4.  Fifty-eight  per  cent  occurred 
between  the  ages  of  forty  and  sixty.     Of  the  6  cases  occurring  under  the 


CANCER  OF  THE  STOMACH.  437 

thirtieth  year,  the  youngest  was  twenty-two.  Of  the  large  number  of  cases 
analyzed  by  Welch,  three  fourths  occurred  between  the  fortieth  and  seven- 
tieth years.  Congenital  cancer  of  the  stomach  has  been  described,  and 
cases  have  been  met  with  in  children. 

Race. — Among  our  150  cases,  131  were  white;  19  were  negroes. 

Heredity. — Of  the  150  cases  in  only  11  was  there  a  positive  history  of 
cancer  in  the  family.  In  some  families,  as  the  Bonapartes,  the  disease  seems 
to  prevail.  In  our  series  a  very  much  larger  number — 38 — had  a  family 
history  of  tuberculosis. 

Previous  Diseases,  Habits,  etc. — A  history  of  dyspepsia  was  present  in 
only  33  cases;  of  these,  17  had  had  attacks  at  intervals,  11  had  had  chronic 
stomach  trouble,  and  5  had  had  dyspepsia  for  one  or  two  years  before  the 
symptoms  of  cancer  developed.  Napoleon,  discussing  this  interesting  point 
with  his  physician  Autommarchi,  said  that  he  had  always  had  a  stomach 
of  iron  and  felt  no  inconvenience  until  the  onset  of  what  proved  to  be 
his  fatal  illness. 

Alcohol. — Seventy-seven  of  our  patients  had  used  it  regularly,  65  of 
these  moderately  (?),  8  excessively.  Trauma. — Only  one  case  gave  a  posi- 
tive history.  In  a  recent  case  the  cancer  developed  rapidly  after  a  blow  on 
the  stomach,  and  the  patient  lost  sixty  pounds  in  weight  in  three  months. 
Gastric  Ulcer. — Four  cases  gave  a  history  pointing  to  ulcer,  but  there  was 
no  instance  of  ulcus  carcinomatosum  among  the  autopsies. 

Mental  worry  and  strain  were  given  occasionally  as  causes  of  the  illness. 

Morbid  Anatomy. — The  most  common  varieties  of  gastric  cancer 
are  the  cylindrical-celled  adeno-carcinoma  and  the  encephaloid  or  medul- 
lary carcinoma;  next  in  frequency  is  scirrhous,  and  then  colloid  cancer. 
With  reference  to  the  situation  of  the  tumor,  Welch  analyzed  1,300  cases, 
in  which  the  distribution  was  as  follows:  Pyloric  region,  791;  lesser  curva- 
ture, 148;  cardia,  104;  posterior  wall,  68;  the  whole  or  greater  part  of  the 
stomach,  61;  multiple  tumors,  45;  greater  curvature,  34;  anterior  wall,  30; 
fundus,  19. 

The  medullary  cancer  occurs  in  soft  masses,  which  involve  all  the  coats 
of  the  stomach  and  usually  ulcerate  early.  The  tumor  may  form  villous 
projections  or  cauliflower-like  outgrowths.  It  is  soft,  grayish  white  in 
color,  and  contains  much  blood.  Microscopically  it  shows  a  scanty  stroma, 
enclosing  alveoli  which  contain  irregular  polyhedral  and  cylindrical  cells. 
The  cylindrical-celled  epithelioma  may  also  form  large  irregular  masses, 
but  the  consistence  is  usually  firmer,  particularly  at  the  edges  of  the  can- 
cerous ulcers.  Microscopically  the  section  shows  elongated  tubular  spaces 
filled  with  columnar  epithelium,  and  the  intervening  stroma  is  abundant. 
Cysts  are  not  uncommon  in  this  form.  The  scirrhous  variety  is  character- 
ized by  great  hardness,  due  to  the  abundance  of  the  stroma  and  the  limited 
amount  of  alveolar  structures.  It  is  seen  most  frequently  at  the  pylorus, 
where  it  is  a  common  cause  of  stenosis.  It  may  be  combined  with  the 
medullary  form.  It  may  be  diffuse,  involving  all  parts  of  the  organ,  and 
leading  to  a  condition  which  cannot  be  recognized  macroscopically  from 
cirrhosis.  This  form  has  also  been  seen  in  the  stomach  secondary  to  cancer 
of  the  ovaries.     The  colloid  cancer  is  peculiar  in  its  widespread  invasion 


488  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

of  all  the  coats.  It  also  spreads  with  greater  frequency  to  the  neighhoring 
parts,  and  it  occasionally  causes  extensive  secondary  growths  of  the  same 
nature  in  other  organs.  The  appearance  on  section  is  very  distinctive, 
and  even  with  the  naked  eye  large  alveoli  can  be  seen  filled  with  the  trans- 
lucent colloid  material.  The  term  alveolar  cancer  is  often  applied  to  this 
form.  Ulceration  is  not  constantly  present,  and  there  are  instances  in 
which,  with  most  extensive  disease,  digestion  has  been  but  slightly  dis- 
turbed. There  is  a  specimen  in  the  Warren  Museum,  at  the  Harvard  Medi- 
cal School,  of  the  most  widespread  colloid  cancer,  in  which  the  stomach 
contained  after  death  large  pieces  of  undigested  beef-steak. 

Secondarij  Cancer  of  the  Stomach. — Of  37  cases  collected  by  "Welch,  17 
were  secondary  to  cancer  of  the  breast.  Among  the  first  1,000  autopsies 
at  the  Johns  Hopkins  Hospital  there  were  3  cases  of  secondary  cancer. 

Changes  in  the  Stomach. — Cancer  at  the  cardia  is  usually  associated  with 
wasting  of  the  organ  and  reduction  in  its  size.  The  oesophagus  above  the 
obstruction  may  be  greatly  dilated.  On  the  other  hand,  annular  cancer 
at  the  pylorus  causes  stenosis  with  great  dilatation  of  the  organ.  In  a  few 
rare  instances  the  pylorus  has  been  extremely  narrowed  without  any  in- 
crease in  the  size  of  the  stomach.  In  diffuse  scirrhous  cancer  the  stomach 
may  be  very  greatly  thickened  and  contracted.  It  may  be  displaced  or 
altered  in  shape  by  the  weight  of  the  tumor,  particularly  in  cancer  of  the 
pylorus;  in  such  cases  it  has  been  found  in  every  region  of  the  abdomen,  and 
even  in  the  true  pelvis.  The  mobility  of  the  tumors  is  at  times  extraordi- 
nary and  very  deceptive,  and  they  may  be  pushed  into  the  right  hypochon- 
drium  or  into  the  splenic  region,  entirely  beneath  the  ribs.  Adhesions  very 
frequently  occur,  particularly  to  the  colon,  the  liver,  and  the  anterior 
abdominal  wall. 

Secondary  cancerous  growths  in  other  organs  are  very  frequent,  as 
shown  by  the  following  analysis  by  Welch  of  1,574  cases:  Metastasis  oc- 
curred in  the  lymphatic  glands  in  551;  in  the  liver  in  475;  in  the  peri- 
toneum, omentum,  and  intestine  in  357;  in  the  pancreas  in  122;  in  the 
pleura  and  lung  in  98;  in  the  spleen  in  26;  in  the  brain  and  meninges  in 
9;  in  other  parts  in  92.  The  lymph-glands  affected  are  usually  those  of 
the  abdomen,  but  the  cervical  and  inguinal  glands  are  not  infrequently 
attacked,  and  give  an  important  clue  in  diagnosis.  Secondary  metastatic 
growths  occur  subcutaneously,  either  at  the  navel  or  beneath  the  skin  in 
the  vicinity,  and  are  of  great  value  in  diagnosis.  In  one  instance  a  patient 
with  jaundice,  which  had  developed  somewhat  suddenly  and  was  believed  to 
be  catarrhal,  presented  no  signs  of  enlargement  of  the  liver  or  tumor  of  the 
stomach,  but  a  nodular  body  appeared  at  the  navel,  which  on  removal 
proved  to  be  typical  scirrhus.  A  second  case  in  the  ward  at  the  same 
time,  with  an  obscure  doubtful  tumor  in  the  left  hypochondr^um,  developed 
a  painful  nodular  subcutaneous  growth  midway  between  the  navel  and  the 
left  margin  of  the  ribs. 

Perforation. — In  the  extensive  ulceration  which  occurs  perforation  of 
the  stomach  is  not  uncommon.  It  occurred  into  the  peritonfeum  in  17  of 
the  507  cases  of  cancer  of  the  stomach  collected  by  Brinton.  In  our  series 
perforation  is  recorded  in  4  cases.    When  adhesions  form,  the  most  extensive 


CANCER  OF  THE  STOMACH.  489 

destruction  of  the  walls  may  take  place  without  perforation  into  the  peri- 
toneal cavity.  In  one  instance  which  came  under  my  observation  a  large 
portion  of  the  left  lobe  of  the  liver  lay  within  the  stomach.  Occasionally 
a  gastro-cutaneous  fistula  is  established.  Perforation  may  occur  into  the 
colon,  the  small  bowel,  the  pleura,  the  lung,  or  into  the  pericardium. 

Symptoms. — Latent  Carcinoma. — The  cases  are  not  very  infrequent. 
There  may  be  no  symptoms  pointing  to  the  stomach,  and  the  tumor  may 
be  discovered  accidentally  after  death.  In  a  second  group  the  symptoms 
of  carcinoma  are  present,  not  of  the  stomach,  but  of  the  liver  or  some  other 
organ,  or  there  are  subcutaneous  nodules,  or,  as  in  one  of  our  cases,  second- 
ary masses  on  the  ribs  and  vertebrae.  In  a  third  group,  seen  particularly  in 
elderly  persons  in  institutions,  there  is  gradual  asthenia,  without  nausea, 
vomiting,  or  other  local  symptoms. 

Features  of  Onset. — Of  the  150  cases  in  our  series,  48  complained  of 
pain,  44  of  dyspepsia,  21  of  vomiting,  13  of  loss  in  weight,  3  of  difficulty 
in  swallowing,  1  of  tumor.  In  7  the  features  of  onset  suggested  pernicious 
ana?mia.    In  37  cases  there  was  a  history  of  sudden  onset. 

General  Symptoms.— Loss  of  Weight. — Progressive  emaciation  is  one 
of  the  most  constant  features  of  the  disease.  In  79  of  our  cases  in  which 
exact  figures  were  taken:  To  30  pounds,  32  cases;  30  to  50  pounds,  36  cases; 
50  to  60  pounds,  5  cases;  60  to  70  pounds,  4;  over  70  pounds,  1;  100 
pounds,  a  case  of  cancer  at  the  cardiac  end  with  obstruction  ta  swallowing. 
The  loss  in  weight  is  not  always  progressive.  We  see  increase  in  weight 
under  three  conditions:  (a)  Proper  dieting,  with  treatment  of  the  associated 
catarrh  of  the  stomach;  (&)  in  cases  of  cancer  of  the  pylorus  after  relief  of  the 
dilatation  of  the  organ  by  lavage,  etc.;  (c)  after  a  profound  mental  impres- 
sion. I  have  known  a  gain  of  ten  pounds  to  follow  the  visit  of  an  optimistic 
consultant.  In  Keen  and  D.  D.  Stewart's  case  there  was  a  gain  of  seventy 
pounds  after  an  exploratory  operation! 

Loss  in  strength  is  usually  proportionate  to  the  loss  in  weight.  One  sees 
sometimes  remarkable  vigor  almost  to  the  close,  but  this  is  exceptional. 

Ancemia  is  present  in  a  large  proportion  of  all  cases,  and  with  the  emaci- 
ation gives  the  picture  of  cachexia.  There  is  often  a  yellow  or  lemon  tint 
of  the  skin.  In  59  cases  careful  blood-counts  were  made,  in  3  the  red  cor- 
puscles were  above  6,000,000  per  cubic  millimetre.  This  occurs  in  the 
concentrated  condition  of  the  blood  in  certain  cases  of  cancer  of  the  pylorus 
with  dilatation  of  the  stomach.  The  average  count  in  the  59  cases  was 
3,712,186  per  cubic  millimetre.  In  only  8  cases  was  the  count  below  2,000,- 
000,  and  in  none  below  1,000,000.  The  average  of  the  htemoglobin  was 
44.9  per  cent.  In  only  9  was  it  below  30  per  cent.  In  62  cases  in  which 
the  leucocytes  were  counted  there  were  only  18  cases  in  which  they  were 
above  12,000  per  cubic  millimetre;  in  only  8  cases  were  they  above  20,000. 
As  mentioned,  there  were  7  cases  in  which  the  features  of  onset  suggested 
a  primary  anaemia.     To  this  question  we  shall  return  under  diagnosis. 

Among  other  general  symptoms  may  be  mentioned  fever.  Of  our  150 
cases,  74  showed  some  fever.  In  only  13  of  these  was  the  temperature 
above  101°.  In  2  it  was  above  103°.  Fifteen  presented  fairly  constant 
elevation  of  temperature.     Eight  presented  sudden  rises.     Two  cases  had 


490  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

chill,  with  elevation  to  103°  and  104°.  Chills  may  be  associated  with  sup- 
puration at  the  base  of  the  cancer. 

Urine. — There  may  be  no  changes  throughout;  in  65  of  our  cases  there 
were  no  alterations,  in  36  albumin  was  found,  and  in  34  albumin  with  tube- 
casts.  Glycosuria,  peptonuria,  and  acetonuria  have  been  described.  Indican 
is  common. 

(Edema. — Swelling  of  the  ankles  is  of  frequent  occurrence  toward  the 
close.  In  some  cases  there  is  even  early  a  general  anasarca,  usually  in  com- 
bination with  extreme  angemia.    The  cancer  is  usually  overlooked. 

The  bowels  are  often  constipated.  In  only  12  cases  in  our  series  was 
diarrhoea  present.  In  2  cases  blood  was  passed  per  rectum.  There  are  no 
special  cardiac  symptoms;  the  pulse  becomes  progressively  weaker.  Throm- 
bosis of  one  femoral  vein  may  occur  or,  as  in  one  of  our  cases,  widespread 
thrombosis  in  the  superficial  veins  of  the  body. 

Symptoms  on  the  part  of  the  nervous  system  are  rare;  conscioiTsness 
is  often  retained  to  the  end.  Coma  may  develop — viz.,  similar  to  that  seen 
in  diabetes,  and  is  believed  to  be  due  to  an  acid  intoxication. 

Functional  Disturbances. — Anorexia,  loss  of  desire  for  food,  is  a  fre- 
quent and  valuable  symptdm,  more  constant  perhaps  than  any  other. 
Nausea  is  a  striking  feature  in  many  cases;  there  is  often  a  sudden  re- 
pulsion at  the  sight  of  food.  In  exceptional  cases  the  appetite  is  retained 
throughout. 

Vomiting  may  come  on  early,  or  only  after  the  dyspepsia  has  persisted 
for  some  time.  It  occurred  in  128  cases  in  our  series.  At  first  it  is  at  long 
intervals,  but  subsequently  it  is  more  frequent,  and  may  recur  several  times 
in  the  day.  There  are  cases  in  which  it  comes  on  in  paroxysms  and  then 
subsides;  in  other  cases,  it  sets  in  early,  persists  with  great  violence,  and 
may  cause  a  fatal  termination  within  a  few  weeks.  Vomiting  is  more  fre- 
quent when  the  cancer  involves  the  orifices,  particularly  the  pylorus,  in 
which  case  it  is  usually  delayed  for  an  hour  or  more  after  taking  the  food. 
When  the  cardiac  orifice  is  involved  it  may  follow  at  a  shorter  interval. 
Extensive  disease  of  the  fundus  or  of  the  anterior  or  posterior  wall  may 
be  present  without  the  occurrence  of  vomiting.  The  food  is  sometimes  very 
little  changed,  even  after  it  has  remained  in  the  stomach  for  twenty-four 
hours. 

Hcemorrhage  occurred  in  36  of  our  150  cases;  in  32  the  blood  was  dark 
and  altered,  in  3  it  was  bright  red.  In  2  cases  vomiting  of  blood  was  the 
first  symptom.  The  bleeding  is  rarely  profuse;  more  commonly  there  is 
slight  oozing,  and  the  blood  is  mixed  with,  or  altered  by  the  secretions, 
and,  when  vomited,  the  material  is  dark  brown  or  black,  the  so-called 
"  coffee-ground  "  vomit.  The  blood  can  be  recognized  by  the  microscope  as 
shadows  of  the  red  blood-corpuscles  and  irregular  masses  of  altered  blood 
pigment.  In  cases  of  doubt  the  spectroscope  may  be  employed  or  hasmin 
crystals  obtained. 

Pain,  an  early  and  important  symptom,  was  present  in  130  of  our  cases. 
It  is  very  variable  in  situation,  and  while  most  common  in  the  epigastrium, 
it  may  be  referred  to  the  shoulders,  the  back,  or  the  loins.  The  pain  is 
described  as  dragging,  burning,  or  gnawing  in  character,  and  very  rarely 


CANCER  OF  THE  STOMACH.  .  49I 

occurs  in  severe  paroxysms  of  gastralgia,  as  in  gastric  ulcer.  As  a  rule,  the 
pain  is  aggravated  by  taking  food.  There  is  usually  marked  tenderness  on 
pressure  in  the  epigastric  region.  The  areas  of  skin  tenderness  are  referred, 
as  Head  has  shown,  to  the  region  between  the  nipple  and  the  umbilicus 
in  front  and  behind  from  the  fifth  to  the  twelfth  thoracic  spine. 

Examination  of  the  Stomach  Contents. — The  vomitus  in  suspected  cases 
should  be  carefully  studied,  particularly  as  to  quantity  and  character  of 
ingredients.  Large  amounts  brought  up  at  intervals  of  a  few  days,  with 
the  appearances  already  described,  are  characteristic  of  dilatation  of  the 
stomach.  Some  of  the  material  should  be  spread  in  a  large  glass  plate  and 
any  suspicious  portions  picked  out  for  examination.  Bacteria  in  large  num- 
bers occur,  one,  the  Oppler-Boas  bacillus — an  unusually  long  non-mobile 
form — is  supposed  to  be  of  diagnostic  value,  and  to  be  largely  responsible 
for  the  formation  of  lactic  acid.  The  yeast  fungus  is  very  commonly  found, 
sarcinse  less  frequently  than  in  dilatation  from  stricture.  Blood  is  a  most 
important  ingredient;  the  persistent  presence  microscopically  of  red  cor- 
puscles in  the  early  morning  washings  is  always  very  suspicious.  Later, 
when  coffee-ground  vomiting  takes  place,  the  macroscopic  evidence  is  suf- 
ficient. In  cases  of  doubt  the  spectroscope  may  be  used  or  the  test  made 
for  hgemin  crystals.  Fragments  of  the  new  growth  may  be  vomited  or  may 
appear  in  the  washings.  Positive  evidence  of  cancer  may  be  obtained  from 
them. 

Examination  of  the  Test  Breakfast. — The  Ewald  test  meal,  consisting 
of  a  slice  of  stale  bread  and  a  large  cup  of  weak  tea  without  cream  or  sugar, 
is  given  at  7  a.  m.  and  withdrawn  at  8  a.  m.  The  Boas  test  meal,  consisting 
of  a  gruel  made  of  a  tablespoonful  of  oatmeal  flour  in  a  litre  of  water,  is 
used  in  the  estimation  of  lactic  acid.  As  an  outcome  of  the  enormous 
number  of  observations  made  of  late  years,  it  may  be  said  that  free  HCl 
is  absent  in  a  large  proportion  of  all  cases  of  cancer  of  the  stomach.  Of 
94  cases  in  which  the  contents  were  examined  in  84  free  HCl  was  absent. 
In  5  undoubted  eases  the  reaction  was  good;  in  3  of  these  the  history  sug- 
gested previous  ulcer.  HCl  may  be  absent  in  chronic  gastritis  and  in 
atrophy  of  the  gastric  mucosa.  (For  a  good  discussion  of  hydrochloric-acid 
determinations  see  J.  S.  Thatcher,  Presbyterian  Hospital  Keports,  vol.  iii.) 
The  presence  of  lactic  acid  after  Boas'  test  meal  is  regarded  as  a  valuable 
sign.  It  is  rarely  present  in  chronic  catarrhal  conditions,  but,  as  Stockton 
and  Jones  conclude,  it  is  by  no  means  positive  evidence  of  carcinoma  ven- 
triculi. 

Physical  Examination. — {a)  Inspection. — After  a  preliminary  sur- 
vey, embracing  the  facies,  state  of  nutrition,  etc.,  particular  direction  is 
given  to  the  abdomen.  An  all-important  matter  is  to  have  the  patient  in 
a  good  light.  Fulness  in  the  epigastric  region,  inequality  in  the  infracostal 
grooves,  the  existence  of  peristalsis,  a  wide  area  of  aortic  pulsation,  the 
presence  of  subcutaneous  nodules  or  small  masses  about  the  navel,  and, 
lastly,  a  well-defined  tumor  mass — these,  together  or  singly,  may  be  seen 
on  careful  inspection.  I  cannot  emphasize  too  strongly  the  value  of  this 
method  of  examination.  In  62  of  the  150  cases  a  positive  tumor  could  be 
seen.     In  52  the  tumor  descended  with  inspiration;  in  36  peristalsis  was 


492  .DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

visible;  in  3  cases  movements  were  visible  in  the  tumor  itself.  In  10  eases 
with  visible  peristalsis  no  tumor  was  seen,  but  could  be  felt  on  palpation. 
Inflation  with  carbonic-acid  gas  may  be  tried,  except  when  hsemorrhage 
has  been  profuse  or  the  cancer  is  very  extensive.  The  dilatation  often  ren- 
ders evident  the  peristalsis  or  may  bring  a  tumer  into  view.  The  presence 
of  subcutaneous  and  umbilical  nodules  is  sometimes  a  very  great  help.  They 
were  found  in  5  of  our  series.  Palpation. — In  115  cases  a  tumor  could  be 
felt;  in  48  in  the  epigastric  region,  in  25  in  the  umbilical,  in  18  in  the  left 
hypochondriac,  in  17  in  the  right  hypochondriac  region,  while  in  7  cases  a 
mass  descended  in  deep  inspiration  from  beneath  the  left  costal  margin. 
These  figures  illustrate  in  how  large  a  proportion  of  the  cases  the  tumor  is  in 
evidence.  In  rare  cases  examination  in  the  knee-elbow  position  is  of  value. 
Mobility  in  gastric  tumor  is  a  point  of  much  importance.  First,  the  change 
with  respiration,  already  referred  to;  a  mass  may  descend  3  or  4  inches 
in  deep  inspiration;  secondly,  the  communicated  pulsation  from  the  aorta, 
which  is  often  in  its  extent  suggestive;  thirdly,  the  intrinsic  movements 
in  the  hypertrophied  muscularis  in  the  neighborhood  of  the  cancer.  This 
may  give  a  remarkable  character  to  the  mass,  causing  it  to  appear  and  disap- 
pear, lifting  the  abdominal  wall  in  the  epigastric  region;  and,  fourthly,' 
mechanical  movements,  with  inflation,  with  change  of  posture,  or  com- 
jnunicated  with  the  hand.  Tumors  of  the  pylorus  are  the  most  movable;- 
and  in  extreme  cases  can  be  displaced  to  either  hypochondrium  or  pushed 
far  down  below  the  navel  (see  illustrative  cases  in  my  Lectures  on  the  Diag- 
nosis of  Abdominal  Tumors).  Pain  on  palpation  is  common;  the  mass  is 
usually  hard,  sometimes  nodular.  Gas  can  at  times  be  felt  gurgling  through 
the  tumor  at  the  pyloric  region. 

Percussion  gives  less  important  indications — the  note  over  a  tumor  is 
rarely  flat,  more  often  a  flat  tympany.  Auscultation  may  reveal  the 
gurgling  through  the  pylorus;  sometimes  a  systolic  bruit  is  transmitted 
from  the  aorta,  and  when  a  local  peritonitis  exists  a  friction  may  be  heard. 

Complications.  — Secondary  growths  are  common.  In  44  autopsies  in 
our  series  there  were  metastases  in  38;  in  29  the  lymph-glands,  were  in- 
volved; in  23  the  liver,  in  11  the  peritonaeum,  in  8  the  pancreas,  in  8  the 
bowel,  in  4  the  lung,  in  3  the  pleura,  in  4  the  kidneys,  and  in  2  the  spleen. 
In  8  no  deposits  were  found. 

Perforation  may  lead  to  peritonitis,  but  in  3  of  our  4  cases  there  was 
no  general  involvement.  Cancerous  ascites  is  not  very  uncommon.  Dock 
has  called  attention  to  the  value  of  the  examination  of  the  fluid  in  such 
cases  as  a  help  to  diagnosis.  The  cells  show  mitoses  and  are  very  charac- 
teristic. Secondary  cancer  of  the  liver  is  very  common;  the  enlargement 
may  be  very  great,  and  such  cases  are  not  infrequently  mistaken  for 
primary  cancer  of  the  organ.  Involvement  of  the  lymph-glands  may  give 
valuable  indications.  There  may  be  early  enlargement  of  a  gland  at  the 
posterior  border  of  the  left  sterno-cleido-mastoid  muscle;  later  adjacent 
glands  may  become  affected.  This  occurs  also  in  uterine  cancer.  Accord- 
ing to  Williams,  Trosier  was  the  first  to  describe  this  condition,  which  must 
not  be  confounded  with  the  pseudo-lipome  sus-claviculaire  of  Verneuil. 

A  very  remarkable  picture  is  presented  when  the  cancer  sloughs  or  be- 


CANCER  OF  THE  STOMACH.  493 

comes  gangrenous;  the  vomitus  has  a  foul  odor,  often  of  a  penetrating  na- 
ture, to  be  perceived  throughout  the  room.  In  cases  in  which  the  ulcer 
perforates  the  colon,  the  vomiting  may  be  faecal.  I  have,  however,  met  with 
the  faecal  odor  in  a  case  with  incessant  vomiting;  there  was  no  perforation  of 
the  colon  at  autopsy. 

Course. — While  usually  chronic  and  lasting  from  a  year  to  eighteen 
months,  acute  cancer  of  the  stomach  is  by  no  means  infrequent.  Of  the 
69  cases  in  which  we  could  determine  accurately  the  duration,  15  lasted 
under  three  months,  16  from  three  to  six  months,  14  from  six  to  twelve 
months — a  total  of  45  under  one  year.  Four  cases  lasted  for  two  years  or 
over.     One  case  lived  for  at  least  two  years  and  a  half. 

Diagnosis. — In  115  of  our  150  cases  a  tumor  existed,  and  with  this 
the  recognition  is  rarely  in  doubt.  Practically  the  chief  difficulty  is  in 
those  cases  which  present  gastric  symptoms  or  anaemia,  or  both,  without 
the  presence  of  tumor.  In  the  one  a  chronic  gastritis  is  suspected;  in  the 
other  a  primary  anaemia.  In  chronic  gastritis  the  history  of  long-standing 
dyspepsia,  the  absence  of  cachexia,  the  absence  of  lactic  acid  in  the  test 
meal,  and  the  less  striking  blood  changes  are  the  important  points  for  con- 
sideration. The  cases  with  grave  ancemia  without  tumor  offer  the  greatest 
difficulty.  The  blood-count  is  rarely  so  low  as  in  pernicious  anaemia,  a 
point  on  which  F.  P.  Henry  has  laid  special  stress.  In  only  8  of  our  59 
cases  with  careful  blood  examination  was  the  number  below  2,000,000 
per  cubic  millimetre.  The  lower  color  index,  as  in  secondary  aneemia,  the 
absence  of  megaloblasts,  and  a  leucocytosis  speak  for  cancer.  Some  lay 
stress  on  the  differential  count  of  the  leucocytes,  but  there  is  not  evidence 
enough  to  enable  us  to  speak  positively  on  this  point.  The  digestion  leuco- 
cytosis might  be  a  help  in  some  cases.  The  chemical  findings  are  of  greater 
value.  The  constant  presence  of  lactic  acid  and  the  absence  of  HCl  have 
in  several  of  our  cases  suggested  the  diagnosis  of  cancer,  which  has  been 
verified  later  on  by  the  development  of  a  tumor. 

From  ulcer  of  the  stomach  malignant  disease  is,  as  a  rule,  readily  recog- 
nized. The  ulcus  carcinomatosum  usually  presents  a  well-marked  history  of 
ulcer  for  years.  Hemmeter  has  given  a  good  account  of  this  rare  condi- 
tion in  his  recent  work  on  the  stomach.  The  greatest  difficulty  is  offered 
when  there  is  ulcer  with  tumor  due  to  cicatricial  contraction  about  the 
pylorus.  In  3  such  cases  we  mistook  the  mass  for  cancer,  and  even  at 
operation  it  may  (as  in  one  of  them)  be  impossible  to  say  Nvhether  a  neo- 
plasm is  present.  The  persistent  hyperchlorhydria  is  the  most  important 
single  feature  of  ulcer,  and,  taken  with  the  gastralgic  attacks  and  the  haem- 
orrhages, rarely  leave  doubt  as  to  the  condition. 

Nowadays,  when  exploratory  laparotomy  may  be  advised  with  such 
safety,  the  surgeon  often  makes  the  diagnosis. 

The  practitioner  should  recognize  the  fact  that  there  are  cases  of  cancer 
of  the  stomach  in  which  a  positive  diagnosis  cannot  be  reached  for  weeks 
or  months  by  any  known  means  at  our  command. 

Treatment. — The  disease  is  incurable  and  palliative  measures  are 
alone  indicated.  The  diet  should  consist  of  readily  digested  siibstances  of 
all  sorts.     Many  patients  do  best  on  milk  alone.     Washing  out  of  the 


494  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

stomach,  which  may  be  done  with  a  soft  tube  without  any  risk,  is  particu- 
larly advantageous  when  there  is  obstruction  at  the  pylorus^  and  is  by  far 
the  most  satisfactory  means  of  combating  the  vomiting.  The  excessive 
fermentation  is  also  best  treated  by  lavage.  When  the  pain  becomes  -se- 
vere, particularly  if  it  disturbs  the  rest  at  night,  morphia  must  be  given. 
One  eighth  of  a  grain,  combined  with  carbonate  of  soda  (gr.  v),  bismuth 
(gr.  v-x),  usually  gives  prompt  relief,  and  the  dose  does  not  always  require 
to  be  increased.  Creasote  ("nij-ij)  and  carbolic  acid  are  very  useful.  The 
bleeding  in  gastric  cancer  is  rarely  amenable  to  treatment.  Operative 
measures  have  been  advised  and  practised,  and  in  exceptional  instances 
there  are  eases  in  which  the  limited  cancer  or  even  the  entire  organ  has 
been  resected. 

Other  Forms  of  Tumor. — Non-cancerous  tumors  of  the  stomach  rarely 
cause  inconvenience.  Polypi  (polyadenomata)  are  common  and  they  may 
be  numerous;  as  many  as  150  have  been  reported  in  one  case.  There  is  a 
form  in  which  the  adenoma  exists  as  an  extensive  area  slightly  raised  above 
the  level  of  the  mucosa — polyadenome  en  nappe  of  the  French.  H.  B.  An- 
derson has  described  a  case  of  remarkable  multiple  cysts  in  the  walls  of  the 
stomach  and  small  intestine.  Sarcomata  are  very  rare.  Fibromata  and 
lipomata  have  been  described. 

Foreign  bodies  occasionally  produce  remarkable  tumors  of  the  stomach. 
The  most  extraordinary  is  the  hair  tumor,  of  which  there  are  16  cases  in  the 
literature.  The  cases  occur  in  hysterical  women  who  have  been  in  the  habit 
of  eating  their  own  hair.  A  specimen  in  the  medical  museum  of  McGill 
University  is  in  two  sections,  which  form  an  exact  mould  of  the  stomach. 
The  tumors  are  large,  very  puzzling,  and  are  usually  mistaken  for  cancer. 
Of  7  cases  operated  upon,  6  recovered;  in  9  cases  the  condition  was  found 
post  mortem  (Schulten). 


VI.     HYPERTROPHIC  STENOSIS  OF  THE   PYLORUS. 

(a)  In  Adults. — Any  one  with  a  large  post-mortem  experience  has  met 
with  instances  of  dilated  stomachs  in  connection  with  thickening  or  hyper- 
trophy of  the  pylorus,  sometimes  forming  a  tumor  large  enough  to  be  felt, 
and  suggesting  the  presence  of  a  new  growth.  Microscopically,  however, 
the  condition  is  found  to  be  very  largely  hypertrophy  of  the  muscularis  and 
submucosa  of  the  pylorus.  It  was  well  described  by  the  older  writers.  The 
symptoms  are  those  of  dilatation  of  the  stomach.  The  condition  has  been 
fully  discussed  recently  by  Boas  (Archiv  fiir  Verdauungskrankheiten,  Bd.  4, 
I),  who  reports  two  interesting  cases  with  successful  gastro-enterostomy. 
The  question  is  whether  some  of  these  cases  may  not  really  be  congenital, 
as  there  have  been  instances  reported  in  girls  as  early  as  the  twelfth  and 
sixteenth  years. 

(b)  Conge7iital  Hypertrophy  of  the  Pylorus. — On  this  interesting  condi- 
tion a  closer  study  has  been  made  since  1897,  when  John  Thomson,  of 
Edinburgh,  directed  attention  to  it.  Eolleston  and  Crofton-Aikens  have 
collected  45  cases,  most  of  which  were  under  four  months  old. 


HEMORRHAGE  FROM  THE  STOMACH.  495 

It  has  been  regarded  as  a  congenital  gastric  spasm  (Thomson),  but 
there  is  also  hypertrophy  of  the  pylorus.  In  an  infant  under  four  months 
obstinate  vomiting,  wasting,  constipation,  and  the  presence  of  a  tumor 
suggested  the  diagnosis.  A  few  cases  have  recovered;  six  have  been  oper- 
ated on,  in  one  (Loreta's  operation)  recovery  followed. 


VII.    HvCMORRHAGE    FROM   THE    STOMACH  {Hcematemesia). 

Etiology. — Gastrorrhagia,  as  this  symptom  is  called,  may  result  from 
many  conditions,  local  or  general.  1.  In  local  disease:  (a)  cancer;  (b)  ulcer; 
(c)  disease  of  the  blood-vessels,  such  as  miliary  aneurisms  and  occasionally 
varicose  veins;  {d)  acute  congestion,  as  in  gastritis,  and  possibly  in  vicari- 
ous haemorrhage;  (e)  following  operations  in  the  abdomen,  particularly  when 
the  omentum  is  wounded,  erosions  of  the  gastric  mucosa  may  occur,  from 
which  haemorrhage  takes  place. 

2.  Passive  congestion  due  to  obstruction  in  the  portal  system.  This 
may  be  either  (a)  hepatic,  as  in  cirrhosis  of  the  liver,  thrombosis  of  the 
portal  vein,  or  pressure  upon  the  portal  vein  by  tumor,  and  secondarily  in 
cases  of  chronic  disease  of  the  heart  and  lungs;  (b)  splenic.  Gastrorrhagia 
is  by  no  means  an  uncommon  symptom  in  enlarged  spleen,  and  is  ex- 
plained by  the  intimate  relations  which  exist  between  the  vasa  brevia  and 
the  splenic  circulation. 

3.  Toxic:  (a)  The  poisons  of  the  specific  fevers,  small-pox,  measles, 
yellow  fever;  (&)  poisons  of  unknown  origin,  as  in  acute  yellow  atrophy 
and  in  purpura;  (c)  phosphorus. 

4.  Traumatism:  (a)  Mechanical  injuries,  such  as  blows  and  wounds, 
and  occasionally  by  the  stomach-tube;  (&)  the  result  of  severe  corrosive 
poisons. 

5.  Certain  constitutional  diseases:  (a)  Haemophilia;  (b)  profound  anae- 
mias, whether  idiopathic  or  due  to  splenic  enlargements  or  to  malaria;  (c) 
cholffimia. 

6.  In  certain  nervous  affections,  particularly  hysteria,  and  occasionally 
in  progressive  paralysis  of  the  insane  and  epilepsy. 

7.  The  blood  may  not  always  come  primarily  from  the  stomach.  Thus 
it  may  belong  to  the  nose  or  the  pharynx.  In  haemoptysis  some  of  the 
blood  may  find  its  way  into  the  stomach.  Again,  in  bleeding  from  the 
oesophagus  blood  may  trickle  into  the  stomach,  from  which  it  is  ejected. 
This  occurs  in  the  case  of  rupture  of  aneurism  and  of  the  oesophageal 
varices.  A  child  may  draw  blood  with  the  milk  from  the  mother's  breast 
even  in  considerable  quantities  and  then  vomit  it. 

8.  Miscellaneous  causes:  Aneurism  of  the  aorta  or  of  its  branches  may 
rupture  into  the  stomach.  There  are  instances  in  which  a  patient  has 
vomited  blood  once  without  over  having  a  recurrence  or  without  develop- 
ing symptoms  pointing  to  disease  of  the  stomach. 

In  new-born  infants  haDraatemcsis  may  occur  alone  or  in  connection 
with  bleeding  from  other  mucous  membranes. 
31 


496  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

In  medical  practice,  ligemorrhage  from  the  stomach  occurs  most  fre- 
quently in  connection  with  cirrhosis  of  the  liver  and  ulcer  of  the  stomach. 
It  is  more  frequent  in  women  than  in  men,  owing  to  the  greater  prevalence 
of  round  ulcer  in  the  former. 

Morbid  Anatomy. — When  death  has  occurred  from  the  hsemate- 
mesis  there  are  signs  of  intense  angemia.  The  condition  of  the  stomach 
varies  extremely.  The  lesion  is  evident  in  cancer  and  in  ulcer  of  the  stom- 
ach. It  is  to  be  borne  in  mind  that  fatal  hsemorrhage  may  come  from  a 
small  miliary  aneurism  communicating  with  the  surface  by  a  pin-hole  per- 
foration, or  the  bleeding  may  be  due  to  the  rupture  of  a  submucous  vein 
and  the  erosion  in  the  mucosa  may  be  small  and  readily  overlooked.  It 
may  require  a  careful  and  prolonged  search  to  avoid  overlooking  such 
lesions.  In  the  large  group  associated  with  portal  obstruction,  whether 
due  to  hepatic  or  splenic  disease,  the  mucosa  is  usually  pale,  smooth,  and 
shows  no  trace  of  any  lesion.  In  cirrhosis,  fatal  by  haemorrhage,  one  may 
sometimes  search  in  vain  for  any  focal  lesion  to  account  for  the  gastror- 
rhagia,  and  we  must  conclude  that  it  is  possible  for  even  the  most  profuse 
bleeding  to  occur  by  diapedesis.  The  stomach  may  be  distended  with  blood 
and  yet  the  source  of  the  hsemorrhage  be  not  apparent  either  in  the  stomach 
or  in  the  portal  system.  In  such  cases  the  oesophagus  should  be  examined, 
as  the  bleeding  may  come  from  that  source.  In  toxic  cases  there  are  in- 
variably haemorrhages  in  the  mucous  membrane  itself. 

Symptoms. — In  rare  instances  fatal  syncope  may  occur  without  any 
vomiting.  In  a  ease  of  the  kind,  in  which  the  woman  had  fallen  over  and 
died  in  a  few  minutes,  the  stomach  contained  between  three  and  four 
pounds  of  blood.  The  sudden  profuse  bleedings  rapidly  lead  to  profound 
anemia.  When  due  to  ulcer  or  cirrhosis  the  bleeding  usually  recurs  for 
several  days.  Fatal  haemorrhage  from  the  stomach  is  met  with  in  ulcer, 
cirrhosis,  enlargement  of  the  spleen,  and  in  instances  in  which  an  aneurism 
ruptures  into  the  stomach  or  oesophagus.  Gastrorrhagia  may  occur  in 
splenic  angemia  or  in  leukaemia  before  the  condition  has  aroused  the  at- 
tention of  friends  or  physician. 

The  vomited  blood  may  be  fluid  or  clotted;  it  is  usually  dark  in  color, 
but  in  the  basin  the  outer  part  rapidly  becomes  red  from  the  action  of  the 
air.  The  longer  blood  remains  in  the  stomach  the  more  altered  is  it  when 
ejected. 

The  amount  of  blood  lost  is  very  variable,  and  in  the  course  of  a  day 
the  patient  may  bring  up  three  or  four  pounds,  or  even  more.  In  a  case 
under  the  care  of  George  Eoss,  in  the  Montreal  General  Hospital,  the  pa- 
tient lost  during  seven  days  ten  pounds,  by  measurement,  of  blood.  The 
usual  symptoms  of  anaemia  develop  rapidly,  and  there  may  be  slight  fever, 
and  subsequently  cedema  may  occur.  Syncope,  convulsions,  and  occasion- 
ally hemiplegia  occur  after  very  profuse  haemorrhage.  An  interesting  cir- 
cumstance connected  with  gastro-intestinal  haemorrhage  is  the  development 
of  amaurosis,  the  mode  of  production  of  which  is  still  under  discussion. 

Diagnosis. — In  a  majority  of  instances  there  is  no  question  as  to 
the  origin  of  the  blood.  Occasionally  it  is  difficult,  particularly  if  the  case 
has  not  been  seen  during  the  attack.     Examination  of  the  vomit  readily 


NEUEOSES  OF  THE  STOMACH.  49Y 

determines  whether  blood  is  present  or  not.  The  materials  vomited  may 
be  stained  by  wine,  the  juice  of  strawberries,  raspberries,  or  cranberries, 
which  give  a  color  very  closely  resembling  that  of  fresh  blood,  while  iron 
and  bismuth  and  bile  may  produce  the  blackish  color  of  altered  blood.  In 
such  cases  the  microscope  will  show  clearly  the  presence  of  the  shadowy 
outlines  of  the  red  blood-corpuscles,  and,  if  necessary,  spectroscopic  and 
chemical  tests  may  be  applied. 

Deception  is  sometimes  practised  by  hysterical  patients,  who  swallow 
and  then  vomit  blood  or  colored  liquids.  With  a  little  care  such  cases  can 
usually  be  detected.  The  cases  must  be  excluded  in  which  the  blood  passes 
from  the  nose  or  pharynx,  or  in  which  infants  swallow  it  with  the  milk. 

There  is  not  often  difficulty  in  distinguishing  between  hgemoptysis  and 
hgematemesis,  though  the  coughing  and  the  vomiting  are  not  infrequently 
combined.    The  following  are  points  to  be  borne  in  mind  in  the  diagnosis: 

H^MATEMESIS.  HEMOPTYSIS. 

1.  Previous  history  points  to  gas-  1.  Cough  or  signs  of  some  pul- 
tric,  hepatic,  or  splenic  disease.  monary  or  cardiac  disease  precedes, 

in  many  cases,  the  haemorrhage. 

2.  The  blood  is  brought  up  by  2.  The  blood  is  coughed  up, 
vomiting,  prior  to  which  the  patient  and  is  usually  preceded  by  a  sensa- 
may  experience  a  feeling  of  giddiness  tion  of  tickling  in  the  throat.  If 
or  faintness.  vomiting     occurs,     it     follows     the 

coughing. 

3.  The  blood  is  usually  clotted,  3.  The  blood  is  frothy,  bright 
mixed  with  particles  of  food,  and  red  in  color,  alkaline  in  reaction, 
has  an  acid  reaction.  It  may  be  If  clotted,  rarely  in  such  large  co- 
dark,  grumous,  and  fluid.  agula,  and  muco-pus  may  be  mixed 

with  it. 

4.  Subsequent  to  the  attack  the  4.  The  cough  persists,  physical 
patient  passes  tarry  stools,  and  signs  signs  of  local  disease  in  the  chest 
of  disease  of  the  abdominal  viscera  may  usually  be  detected,  and  the 
may  be  detected.  sputa  may  be  blood-stained  for  many 

days. 

Prognosis. — Except  in  the  case  of  rupture  of  an  aneurism  or  of  large 
veins,  hsematemesis  rarely  proves  fatal.  In  my  experience  death  has  fol- 
lowed more  frequently  in  cases  of  cirrhosis  and  splenic  enlargement  than 
in  ulcer  or  cancer.  In  ulcer  it  is  to  be  remembered  that  in  the  chronic 
ha?morrhagic  form  the  l:)leeding  may  recur  for  years.  The  treatment  of 
haematemesis  is  considered  under  gastric  ulcer. 


VIII.     NEUROSES    OF   THE   STOMACH  (Nervous  Dyspepsia). 

The  studies  of  Leube,  Ewald,  Oser,  Kosenbach,  and  many  others  have 
shown  that  serious  functional  disturbances  of  the  stomach  may  occur  with- 
out any  discoverable  anatomical  basis.     The  cases  are  met  with  most  fre- 


498  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

qiiently  in  those  who  have  either  inherited  a  nervous  constitution  or  who 
have  gradually,  through  indiscretions,  brought  about  a  condition  of  nervous 
prostration.  ISTot  infrequently,  however,  the  gastric  symptoms  stand  so  far 
in  the  foreground  that  the  general  neuropathic  character  of  the  patient 
quite  escapes  notice.  Sometimes  the  gastric  manifestations  have  appar- 
ently a  reflex  origin  depending  on  organic  disturbances  in  remote  parts  of 
the  body. 

The  nervous  derangements  of  the  stomach  may  be  divided  into  motor, 
secretory,  and  sensory  neuroses.  These  disturbances  rarely  occur  singly; 
they  are  usually  met  with  in  combined  forms.  The  clinical  picture  result- 
ing from  such  a  complex  of  gastric  neuroses  is  known  as  nervous  dyspepsia. 
There,  as  Leube  has  pointed  out,  the  sensory  disturbances  usually  play  the 
more  important  part. 

The  sufferer  from  nervous  dyspepsia  presents  a  varying  picture.  All 
grades  occur,  from  the  emaciated  skeleton-like  patient  with  anorexia 
nervosa  to  the  well-nourished,  healthy-looking,  fresh-complexioned  indi- 
vidual whose  only  complaint  is  distress  and  uneasiness  after  eating.  I  have 
followed  Eiegel's  classification  as  given  in  his  recent  exhaustive  work  on 
the  stomach. 

I.  Motor  Neuroses. — (a)  Eyperlcinesis  or  Supermotility. — An  increase  in 
the  normal  motor  activity  of  the  stomach  results  in  too  early  a  discharge  of 
the  ingesta  into  the  intestine.  It  is  more  commonly  a  secondary  neurosis 
dependent  upon  superacidity  or  supersecretion  of  the  gastric  juice;  but  it 
may  occur  primarily,  possibly  from  reflex  causes.  The  diagnosis  is  to  be 
reached  only  by  means  of  the  stomach-tube.  It  gives  rise  to  no  charac- 
teristic clinical  symptoms. 

{b)  Peristaltic  Unrest. — This  condition,  as  described  by  Kussmaul,  is 
an  extremely  common  and  distressing  symptom  in  neurasthenia.  Shortly 
after  eating  the  peristaltic  movements  of  the  stomach  are  increased,  and 
borborygmi  and  gurgling  may  be  heard,  even  at  a  distance.  The  sub- 
jective sensations  are  most  annoying,  and  it  would  appear  as  if  in  the  hyper- 
sesthetic  condition  of  the  nervous  system  the  patient  felt  normal  peristalsis, 
just  as  in  these  states  the  usual  beating  of  the  heart  may  be  perceptible 
to  him.  A  further  analogy  is  afforded  by  the  fact  that  emotion  increases 
this  peristalsis.  It  may  extend  to  the  intestines,  particularly  to  the  duode- 
num, and  on  palpation  over  this  region  the  gurgling  is  most  marked.  The 
movement  may  be  anti-peristalsis,  in  which  the  wave  passes  from  right  to 
left,  a  condition  which  may  also  extend  to  the  intestines.  There  are  cases 
on  record  in  which  colored  enemata  or  even  scybala  have  been  discharged 
from  the  mouth. 

(c)  Nervous  Eructations. — In  this  condition  severe  attacks  of  noisy 
eructations,  following  one  another  often  in  rapid  succession,  occur.  When 
violent  they  last  for  hours  or  days.  At  other  times  they  occur  in  paroxysms, 
depending  often  upon  mental  excitement.  They  are  more  commonly  ob- 
served in  hysterical  women  and  neurasthenics,  but  also,  not  infrequently, 
in  children.  The  hysterical  nature  of  the  affection  is  sometimes  testified 
to  by  the  occurrence,  especially  in  children,  of  several  instances  in  one 
household. 


NEUROSES  OF  THE  STOMACH.  499 

The  expelled  gas  in  these  cases  is  atmospheric  air,  which  is  swallowed 
or  aspirated  from  without.  Sometimes  the  whole  process  may  be  clearly 
observed,  but  in  other  instances  the  act  of  swallowing  may  be  almost  or 
quite  imperceptible.  Bouveret  considers  the  condition  due  to  a  spasm  of 
the  pharynx  which  causes  involuntary  swallowing.  Oser  has  suggested  that 
the  air  may  enter  by  aspiration,  the  stomach  acting  like  an  elastic  rubber 
bag  which  tends  to  fill  again  after  the  air  is  expressed.  It  is  quite  possible 
that  in  some  instances  the  eructations  consist  of  gas  which  has  never  actually 
reached  the  stomach,  but  is  brought  up  from  the  oesophagus. 

(d)  Nervous  Vomiting. — A  condition  which  is  not  associated  with  ana- 
tomical changes  in  the  stomach  or  with  any  state  of  the  contents,  but  is  due 
to  nervous  influences  acting  either  directly  or  indirectly  upon  the  centres 
presiding  over  the  act  of  vomiting.  The  patients  are,  as  a  rule,  women — 
usually  brunettes — and  the  subject  of  more  or  less  marked  hysterical  mani- 
festations. A  special  feature  of  this  form  is  the  absence  of  the  preliminary 
nausea  and  of  the  straining  efforts  of  the  ordinary  act  of  vomiting.  It  is 
rather  a  regurgitation,  and  without  visible  effort  and  without  gagging  the 
mouth  is  filled  with  the  contents  of  the  stomach,  which  are  then  spat  out. 
It  comes  on,  as  a  rule,  after  eating,  but  may  occur  at  irregular  intervals. 
In  some  cases  the  nutrition  is  not  impaired,  a  feature  which  may  give  a 
clew  to  the  true  nature  of  the  disease,  as  there  may  be  no  other  hysterical 
manifestation  present.  As  noted  by  Tuckwell,  it  may  occur  in  children. 
Nervous  vomiting  is  rarely  serious. 

A  type  of  vomiting  is  that  associated  with  certain  diseases  of  the  nerv- 
ous system — particularly  locomotor  ataxia — forming  part  of  the  gastric 
crises.  Leyden  has  reported  cases  of  primary  periodic  vomiting,  which  he 
regards  as  a  neurosis. 

(e)  Rumination;  Merycism,us. — In  this  remarkable  and  rare  condition 
the  patients  regurgitate  and  chew  the  cud  like  ruminants.  It  occurs  in 
neurasthenic  or  hysterical  persons,  epileptics,  and  idiots.  In  some  patients 
it  is  hereditary.  There  is  an  instance  in  which  a  governess  taught  it  to  two 
children.  The  habit  may  persist  for  years,  and  does  not  necessarily  impair 
the  health. 

(/)  Spasm  of  the  Cardia. — Spasmodic,  usually  painful  contraction  of  the 
circular  muscle  fibres  at  the  cardiac  orifice  may  follow  the  introduction  of 
a  sound,  hasty  eating,  or  the  taking  of  too  hot  or  too  cold  food.  It  may 
occur  in  tetanus  and  also  in  hysterical  and  neurasthenic  individuals,  espe- 
cially in  air  swallowers,  in  whom,  if  it  be  combined  with  pyloric  spasm,  it 
may  result  in  painful  gastric  distention — "  pneumatosis."  Here  the  spasm 
may  be  of  considerable  duration.  The  condition  is  rare  and  practically 
not  of  much  moment. 

(g)  Pyloric  Spasm. — This  is  usually  a  secondary  occurrence,  following 
superacidity,  supersecretion,  ulcer,  or  the  introduction  into  the  stomach 
of  irritating  substances.  The  spasm  often  causes  pain  in  the  region  of  the 
pylorus  and  increased  gastric  peristalsis.  In  cases  whore  the  spasm  is  com- 
bined with  superacidity  and  supersecretion  marked  dilatation  with  atony 
may  follow;  it  is  questionable,  however,  whether  a  primary  nervous  pyloric 
spasm  ever  gives  rise  to  serious  results.     I  have  already  referred  to  John 


500  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

Thomson's  views  of  pyloric  spasm  in  association  with  the  congenital  form 
of  hypertrophic  stenosis  of  the  pylorus. 

(Ji)  Atony  of  the  Stomach. — Motor  insufficiency  of  the  stomach  is  gen- 
erally due  to  injudicious  feeding,  to  organic  disease  of  the  stomach  itself, 
or  to  general  wasting  processes.  In  some  otherwise  normal  individuals  of 
neurotic  temperaments  an  atony  may,  however,  occur  which  possibly  de- 
serves to  be  classed  among  the  neuroses.  The  symptoms  are  usually  those 
of  a  moderate  dilatation,  and  are  often  associated  with  marked  sensory  dis- 
turbances— feelings  of  weight  and  pressure,  distention,  eructations,  and  so 
forth. 

Great  care  must  be  taken  in  the  diagnosis  to  rule  out  all  other  possible 
causes. 

(i)  Insufficiency  or  Incontinence  of  the  Pylorus. — This  condition  was  de- 
scribed first  by  de  Sere  and  later  by  Ebstein.  It  may  be  recognized  by  the 
rapid  passing  of  gas  from  the  stomach  into  the  bowel  on  attempts  at  infla- 
tion of  the  former,  as  well  as  by  the  presence  of  bile  and  intestinal  contents 
in  the  stomach.    There  are  no  distinctive  clinical  symptoms. 

(j)  Insufficiency  of  the  Cardia. — This  condition  is  only  recognized  by 
the  occurrence  of  eructations  or  in  rumination. 

II.  Secretory  Neuroses. — (a)  Hyperacidity ;  Superacidity ;  Hyper- 
chlorhydria. — Nervous  dyspepsia  with  hyperacidity  of  the  gastric  juices. 
The  symptoms  depend  upon  the  secretion  of  an  abnormally  acid  gastric  juice 
at  the  time  of  digestion.  This  is  a  common  form  of  dyspepsia  in  young  and 
neurotic  individuals.  Osswald  has  pointed  out  its  remarkable  frequency 
in  ehlorotic  girls.  The  symptoms  are  very  variable.  They  do  not,  as  a  rule, 
immediately  follow  the  ingestion  of  food,  but  occur  one  to  three  hours  later, 
at  the  height  of  digestion.  There  is  a  sense  of  weight  and  pressure,  some- 
times of  burning  in  the  epigastrium,  commonly  associated  with  acid  eructa- 
tions. If  vomiting  occurs,  the  pain  is  relieved.  The  patient  is  usually  rela- 
tively well  nourished,  and  the  appetite  is  often  good,  though  the  sufferer 
may  be  afraid  to  eat  on  account  of  the  anticipated  pain.  Its  association 
wdth  ulcer  has  been  referred  to.    There  is  commonly  constipation. 

(b)  Supersecretion,  Intermittent  and  Continuous. — This  is  a  form  of  dys- 
pepsia which  has  been  long  recognized,  but  of  late  has  been  specially  studied 
by  Eeichmann  and  others.  The  increased  flow  of  the  gastric  juice  may  be 
intermittent  or  continuous.  The  secretion  under  such  circumstances  is 
usually  superacid,  though  this  is  not  always  the  case.  The  periodical  form— 
the  gastroxynsis  of  Eossbach — may  be  quite  independent  of  the  time  of 
digestion.  Great  quantities  of  highly  acid  gastric  juice  may  be  secreted 
in  a  very  small  space  of  time.  Such  cases  are  rare,  and  are  especially  asso- 
ciated either  with  profound  neurasthenia  or  with  locomotor  ataxia.  The 
attack  may  last  for  several  days.  It  usually  sets  in  with  a  gnawing,  unpleas- 
ant sensation  in  the  stomach,  severe  headache,  and  shortly  after  the  patient 
vomjts  a  clear,  watery  secretion  of  such  acidity  that  the  throat  is  irritated 
and  made  raw  and  sore.  As  mentioned,  the  attacks  may  be  quite  inde- 
pendent of  food.  Continuous  supersecretion  is  more  common.  The  con- 
stant presence  of  fluid  in  the  stomach,  together  with  the  pyloric  spasm, 
which  commonly  results  from  the  irritation  of  the  overacid  gastric  jwice," 


NEUROSES  OF  THE  STOMACH.  501 

are  followed  by  a  more  or  less  extensive  dilatation.  Digestion  of  the  starches 
is  retarded,  and  there  are  eructations  of  acid  flnid  and  gastric  distress. 
This  secretion  of  highly  acid  gastric  juice  may  continue  when  the  stomach  is 
free  from  food.  In  these  cases  pain,  burning  acid  eructations,  and  even 
vomiting,  occurring  during  the  night  and  early  in  the  morning,  are  rather 
characteristic. 

(c)  Nervous  Subacidity  or  Inacidity;  Achylia  Gastrica  Nervosa. — Lack  of 
the  normal  amount  of  acid  is  found  in  chronic  catarrh,  and  particularly  in 
cancer.  As  Leube  has  shown,  a  reduction  in  the  normal  amount  of  acid 
may  exist  with  the  most  pronounced  symptoms  of  nervous  dyspepsia  and 
yet  the  stomach  will  be  free  from  food  within  the  regular  time.  A  condi- 
tion in  which  free  acid  is  absent  in  the  gastric  juice  may  occur  in  cancer, 
in  extreme  sclerosis  of  the  mucous  membrane,  as  a  nervous  manifestation  of 
hysteria,  and  occasionally  of  tabes.  In  most  of  these  cases,  though  there 
be  no  free  acid,  yet  the  other  digestive  ferments — pepsin  and  the  curdling 
ferments — or  their  zymogens  are  to  be  demonstrated  in  the  gastric  juice. 
There  may,  however,  be  a  complete  absence  of  the  gastric  secretion.  To 
these  cases  Einhorn  has  given  the  name  of  achylia  gastrica.  This  condition 
was  at  first  thought  to  occur  only  in  cases  of  total  atrophy  of  the  gastric 
mucosa,  but  recent  observations  have  shown  that  it  may  occur  as  a  neurosis. 
In  a  case  of  Einhorn's  the  gastric  secretions  returned  after  five  years  of  total 
achylia  gastrica. 

The  symptoms  of  subacidity,  or  even  of  achylia  gastrica,  vary  greatly 
in  intensity;  they  may  be  almost  or  quite  absent  in  cases  of  advanced  atro- 
phy of  the  mucosa,  and,  as  a  rule,  are  not  marked  so  long  as  the  motor 
activity  of  the  stomach  remains  good.  If  atony,  however,  develop  and  ab- 
normal fermentative  processes  arise,  severe  gastric  and  intestinal  symptoms 
may  follow.  In  the  cases  associated  with  hysteria  and  neurasthenia,  even 
though  the  food  may  be  well  taken  care  of  by  the  intestines,  there  are  very 
commonly  grave  sensory  disturbances  in  the  region  of  the  stomach,  in  ad- 
dition to  the  general  nervous  symptoms. 

III.  Sensory  Neuroses. — (a)  Hypercesthesia. — In  this  condition  the  pa- 
tients complain  of  fulness,  pressure,  weight,  burning,  and  so  forth,  during 
digestion,  just  such  symptoms  as  accompany  a  variety  of  organic  diseases  of 
the  stomach,  and  yet  in  all  other  respects  the  gastric  functions  appear  quite 
normal.  Sometimes  these  distressing  sensations  are  present  even  when  the 
stomach  is  empty.  These  symptoms  are  usually  associated  with  other  mani- 
festations of  hysteria  and  neurasthenia.  The  pain  often  follows  particular 
articles  of  food.  An  hysterical  patient  may  apparently  suffer  excruciating 
pain  after  taking  the  smallest  amount  of  food  of  any  sort,  while  anything 
prescribed  as  a  medicine  may  be  well  borne.  In  severe  cases  the  patient 
may  be  reduced  to  an  extreme  degree  of  starvation. 

(h)  Gastralgia;  Gastrodynia. — Severe  pains  in  the  epigastrium,  parox- 
ysmal in  character,  occur  (a)  as  a  manifestation  of  a  functional  neurosis, 
independent  of  organic  disease,  and  usually  associated  with  other  nervous 
symptoms  (it  is  this  form  which  will  here  be  described);  (h)  in  chronic 
disease  of  the  nervous  system,  forming  the  so-called  gastric  crises;  and  (c) 
in  organic  disease  of  the  stomach,  such  as  ulcer  or  cancer. 


502  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  functional  neurosis  occurs  chiefly  in  women^  very  commonly  in  con- 
nection with  disturbed  menstrual  function  or  with  pronounced  hysterical 
symptoms.  The  afl:ection  may  set  in  as  early  as  puberty,  but  it  is  more 
common  at  the  menopause.  Anaemic,  constipated  women  who  have  worries 
and  anxieties  at  home  are  most  prone  to  the  affection.  It  is  more  frequent 
in  brunettes  than  in  blondes.  Attacks  of  it  sometimes  occur  in  robust, 
healthy  men.  More  often  it  is  only  one  feature  in  a  condition  of  general 
neurasthenia  or  a  manifestation  of  that  form  of  nervous  dyspepsia  in  which 
the  gastric  Juice  or  hydrochloric  acid  is  secreted  in  excess.  I  am  very 
sceptical  as  to  the  existence  of  a  gastralgia  of  purely  malarial  origin. 

The  symptoms  are  very  characteristic;  the  patient  is  suddenly  seized 
with  agonizing  pains  in  the  epigastrium,  which  pass  toward  the  back  and 
around  the  lower  ribs.  The  attack  is  usually  independent  of  the  taking 
of  food,  and  may  recur  at  definite  intervals,  a  periodicity  which  has  given 
rise  to  the  supposition  in  some  cases  that  the  affection  is  due  to  malaria. 
The  most  marked  periodicity,  however,  may  be  in  the  gastralgic  attacks  of 
ulcer.  They  frequently  come  on  at  night.  Vomiting  is  rare;  more  com- 
monly the  taking  of  food  relieves  the  pain.  To  this,  however,  there  are 
striking  exceptions.  Pressure  upon  the  epigastrium  commonly  gives  relief, 
but  deep  pressure  may  be  painful.  It  seems  scarcely  necessary  to  separate 
the  forms,  as  some  have  done,  into  irritative  and  depressive,  as  the  cases 
insensibly  merge  into  each  other.  Stress  has  been  laid  upon  the  occurrence 
of  painful  points,  but  they  are  so  common  in  neurasthenia  that  very  little 
importance  can  be  attributed  to  them. 

The  diagnosis  offers  many  difficulties.  Organic  disease  either  of  the 
stomach  or  of  the  nervous  system,  particularly  the  gastric  crises  of  loco- 
motor ataxia,  must  be  excluded.  In  the  case  of  ulcer  or  cancer  this  is  not 
always  easy.  The  fact  that  the  pain  is  most  marked  when  the  stomach  is 
empty  and  is  relieved  by  the  taking  of  food  is  sometimes  regarded  as  pathog- 
nomonic of  simple  gastralgia,  but  to  this  there  are  many  exceptions,  and 
in  cancer  the  pains  may  be  relieved  on  eating.  The  prolonged  intervals 
between  the  attacks  and  their  independence  of  diet  are  important  features 
in  simple  gastralgia;  but  in  many  instances  it  is  less  the  local  than  tke  gen- 
eral symptoms  of  the  case  which  enable  us  to  make  the  diagnosis.  It  is  to 
be  remembered  that  in  gall-stone  colic  Jaundice  is  frequently  absent,  and  in 
any  long-standing  case  of  gastralgia,  in  which  the  attacks  recur  at  intervals 
for  years,  the  question  of  cholelithiasis  should  be  considered. 

(c)  Anomalies  of  the  Sense  of  Hunger  and  Repletion;  Bulimia. — Ab- 
normally excessive  hunger  coming  on  often  in  paroxysmal  attacks,  which 
cause  the  patient  to  commit  extraordinary  excesses  in  eating.  This  condi- 
tion may  occur  in  diabetes  mellitus  and  sometimes  in  gastric  disorders,  par- 
ticularly those  associated  with  supersecretion.  It  is,  however,  more  com- 
monly seen  in  hysteria  and  in  psychoses.  It  may  occur  in  cerebral  tumors, 
in  Graves'  disease,  and  in  epilepsy. 

The  attacks  often  begin  suddenly  at  night,  the  patient  waking  with  a 
feeling  of  faintness  and  pain,  and  an  uncontrollable  desire  for  food.  Some- 
times such  attacks  occur  immediately  after  a  large  meal.  The  attack  may 
be  relieved  by  a  small  amount  of  food,  while  at  other  times  enormous  quan- 


NEUROSES  OP   THE  STOMACH.  503 

titles  may  be  taken.  In  obstinate  cases  gastritis,  atony,  and  dilatation  fre- 
quently result  from  the  abuse  of  the  stomach. 

Akoria. — An  absence  of  the  sense  of  satiety.  This  condition  is  com- 
monly associated  with  bulimia  and  polyphagia,  but  not  always.  The  patient 
always  feels  "  empty."  There  are  usually  other  well-marked  manifestations 
of  hysteria  or  neurasthenia. 

Anorexia  Nervosa. — This  condition,  which  is  a  manifestation  of  a 
neurotic  temperament,  is  discussed  subsequently  under  the  general  head- 
ing of  Hysteria. 

Treatment  of  Neuroses  of  the  Stomach. — The  most  important  part  of  the 
treatment  of  nervous  dyspepsia  is  often  that  directed  toward  the  improve- 
ment of  the  general  physical  and  mental  condition  of  the  patient.  The 
possibility  that  the  symptoms  may  be  of  reflex  origin  should  be  borne  in 
mind.  A  large  proportion  of  cases  of  nervous  dyspepsia  are  dependent  upon 
mental  and  physical  exhaustion  or  worry,  and  a  vacation  or  a  change  of 
scene  will  often  accomplish  what  years  of  treatment  at  home  have  failed 
to  do.  The  manner  of  life  of  the  patient  should  be  investigated  and  a 
proper  amount  of  physical  exercise  in  the  open  air  insisted  upon.  This 
alone  will  in  some  cases  be  sufficient  to  cause  the  disappearance  of  the  symp- 
toms. 

Many  eases  of  nervous  dyspepsia  with  marked  neurasthenic  or  hysterical 
symptoms  do  well  on  the  Weir-Mitchell  treatment,  and  in  obstinate  forms 
it  should  be  given  a  thorough  trial.  The  most  striking  results  are  perhaps 
seen  in  the  case  of  anorexia  nervosa,  which  will  be  referred  to  subsequently. 
It  is  also  of  value  in  nervous  vomiting. 

In  cardiac  spasm  care  should  be  taken  to  eat  slowly,  to  avoid  swallow- 
ing too  large  morsels  or  irritating  substances.  The  methodical  introduction 
of  thick  sounds  may  be  of  value. 

The  treatment  in  atony  of  the  stomach  should  be  similar  to  that  adopted 
in  moderate  dilatation — the  administration  of  small  quantities  of  food  at 
frequent  intervals;  the  limitation  of  the  fluids,  which  should  also  be  taken 
in  small  amounts  at  a  time;  lavage.  Strychnine  in  full  doses  may  be  of 
value. 

In  the  distressing  cases  of  hyperacidity,  in  addition  to  the  treatment  of 
the  general  neurotic  condition,  alkalies  must  be  employed  either  in  the 
form  of  magnesia  or  bicarbonate  of  soda.  These  should  be  given  in  large 
doses  and  at  the  height  of  digestion.  The  burning  acid  eructations  may  be 
relieved  in  this  way.  The  diet  should  be  mainly  albuminous,  and  should 
be  administered  in  a  non-irritating  form.  Stimulating  condiments  and 
alcohol  should  be  avoided.  Starches  should  be  sparingly  allowed,  and  only 
in  most  digestible  forms.    Fats  are  fairly  M^ell  borne. 

Limiting  the  patient  to  a  strictly  meat  diet  is  a  valuable  procedure 
in  many  cases  of  dyspepsia  associated  with  hyperacidity.  The  meat  should 
be  taken  either  raw  or,  if  an  insuperable  objection  exists  to  this,  very 
slightly  cooked.  It  is  best  given  finely  minced  or  grated  on  stale  bread. 
An  ample  dietary  is  3^  ounces  (100  grammes)  of  meat,  two  medium  slices 
of  stale  bread,  and  an  ounce  (30  grammes)  of  butter.  This  may  be  taken 
three  times  a  day  with  a  glass  of  Apollinaris  water,  soda  water,  or,  what 


504  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

is  just  as  satisfactory,  spring  water.  The  fluid  should  not  be  taken  too  cold. 
Special  care  should  be  taken  in  the  examination  of  the  meat  to  guard  against 
tape-worm  infection,  but  suitable  instructions  on  this  point  can  be  given. 
This  is  sufficient  for  an  adult  man,  and  many  obstinate  cases  yield  satis- 
factorily to  a  month  or  six  weeks  of  this  treatment,  after  which  time  the 
less  readily  digested  articles  of  food  may  be  gradually  added  to  the  dietary. 

In  supersecretioii  the  use  of  the  stomach-tube  is  of  the  greatest  value. 
In  the  periodical  form  it  should  be  used  as  soon  as  the  attack  begins.  The 
stomach  may  be  washed  with  alkaline  solutions  or  solutions  of  nitrate  of 
silver,  1  to  1,000,  may  be  used.  Where  this  is  impracticable  the  taking  of 
albuminous  food  may  give  relief.  One  of  my  patients  used  to  have  two 
hard-boiled  eggs  by  his  bedside,  by  the  eating  of  which  nocturnal  attacks 
were  alleviated.    Alkalies  in  large  doses  are  also  indicated. 

In  cases  of  continued  supersecretion  there  is  usually  atony  and  dilata- 
tion. The  diet  here  should  be  much  as  in  superacidity,  but  should  be 
administered  in  smaller  quantities  at  frequent  intervals.  Lavage  with 
alkaline  solutions  or  with  nitrate  of  silver  is  of  great  value.  To  relieve  pain 
large  quantities  of  bicarbonate  of  soda  or  magnesia  should  be  given  at  the 
height  of  digestion. 

In  subacidity  a  carefully  regulated,  easily  digestible  mixed  diet,  not  too 
rich  in  albuminoids,  is  advisable.  Bitter  tonics  before  meals  are  sometimes 
of  value.  In  acliylia  gastrica  the  use  of  predigested  foods  and  of  hydro- 
chloric acid  in  full  doses  may  be  of  assistance. 

In  marked  hypercestliesia,  beside  the  treatment  of  the  general  condition, 
nitrate  of  silver  in  doses  of  gr.  i— |,  taken  in  §  iij-o  iv  of  water  on  an  empty 
stomach,  is  advised  by  Eosenheim. 

In  some  instances  rectal  feeding  may  have  to  be  resorted  to. 

The  gastralgia,  if  very  severe,  requires  morphia,  which  is  best  admin- 
istered subcutaneously  in  combination  with  atropia.  In  the  milder  attacks 
the  combination  of  morphia  (gr.  ^)  with  cocaine  and  belladonna  is  recom- 
mended by  Ewald.  The  greatest  caution  should,  however,  be  exercised  in 
these  cases  in  the  use  of  the  hypodermic  syringe.  It  is  preferable,  if  opium 
is  necessary,  to  give  it  by  the  mouth,  and  not  to  let  the  patient  know  the 
character  of  the  drug.  Chloroform,  in  from  10-  to  20-drop  doses,  or  Hoff- 
man's anodyne  will  sometimes  allay  the  severe  pains.  The  general  condi- 
tion should  receive  careful  attention,  and  in  many  cases  the  attacks  recur 
until  the  health  is  restored  by  change  of  air  with  the  prolonged  use  of 
arsenic.  If  there  is  anaemia  iron  may  be  given  freely.  Nitrate  of  silver  in 
doses  of  gr.  ^  to  -J  in  a  large  claret-glass  of  water  taken  on  an  empty  stomach 
is  useful  in  some  cases. 

There  are  forms  of  nervous  dyspepsia  occurring  in  women  who  are  often 
well  nourished  and  with  a  good  color,  yet  who  suffer — particularly  at  night 
— with  flatulency  and  abdominal  distress.  The  sleep  may  be  quiet  and  un- 
disturbed for  two  or  three  hours,  after  which  they  are  aroused  with  painful 
sensations  in  the  abdomen  and  eructations.  The  appetite  and  digestion  may 
appear  to  be  normal.  Constipation  is,  however,  usually  present.  In  many 
of  these  patients  the  condition  seems  rather  intestinal  dyspepsia,  and  the 
distress  is  due  to  the  accumulation  of  gases,  the  result  of  excessive  putre- 


■     DISEASES  OF  THE  INTESTINES  ASSOCIATED  WITH  DIARRHCEA.     505 

faction.  The  fats,  starches,  and  sugars  should  be  restricted.  A  diastase 
ferment  is  sometimes  useful.  The  flatulency  may  be  treated  by  the  methods 
above  mentioned.  Naphthalin,  salicylate  of  bismuth,  and  salol  have  been 
recommended.  Some  of  these  cases  obtain  relief  from  thorough  irrigation 
of  the  colon  at  bedtime. 

The  treatment  of  anorexia  nervosa  is  described  subsequently. 


YII.    DISEASES   OF  THE  INTESTINES. 

I.     DISEASES     OF    THE    INTESTINES     ASSOCIATED    WITH 

DIARRHCEA. 

CATARRHAL  ENTERITIS;   DIARRHCEA. 

In  the  classification  of  catarrhal  enteritis  the  anatomical  divisions  of 
the  bowel  have  been  too  closely  followed,  and  a  duodenitis,  jejunitis,  ilei- 
tis, typhlitis,  colitis,  and  proctitis  have  been  recognized;  whereas  in  a 
majority  of  cases  the  entire  intestinal  tract,  to  a  greater  or  lesser  extent,  is 
involved,  sometimes  the  small  most  intensely,  sometimes  the  large  bowel; 
but  during  life  it  may  be  quite  impossible  to  say  which  portion  is  specially 
affected. 

Etiology. — The  causes  may  be  either  primary  or  secondary.  Among 
the  causes  of  primary  catarrhal  enteritis  are:  (a)  Improper  food,  one  of 
the  most  frequent,  especially  in  children,  in  whom  it  follows  overeating, 
or  the  ingestion  of  unripe  fruit.  In  some  individuals  special  articles  of 
diet  will  always  produce  a  slight  diarrhoea,  which  may  not  be  due  to  a 
catarrh  of  the  mucosa,  but  to  increased  peristalsis  induced  by  the  offending 
material,  (b)  Various  toxic  substances.  Many  of  the  organic  poisons,  such 
as  those  produced  in  the  decomposition  of  milk  and  articles  of  food,  excite 
the  most  intense  intestinal  catarrh.  Certain  inorganic  substances,  as  arsenic 
and  mercury,  act  in  the  same  way.  (c)  Changes  in  the  weather.  A  fall  in 
the  temperature  of  from  twenty  to  thirty  degrees,  particularly  in  the  spring 
or  autumn,  may  induce — how,  it  is  difficult  to  say — an  acute  diarrhoea.  We 
speak  of  this  as  a  catarrhal  process,  the  result  of  cold  or  of  chill.  On  the 
other  hand,  the  diarrhceal  diseases  of  children  are  associated  in  a  very  spe- 
cial way  with  the  excessive  heat  of  summer  months,  (d)  Changes  in  the 
constitution  of  the  intestinal  secretions.  We  know  too  little  about  the 
succus  entericus  to  be  able  to  speak  of  influences  induced  by  change  in  its 
quantity  or  quality.  It  has  long  been  held  that  an  increase  in  the  amount 
of  bile  poured  into  the  bowel  might  excite  a  diarrhoea;  hence  the  term 
bilious  diarrhoea,  so  frequently  used  by  the  older  writers.  Possibly  there 
are  conditions  in  which  an  excessive  amount  of  bile  is  poured  into  the  intes- 
tine, increasing  the  peristalsis,  and  hurrying  on  the  contents;  but  the  oppo- 
site state,  a  scanty  secretion,  by  favoring  the  natural  fermentative  processes, 
much  more  commonly  causes  an  intestinal  catarrli.  Absence  of  the  pan- 
creatic secretion  from  the  intestine  has  been  associated  in  certain  cases  with 


506  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

a  fatty  diarrhoea,  (e)  Nervous  influences.  It  is  by  no  means  clear  how 
mental  states  act  upon  the  bowels,  and  yet  it  is  an  old  and  trustworthy  ob- 
servation, which  every-day  experience  confirms,  that  the  mental  state  may 
profoundly  afEect  the  intestinal  canal.  These  influences  should  not  prop- 
erly be  considered  under  catarrhal  processes,  as  they  result  simply  from  in- 
creased peristalsis  or  increased  secretion,  and  are  usually  described  under 
the  heading  nervous  diarrhoea.  In  children  it  frequently  follows  fright. 
It  is  common,  too,  in  adults  as  a  result  of  emotional  disturbances.  Can- 
statt  mentions  a  surgeon  who  always  before  an  important  operation  had 
watery  diarrhoea.  In  hysterical  women  it  is  seen  as  an  occasional  occur- 
rence, due  to  transient  excitement,  or  as  a  chronic,  protracted  diarrhoea, 
which  may  last  for  months  or  even  years. 

Among  the  secondary  causes  of  intestinal  catarrh  may  be  mentioned: 
{a)  Infectious  diseases.  Dysentery,  cholera,  typhoid  fever,  pyemia,  septi- 
csemia,  tuberculosis,  and  pneumonia  are  occasionally  associated  with  intes- 
tinal catarrh.  In  dysentery  and  typhoid  fever  the  ulceration  is  in  part 
responsible  for  the  catarrhal  condition,  but  in  cholera  it  is  probably  a  direct 
influence  of  the  bacilli  or  of  the  toxic  materials  produced  by  them.  (&) 
The  extension  of  inflammatory  processes  from  adjacent  parts.  Thus,  in 
peritonitis,  catarrhal  swelling  and  increased  secretion  are  always  present  in 
the  mucosa.  In  cases  of  invagination,  hernia,  tuberculous  or  cancerous  ul- 
ceration, catarrhal  processes  are  common,  (c)  Circulatory  disturbances 
cause  a  catarrhal  enteritis,  usually  of  a  very  chronic  character.  This  ie 
common  in  diseases  of  the  liver,  such  as  cirrhosis,  and  in  chronic  affections 
of  the  heart  and  lungs — all  conditions,  in  fact,  which  produce  engorgement 
of  the  terminal  branches  of  the  portal  vessels,  {d)  In  the  cachectic  condi- 
tions met  with  in  cancer,  profound  anaemia,  Addison's  disease,  and  Bright's 
disease  intestinal-  catarrh  may  develop,  and  may  terminate  life. 

Morbid  Anatomy. — Changes  in  the  mucous  membrane  are  not  al- 
ways visible,  and  in  cases  in  which,  during  life,  the  symptoms  of  intestinal 
catarrh  have  been  marked,  neither  redness,  swelling,  nor  increased  secre- 
tion— the  three  signs  usually  laid  down  as  characteristic  of  catarrhal  inflam- 
mation— may  be  present  post  mortem.  It  is  rare  to  see  the  mucous  mem- 
brane injected;  more  commonly  it  is  pale  and  covered  with  mucus.  In 
the  upper  part  of  the  small  intestine  the  tips  of  the  valvulae  conniventes 
may  be  deeply  injected.  Even  in  extreme  grades  of  portal  obstruction  in- 
tense hyperemia  is  not  often  seen.  The  entire  mucosa  may  be  softened  and 
inflltrated,  the  lining  epithelium  swollen,  or  even  shed,  and  appearing  as 
large  flakes  among  the  intestinal  contents.  This  is,  no  doubt,  a  post-mor- 
tem change.  The  lymph  follicles  are  almost  always  swollen,  particularly 
in  children.  The  Peyer's  patches  may  be  prominent  and  the  solitary  fol- 
licles in  the  large  and  small  bowel  may  stand  out  with  distinctness  and 
present  in  the  centres  little  erosions,  the  so-called  follicular  ulcers.  This 
may  be  a  striking  feature  in  the  intestine  in  all  forms  of  catarrhal  enteritis 
in  children,  quite  irrespective  of  the  intensity  of  the  diarrhoea. 

When  the  process  is  more  chronic  the  mucosa  is  firmer,  in  some  instances 
thickened,  in  others  distinctly  thinned,  and  the  villi  and  follicles  present  a 
slaty  pigmentation. 


DISEASES  OF  THE   INTESTINES  ASSOCIATED  WITH  DIARRHCEA.     507 

Symptoms. — Acute  and  chronic  forms  may  be  recognized.  The  im- 
portant symptom  of  both  is  diarrhoea,  which,  in  the  majority  of  instances, 
is  the  sole  indication  of  this  condition.  It  is  not  to  be  supposed  that  diar- 
rhoea is  invariably  caused  by,  or  associated  with,  catarrhal  enteritis,  as  it 
may  be  produced  by  nervous  and  other  influences.  It  is  probable  that 
catarrh  of  the  jejunum  may  exist  without  any  diarrhoea;  indeed,  it  is  a 
very  common  circumstance  to  find  post  mortem  a  catarrhal  state  of  the 
small  bowel  in  persons  who  have  not  had  diarrhoea  during  life.  The  stools 
vary  extremely  in  character.  The  color  depends  upon  the  amount  of  bile 
with  which  they  are  mixed,  and  they  may  be  of  a  dark  or  blackish  brown, 
or  of  a  light-yellow,  or  even  of  a  grayish-white  tint.  The  consistence  is 
usually  very  thin  and  watery,  but  in  some  instances  the  stools  are  pultaceous 
like  thin  gruel.  Portions  of  undigested  food  can  often  be  seen  (lienterie 
diarrhoea),  and  flakes  of  yellowish-brown  mucus.  Microscopically  there 
are  innumerable  micro-organisms,  epithelium  and  mucous  cells,  crystals  of 
phosphate  of  lime,  oxalate  of  lime,  and  occasionally  cholesterin  and  Char- 
cot's crystals. 

Pain  in  the  abdomen  is  usually  present  in  the  acute  catarrhal  enteritis, 
particularly  when  due  to  food.  It  is  of  a  colicky  character,  and  when  the 
colon  is  involved  there  may  be  tenesmus.  More  or  less  tympanites  exists, 
and  there  are  gurgling  noises  or  borborygmi,  due  to  the  rapid  passage  of 
fluid  and  gas  from  one  part  to  another.  In  the  very  acute  attacks  there 
may  be  vomiting.  Fever  is  not,  as  a  rule,  present,  but  there  may  be  a 
slight  elevation  of  one  or  two  degrees.  The  appetite  is  lost,  there  is  intense 
thirst,  and  the  tongue  is  dry  and  coated.  In  very  acute  cases,  when  the 
quantity  of  fluid  lost  is  great  and  the  pain  excessive,  there  may  be  collapse 
symptoms.  The  number  of  evacuations  varies  from  four  or  five  to  twenty 
or  more  in  the  course  of  the  day.  The  attack  lasts  for  two  or  three  days, 
or  may  be  prolonged  for  a  week  or  ten  days. 

Chronic  catarrh  of  the  bowels  may  follow  the  acute  form,  or  may  de- 
velop gradually  as  an  independent  affection  or  as  a  sequence  of  obstruction 
in  the  portal  circulation.  It  is  characterized  by  diarrhoea,  with  or  without 
colic.  The  dejections  vary;  when  the  small  bowel  is  chiefly  involved  the 
diarrhoea  is  of  a  lienterie  character,  and  when  the  colon  is  affected  the 
stools  are  thin  and  mixed  with  much  mucus.  A  special  form  of  mucous 
diarrhoea  will  be  subsequently  described.  The  general  nutrition  in  these 
chronic  cases  is  greatly  disturbed;  there  may  be  much  loss  of  flesh  and 
great  pallor.  The  patients  are  inclined  to  suffer  from  low  spirits,  or  hypo- 
chondriasis may  develop. 

Diagnosis. — It  is  important,  in  the  first  place,  to  determine,  if  pos- 
sible, whether  the  large  or  small  bowel  is  chiefly  affected.  In  catarrh  of 
the  small  bowel  the  diarrhoea  is  less  marked,  the  pains  are  of  a  colicky  char- 
acter, borborygmi  are  not  so  frequent,  the  faeces  usually  contain  portions 
of  food,  and  are  more  yellowish-green  or  grayish-yellow  and  flocculcnt  and 
do  not  contain  much  mucus.  "When  the  large  intestine  is  at  fault  there 
may  be  no  pain  whatever,  as  in  the  catarrh  of  the  large  intestine  associated 
with  tuberculosis  and  Bright's  disease.  Wlien  present,  the  pains  are  most 
intense  and,  if  the  lower  portion  of  the  bowel  is  involved,  there  may  be 


508  DISEASES  OP  THE   DIQESTIVE  SYSTEM. 

marked  tenesmus.  The  stools  have  a  uniform  soupy  consistence;  they  are 
grayish  in  color  and  granular  throughout^  with  here  and  there  flakes  of 
mucus,  or  they  may  contain  very  large  quantities  of  mucus. 

There  are  no  positive  symptoms  by  which  the  diagnosis  of  duodenitis 
can  be  made.  It  is  usually  associated  with  acute  gastritis  and,  if  the  process 
extends  into  the  bile-duct,  with  jaundice.  Xeither  Jejunitis  nor  ileitis  can 
be  separated  from  general  intestinal  catarrh. 

ENTERITIS  IN  CHILDREN. 

We  may  recognize  three  forms:  (1)  The  acute  dyspeptic  diarrhoea;  (2) 
cholera  infantum;  and  (3)  acute  entero-colitis. 

General  Etiology  of  the  Diarrlioeas  of  Children. — The  dis- 
ease is  most  frequent  in  artificially  fed  children,  and  the  greatest  number 
of  cases  occur  between  the  ages  of  six  and  eighteen  months.  A  popular  and 
well-founded  belief  ascribes  special  danger  to  the  second  summer  of  the  in- 
fant. Infantile  diarrhoea  is  very  prevalent  among  the  poorer  classes  in  the 
large  cities.  It  attacks,  however,  children  with  the  most  favorable  sur- 
roundings. Two  factors  influence  the  disease,  diet  and  temperature.  An 
immense  majority  of  all  fatal  cases  are  artificially  fed.  Of  l,9i3  fatal  cases 
in  Holt's  statistics,  only  three  per  cent  were  exclusively  breast  fed.  Among 
the  poor  the  bowel  complaint  in  children  begins  with  the  artificial  feeding. 
The  relation  of  temperature  to  the  prevalence  of  diarrhceal  diseases  in  chil- 
dren- has  long  been  recognized.  The  mortality  curve  begins  to  rise  in 
May,  increases  in  June,  reaches  the  maximum  in  July,  and  gradually  sinks 
through  August  and  September.  The  maximum  corresponds  closely  with 
the  highest  mean  temperature;  yet  we  cannot  regard  the  heat  itself  as  the 
direct  agent,  but  only  as  one  of  several  factors.  Thus  the  mean  temper- 
ature of  June  is  only  four  or  five  degrees  lower  than  that  of  July,  and  yet 
the  mortality  is  not  more  than  one  third.  Seibert,  who  has  carefully  ana- 
lyzed the  mortality  and  the  temperature,  month  by  month,  in  New  York, 
for  ten  years,  fails  to  find  a  constant  relation  between  the  degree  of  heat 
and  the  number  of  cases  of  diarrhcea.  jSTeither  barometric  pressure  nor 
humidity  appears  to  have  any  influence. 

Helation  of  Bacteria. — The  healthy  fgeces  of  sucklings  contain  a 
number  of  bacteria  and  micrococci,  the  most  imjjortant  of  which  are  the 
laderium  lactis  aerogenes  and  the  iacterium  coli  commune.  The  former  is 
only  present  in  the  intestine  after  a  milk  diet,  the  milk  sugar  appearing  to 
furnish  the  materials  necessary  for  its  growth.  It  occurs  rather  in  the 
upper  portion  of  the  bowel,  and  in  this  region  excites  the  fermentative 
processes  in  the  milk.  The  hactermm  coli  commune  is  found  more  abun- 
dantly in  the  lower  portion  of  the  small  intestine  and  in  the  colon,  and  ex- 
cites fermentative  changes  which  are  probably  associated  with  certain  phases 
of  digestion.  The  observations  of  Escherich  show  the  remarkable  simplic- 
ity of  this  bacterial  vegetation  in  the  healthy  faeces  of  milk-fed  children,  as 
these  two  organisms  alone  develop  and  are  constant.  In  infantile  diarrhoea 
the  number  of  bacteria  which  may  be  isolated  from  the  stools  is  remarkable. 
Booker  has  discriminated  forty  varieties,  the  greatest  number  of  which  were 


DISEASES  OP  THE  INTESTINES  ASSOCIATED  WITH   DIARRHCEA.     509 

found  in  the  eases  of  cholera  infantum.  The  two  constant  forms  noted 
above  do  not  disappear  in  the  diarrhoeal  stools.  No  forms  have  been  found 
to  bear  a  constant  or  specific  relation  to  the  diarrhoeal  faeces,  such  as  the 
two  above  mentioned  do  to  the  healthy  milk  faeces.  The  bacteria  of 
the  froteus  group  are  most  frequent,  and  possess  pathogenic  properties. 
All  the  varieties  develop  and  produce  important  changes  in  the  milk,  which 
have  been  dealt  with  very  fully  by  Booker  in  his  exhaustive  monograph 
(Johns  Hopkins  Hospital  Eeports,  vol.  vi).  This  author  concludes  that  in 
the  diarrhoea  of  infants  "  not  one  specific  kind,  but  many  different  kinds 
of  bacteria  are  concerned,  and  that  their  action  is  manifested  more  in  the 
alteration  of  the  food  and  intestinal  contents  and  in  the  production  of  in- 
jurious jjroducts  than  in  a  direct  irritation  upon  the  intestinal  wall."  With 
these  agree  the  conclusions  of  JefEries  and  Baginsky  regarding  cholera  in- 
fantum. 

Morbid  Anatomy. — We  find  most  frequently  a  catarrhal  swelling 
of  the  mucosa  of  both  small  and  large  bowel  with  enlargement  of  the  lymph 
follicles.  In  more  chronic  cases  the  latter  show  small  erosions  or  follicular 
ulcers;  more  rarely  there  is  croupous  enteritis  affecting  the  lower  part  of 
the  ileum  and  the  colon.  The  changes  in  the  other  organs  are  neither 
numerous  nor  characteristic.  Broncho-pneumonia  occurs  in  many  cases. 
The  spleen  may  be  swollen.  Brain  lesions  are  rare;  the  membranes  and 
substance  are  often  angemic,  but  meningitis  or  thrombosis  is  very  im- 
common. 

Clinical  Forms. — Acute  Dyspeptic  Diarrhoea. — The  child  may  ap- 
pear in  its  usual  health,  but  has  an  increase  in  the  number  of  stools,  with- 
out fever  or  special  disturbance  except  slight  restlessness  at  night.  After 
persisting  for  a  day  or  two  the  stools  become  more  frequent  and  contain 
undigested  food  and  curds,  and  are  very  offensive.  In  other  cases  the  dis- 
ease sets  in  abruptly  with  vomiting,  griping  pains,  and  fever,  which  may  rise 
rapidly  and  reach  104°  or  105°.  There  may  be  convulsions  at  the  outset. 
The  abdomen  is  sensitive,  and  the  child  lies  with  the  legs  drawn  up.  The 
stools  consist  of  grayish  or  greenish-yellow  fasces  mixed  with  gas,  curds,  and 
portions  of  food.  In  children  over  two  years  of  age  such  attacks  not  infre- 
quently follow  eating  freely  of  unripe  fruit  or  the  drinking  of  milk  which 
has  been  tainted.  With  judicious  treatment  the  children  improve  in  a  few 
days;  but  relapses  are  not  uncommon,  and  in  the  hot  weather  the  attack 
may  be  the  starting  point  of  a  severe  entero-colitis.  In  a  debilitated  child 
a  mild  attack  may  prove  fatal.  This  dyspeptic  diarrhoea  is  distinguished 
sharply  from  cholera  infantum  by  the  character  of  the  stools,  which  never 
have  a  watery,  serous  character.  In  many  instances  this  form  precedes  the 
onset  of  the  specific  fevers,  particularly  during  the  hot  weather. 

Cholera  Infantum. — This  is  by  no  means  so  common  as  the  ordinary 
dyspeptic  diarrhoea  of  children,  and,  according  to  Holt,  occurs  only  in  two 
or  three  per  cent  of  the  cases  of  summer  diarrhoea.  It  prevails  in  the  hot 
weather  and  in  children  artificially  fed  or  who  have  had  previously  some 
slight  dyspeptic  derangement.  It  is  characterized  by  vomiting,  uncon- 
trollable diarrhoea,  and  collapse.  The  disease  sets  in  with  vomiting,  which 
is  incessant  and  is  excited  by  an  attempt  to  take  food  or  drink.     The  stools 


510  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

are  profuse  and  frequent;  at  first  fsecal  in  character,  brown  or  yellow  in 
color,  and  finally  thin,  serous,  and  watery.  The  stools  first  passed  are  very 
offensive;  subsequently  they  are  odorless.  The  thin,  serous  stools  are  alka- 
line. There  is  fever,  but  the  axillary  temperature  may  register  three  or 
more  degrees  below  that  of  the  rectum.  From  the  outset  there  is  marked 
prostration;  the  eyes  are  sunken,  the  features  pinched,  the  fontanelle  de- 
pressed, and  the  skin  has  a  peculiar  ashy  pallor.  At  first  restless  and  ex- 
cited, the  child  subsequently  becomes  heavy,  dull,  and  listless.  The  tongue 
is  coated  at  the  onset,  but  subsequently  becomes  red  and  dry.  As  in  all 
choleraic  conditions,  the  thirst  is  insatiable;  the  pulse  is  rapid  and  feeble, 
and  toward  the  end  becomes  irregular  and  imperceptible.  Death  may 
occur  within  twenty-four  hours,  with  symptoms  of  collapse  and  great  eleva- 
tion of  the  internal  temperature.  Before  the  end  the  diarrhoea  and  vom- 
iting may  cease.  In  other  instances  the  intense  symptoms  subside,  but  the 
child  remains  torpid  and  semi-comatose  with  fingers  clutched,  and  there 
may  be  convulsions.  The  head  may  be  retracted  and  the  respirations  in- 
terrupted, irregular,  and  of  the  Cheyne- Stokes  type.  The  child  may  re- 
main in  this  condition  for  some  days  without  any  signs  of  improvement. 
It  was  to  this  group  of  symptoms  in  infantile  diarrhoea  that  Marshall  Hall 
gave  the  term  "  hydrencephaloid ''  or  spurious  hydrocephalus.  As  a  rule, 
no  changes  in  the  brain  or  other  organs  are  found,  and  the  condition  is  no 
doubt  caused  by  the  toxic  agents  absorbed  from  the  intestine.  A  remark- 
able condition  of  sclerema  is  described  as  a  sequel  of  cholera  infantum. 
The  skin  and  subcutaneous  tissues  become  hard  and  firm  and  the  appear- 
ance has  been  compared  to  that  of  a  half-frozen  cadaver. 

No  constant  organism  has  been  found  in  these  cases.  Baginsky  con- 
siders the  disease  the  result  of  the  action  on  the  system  of  the  poisonous 
products  of  decomposition  encouraged  by  the  various  bacteria  present — a 
Fdulniss  disease.  The  clinical  picture  is  that  produced  by  an  acute  bac- 
terial infection,  as  in  Asiatic  cholera. 

The  diagnosis  is  readily  made.  There  is  no  other  intestinal  affection  in 
children  for  which  it  can  be  mistaken.  The  constant  vomiting,  the  fre- 
quent watery  discharges,  the  collapse  symptoms,  and  the  elevated  temper- 
ature make  an  unmistakable  clinical  picture.  The  outlook  in  the  majority 
of  cases  is  bad,  particularly  in  children  artificially  fed.  Hyperpyrexia,  ex- 
treme collapse,  and  incessant  vomiting  are  the  most  serious  symptoms. 

Acute  Entero-colitis. — In  this  form  the  ileum  and  colon  are  most  af- 
fected, chiefiy  in  the  lymph  follicles,  hence  the  term  follicular  enteritis  or 
follicular  dysentery.  Catarrhal  ulceration  is  a  common  sequence.  It  oc- 
curs most  frequently  in  warm  weather,  in  artificially  fed  children;  but  it 
may  set  in  at  any  season  of  the  year,  and  is  the  form  of  enteritis  most 
common  as  a  secondary  complication  in  the  specific  fevers  of  childhood. 

The  attack  may  follow  the  ordinary  dyspeptic  diarrhoea.  The  temper- 
ature increases,  the  stools  change  in  character  and  contain  traces  of  blood 
and  mucus,  the  former  usually  only  in  streaks.  The  ffeces  are  passed  with- 
out any  pain.  The  abdomen  is  distended  and  tender  along  the  line  of  the 
colon.  Vomiting  may  be  present  at  the  outset,  but  is  not  a  characteristic 
feature,  as  in  cholera  infantum.     The  diarrhoea  may  be  gradually  checked 


DISEASES  OP  THE  INTESTINES  ASSOCIATED  WITH   DIARRHOEA.     51I 

and  convalescence  is  established  in  two  or  three  weeks;  in  other  instances 
the  disease  becomes  siibacnte,  the  fever  subsides,  but  the  diarrhoea  persists 
and  the  general  health  of  the  child  rapidly  deteriorates.  The  case  may 
drag  on  for  five  or  six  weeks,  when  improvement  gradually  occurs  or  the 
child  is  carried  off  by  a  severe  intercurrent  attack.  In  a  third  form  of 
acute  entero-colitis,  in  which  anatomically  the  lesions  are  those  already 
mentioned — namely,  an  intense  follicular  inflammation — the  symptoms  are 
of  a  more  severe  character,  and  the  affection  is  sometimes  spoken  of  as  acute 
dysentery.  It  attacks  children  up  to  the  third  or  fourth  year  or  even  older. 
The  onset  is  sudden,  with  high  fever,  vomiting,  frequent  stools,  which  at 
first  contain  remnants  of  food  and  fseces  and  subsequently  much  mucus  and 
some  blood.  There  is  incessant  pain,  which  may  be  more  severe  than  in 
any  intestinal  affection  of  childhood.  The  prostration  is  very  great  and 
the  fatal  termination  may  occur  within  forty-eight  hours.  More  commonly 
the  case  lasts  for  a  week  or  longer. 

The  Coeliao  Affection. — Under  this  heading  Gee  has  described  an  intes- 
tinal disorder,  most  commonly  met  with  in  children  between  the  ages  of 
one  and  five,  characterized  by  the  occurrence  of  pale,  loose  stools,  not  un- 
like ^ruel  or  oatmeal  porridge.  They  are  bulky,  not  watery,  yeasty,  frothy, 
and  extremely  offensive.  The  affection  has  received  various  names,  such  as 
diarrhoea  alba  or  diarrhoea  chylosa.  It  is  not  associated  with  tuberculous 
or  other  hereditary  disease.  It  begins  insidiously  and  there  are  progressive 
wasting,  weakness,  and  pallor.  The  belly  becomes  doughy  and  inelastic. 
There  is  often  flatulency.  Fever  is  usually  absent.  The  disease  is  linger- 
ing and  a  fatal  termination  is  common.  So  far  nothing  is  known  of  the 
pathology  of  the  disease.  Ulceration  of  the  intestines  has  been  met  with, 
but  it  is  not  constant. 

Sprue  or  Psilosis. — A  remarkable  disease  of  the  tropics,  character- 
ized by  "  a  peculiar,  inflamed,  superficially  ulcerated,  exceedingly  sensitive 
condition  of  the  mucous  membrane  of  the  tongue  and  mouth;  great  wast- 
ing and  anaemia;  pale,  copious,  and  often  loose,  frequent,  and  frothy  fer- 
menting stools;  very  generally  by  more  or  less  diarrhoea;  and  also  by  a 
marked  tendency  to  relapse  "  (Manson). 

It  is  very  prevalent  in  India,  China,  and  Java.  Nothing  definite  is 
known  as  to  its  cause. 

When  fully  established  the  chief  symptoms  are  a  disturbed  condition  of 
the  bowels,  pale,  yeasty-looking  stools,  a  raw,  bare,  sore  condition  of  the 
tongue,  mouth,  and  gullet,  sometimes  with  actual  superficial  ulceration. 
With  these  gastro-intestinal  symptoms  there  are  associated  anaemia  and 
general  wasting.  It  is  very  chronic,  with  numerous  relapses.  There  are 
no  characteristic  anatomical  changes.  There  are  usually  ulcers  in  the 
colon,  and  the  French  think  it  is  a  form  of  dysentery. 

Manson  recommends  rest  and  a  milk  diet  as  curative  in  a  large  propor- 
tion of  the  cases.  The  recent  monograph  by  Thin  and  the  article  by  Man- 
Bon  in  Allbutt's  System  give  very  full  descriptions  of  the  disease. 


32 


512  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

DIPHTHERITIC  OR  CROUPOUS  ENTERITIS. 

A  croupous  or  diphtheritic  inflammation  of  the  mucosa  of  the  small 
and  large  intestines  occurs  (a)  most  frequently  as  a  secondary  process  in  the 
infectious  diseases — pneumonia,  pyaemia  in  its  various  forms,  and  typhoid 
fever;  (&)  as  a  terminal  process  in  many  chronic  affections,  such  as  Bright's 
disease,  cirrhosis  of  the  liver,  or  cancer;  and  (c)  as  an  effect  of  certain  poi- 
sons— mercury,  lead,  and  arsenic. 

There  are  three  different  anatomical  pictures.  In  one  group  of  cases 
the  mucosa  presents  on  the  top  of  the  folds  a  thin  grayish-yellow  diph- 
theritic exudate  situated  upon  a  deeply  congested  base.  In  some  cases  all 
grades  may  be  seen  between  the  thinnest  film  of  superficial  necrosis  and  in- 
volvement of  the  entire  thickness  of  the  mucosa.  In  the  colon  similar 
transversely  arranged  areas  of  necrosis  are  seen  situated  upon  hypersemic 
patches,  and  it  may  be  here  much  more  extensive  and  involve  a  large  por- 
tion of  the  membrane.  There  may  be  most  extensive  inflammation  without 
any  involvement  of  the  solitary  follicles  of  the  large  or  small  bowel. 

In  a  second  group  of  cases  the  membrane  has  rather  a  croupous  character. 
It  is  grayish  white  in  color,  more  flake-like  and  extensive,  limited,  perhaps, 
to  the  caecum  or  to  a  portion  of  the  colon;  thus,  in  several  cases  of  pneumonia 
I  found  this  flaky  adherent  false  membrane,  in  one  instance  forming  patches 
1  to  2  cm.  in  diameter,  which  in  form  were  not  unlike  rupia  crusts. 

In  a  third  group  the  affection  is  really  a  follicular  enteritis,  involving 
the  solitary  glands,  which  are  swollen  and  capped  with  an  area  of  diph- 
theritic necrosis  or  are  in  a  state  of  suppuration.  Follicular  ulcers  are  com- 
mon in  this  form.  The  disease  may  run  its  course  without  any  symptoms, 
and  the  condition  is  unexpectedly  met  with  post  mortem.  In  other  in- 
stances there  are  diarrhoea,  pain,  but  not  often  tenesmus  or  the  passage  of 
blood-stained  mucus.  In  the  toxic  cases  the  intestinal  symptoms  may  be 
very  marked,  but  in  the  terminal  colitis  of  the  fevers  and  of  constitutional 
affections  the  symptoms  are  often  trifling. 

The  ulcerative  colitis  of  chronic  disease  may  be  only  a  terminal  event 
in  these  diphtheritic  processes. 

PHLEGMONOUS  ENTERITIS. 

As  an  independent  affection  this  is  excessively  rare,  even  less  frequent 
than  its  counterpart  in  the  stomach.  It  is  seen  occasionally  in  connection 
with  intussusception,  strangulated  hernia,  and  chronic  obstruction.  Apart 
from  these  conditions  it  occurs  most  frequently  in  the  duodenum,  and  leads 
to  suppuration  in  the  submucosa  and  abscess  formation.  Except  when 
associated  with  hernia  or  intussusception  the  affection  cannot  be  diagnosed. 
The  symptoms  usually  resemble  those  of  peritonitis. 

ULCERATIVE  ENTERITIS. 

In  addition  to  the  specific  ulcers  of  tuberculosis,  syphilis,  and  typhoid 
fever,  the  following  forms  of  ulceration  occur  in  the  bowels: 

(a)  Follicular  Ulceration. — As  previously  mentioned,  this  is  met  with 
very  commonly  in  the  diarrhceal  diseases  of  children,  and  also  in  the  sec- 
ondary or  terminal  inflammations  in  many  fevers  and  constitutional  disor- 


DISEASES  OP   THE  INTESTINES  ASSOCIATED  WITH  DIARRHCEA.     51 3 

ders.  The  ulcers  are  small,  punched  out,  with  sharply  cut  edges,  and  they 
are  usually  limited  to  the  follicles.  With  this  form  may  be  placed  the 
catarrhal  ulcers  of  some  writers. 

(b)  Stercoral  ulcers,  which  occur  in  long  standing  cases  of  constipation. 
Very  remarkable  indeed  are  the  cases  in  which  the  sacculi  of  the  colon  be- 
come filled  with  rounded  small  scybala,  some  of  which  produce  distinct 
ulcers  in  the  mucous  membrane.  The  fsecal  masses  may  have  lime  salts 
deposited  in  them,  and  thus  form  little  enteroliths. 

(c)  Simple  Ulcerative  Colitis. — This  affection,  which  clinically  is  char- 
acterized by  diarrhoea,  is  often  regarded  wrongly  as  a  form  of  dysentery. 
It  is  not  a  very  uncommon  affection,  and  is  most  frequently  met  with  in 
men  above  the  middle  period  of  life.  The  ulceration  may  be  very  exten- 
sive, so  that  a  large  proportion  of  the  mucosa  is  removed.  The  lumen  of 
the  colon  is  sometimes  greatly  increased,  and  the  muscular  walls  hyper- 
trophied.  There  are  instances  in  which  the  bowel  is  contracted.  Fre- 
quently the  remnants  of  the  mucosa  are  very  dark,  even  black,  and  there 
may  be  polypoid  outgrowths  between  the  ulcers. 

These  cases  rarely  come  under  observation  at  the  outset,  and  it  is  diffi- 
cult to  speak  of  the  mode  of  origin.  They  are  characterized  by  diarrhoea 
of  a  lienteric  rather  than  of  a  dysenteric  character.  There  is  rarely  blood  or 
pus  in  the  stools.  Constipation  may  alternate  with  the  diarrhoea.  There 
is  usually  great  impairment  of  nutrition,  and  the  patients  get  weak  and 
sallow.     Perforation  occasionally  occurs. 

The  disease  may  prove  fatal,  or  it  may  pass  on  and  become  chronic. 
The  affection  was  not  very  infrequent  at  the  Philadelphia  Hospital,  and 
though  the  disease  bears  some  resemblance  to  dysentery,- it  is  to  be  sepa- 
rated from  it.  Some  of  the  cases  which  we  have  learned  to  recognize  as 
amoebic  dysentery  resemble  this  form  very  closely.  An  excellent  descrip- 
tion of  it  is  given  by  Hale  White  in  Allbutt's  System.  The  ulcerative 
colitis  met  with  in  institutions,  such  as  that  described  by  Gemmel,  of  the 
Lancaster  Asylum,  in  a  recent  monograph,  seems  to  be  a  true  dysentery. 
Dickinson  has  described  what  he  calls  albuminuric  ulceration  of  the  bowels 
in  cases  of  contracted  kidney. 

(d)  Ulceration  from  External  Perforation. — This  may  result  from  the 
erosion  of  new  growths  or,  more  commonly,  from  localized  peritonitis 
with  abscess  formation  and  perforation  of  the  bowel.  This  is  met  with 
most  frequently  in  tuberculous  peritonitis,  but  it  may  occur  in  the 
abscess  which  follows  perforation  of  the  appendix  or  suppurative  or 
gangrenous  pancreatitis.  Fatal  hsemorrhage  may  result  from  the  perfora- 
tion. 

{e)  Cancerous  Ulcers. — In  very  rare  instances  of  multiple  cancer  or  sar- 
coma the  submucous  nodules  break  down  and  ulcerate.  In  one  case  the 
ileum  contained  eight  or  ten  sarcomatous  ulcers  secondary  to  an  extensive 
sarcoma  in  the  neighborhood  of  the  shoulder-joint. 

(/)  Occasionally  a  solitary  ulcer  is  met  with  in  the  cgecum  or  colon,  which 
may  lead  to  perforation.  Two  instances  of  ulcer  of  the  cascum,  both  with 
perforation,  have  come  under  my  observation,  and  in  one  instance  a  simple 
ulcer  of  the  colon  perforated  and  led  to  fatal  peritonitis. 


514  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

Diagnosis  of  Intestinal  Ulcers. — As  a  rule,  diarrhoea  is  present 
in  all  cases,  but  exceptionally  there  may  be  extensive  ulceration,  particu- 
larly in  the  small  bowel,  without  diarrhoea.  Very  limited  ulceration  in  the 
colon  may  be  associated  with  frequent  stools.  The  character  of  the  dejec- 
tions is  of  great  importance.  Pus,  shreds  of  tissue,  and  blood  are  the  most 
valuable  indications.  Pus  occurs  most  frequently  in  connection  with  ulcers 
in  the  large  intestine,  but  when  the  bowel  alone  is  involved  the  amount  is 
rarely  great,  and  the  passage  of  any  quantity  of  pure  pus  is  an  indication 
that  it  has  come  from  without,  most  commonly  from  the  rupture  of  a  peri- 
cecal abscess,  or  in  women  of  an  abscess  of  the  broad  ligament.  Pus  may 
also  be  present  in  cancer  of  the  bowel,  or  it  may  be  due  to  local  disease  in 
the  rectum.  A  purulent  mucus  may  be  present  in  the  stools  in  cases  of  ulcer, 
but  it  has  not  the  same  diagnostic  value.  The  swollen,  sago-like  masses 
of  mucus  which  are  believed  by  some  to  indicate  follicular  ulceration  are 
met  with  also  in  mucous  colitis.  Haemorrhage  is  an  important  and  valu- 
able symptom  of  ulcer  of  the  bowel,  particularly  if  profuse.  It  occurs 
under  so  many  conditions  that  taken  alone  it  may  not  be  specially  signifi- 
cant, but  with  other  coexisting  circumstances  it  may  be  the  most  important 
indication  of  all. 

Fragments  of  tissue  are  occasionally  found  in  the  stools  in  ulcer,  par- 
ticularly in  the  extensive  and  rapid  sloughing  in  dysenteric  processes. 
Definite  portions  of  mucosa,  shreds  of  connective  tissue,  and  even  bits  of 
the  muscular  coat  may  be  found.  Pain  occurs  in  many  cases,  either  of  a 
difEuse,  colicky  character,  or  sometimes,  in  the  ulcer  of  the  colon,  very  lim- 
ited and  well  defined. 

Perforation  is  an  accident  liable  to  happen  when  the  ulcer  extends 
deeply.  In  the  small  bowel  it  leads  to  a  localized  or  general  peritonitis. 
In  the  large  intestine,  too,  a  fatal  peritonitis  may  result,  or  if  perforation 
takes  place  in  the  posterior  wall  of  the  ascending  or  descending  colon,  the 
production  of  a  large  abscess  cavity  in  the  retro-peritongeum.  In  a  case 
at  the  University  Hospital,  Philadelphia,  there  was  a  perforation  at  the 
splenic  flexure  of  the  colon  with  an  abscess  containing  air  and  pus — a  con- 
dition of  subphrenic  pyo-pneumothorax. 

Treatment  of  the  Previous  Conditions. 

(a)  Acute  Dyspeptic  Diarrhoea. — All  solid  food  should  be  withheld.  If 
vomiting  is  present  ice  may  be  given,  and  small  quantities  of  milk  and  soda 
water  may  be  taken.  If  the  attack  has  followed  the  eating  of  large  quan- 
tities of  undigestible  material,  castor  oil  or  calomel  is  advisable,  but  is  not 
necessary  if  the  patient  has  been  freely  purged.  If  the  pain  is  severe,  20 
drops  of  laudanum  and  a  drachm  of  spirits  of  chloroform  may  be  given,  or, 
i-f  the  colic  is  very  intense,  a  hypodermic  of  a  quarter  of  a  grain  of  morphia. 
It  is  not  well  to  check  the  diarrhoea  unless  it  is  profuse,  as  it  usually  stops 
spontaneously  within  forty-eight  hours.  If  persistent,  the  aromatic  chalk 
powder  or  large  doses  of  bismuth  (30  to  40  grains)  may  be  given.  A  small 
enema  of  starch  (2  ounces)  with  20  drops  of  laudanum,  every  six  hours,  is 
a  most  valuable  remedy. 

(b)  Chronic  diarrhoea,  including  chronic  catarrh  and  ulcerative  enter- 
itis.    It  is  important,  in  the  first  place,  to  ascertain,  if  possible,  the  cause 


DISEASES  OF  THE  INTESTINES  ASSOCIATED  WITH  DIARRHOEA.     515 

and  whether  ulceration  is  present  or  not.  So  much  in  treatment  depends 
upon  the  careful  examination  of  the  stools — as  to'  the  amount  of  mucus, 
the  presence  of  pus,  the  occurrence  of  parasites,  and,  above  all,  the  state  of 
digestion  of  the  food — that  the  practitioner  should  pay  special  attention 
to  them.  Many  cases  simply  require  rest  in  bed  and  a  restricted  diet. 
Chronic  diarrhoea  of  many  months'  or  even  of  several  years'  duration  may 
be  sometimes  cured  by  strict  confinement  to  bed  and  a  diet  of  boiled  milk 
and  albumen  water. 

In  that  form  in  which  immediately  after  eating  there  is  a  tendency  to 
loose  evacuations  it  is  usually  found  that  some  one  article  of  diet  is  at 
fault.  The  patient  should  rest  for  an  hour  or  more  after  meals.  Some- 
times this  alone  is  sufficient  to  prevent  the  occurrence  of  the  diarrhcEa. 
In  those  forms  which  depend  upon  abnormal  conditions  in  the  small  intes- 
tine, either  too  rapid  peristalsis  or  faulty  fermentative  processes,  bismuth 
is  indicated.  It  must  be  given  in  large  doses — from  half  a  drachm  to  a 
drachm  three  times  a  day.  The  smaller  doses  are  of  little  use.  Naphthalin 
preparations  here  do  much  good,  given  in  doses  of  from  10  to  15  grains  (in 
capsule)  four  or  five  times  a  day.  Larger  doses  may  be  needed.  Salol  and 
the  salicylate  of  bismuth  may  be  tried. 

An  extremely  obstinate  and  intractable  form  is  the  diarrhoea  of  hyster- 
ical women.  A  systematic  rest  cure  will  be  found  most  advantageous,  and 
if  a  milk  diet  is  not  well  borne  the  patient  may  be  fed  exclusively  on  egg 
albumen.  The  condition  seems  to  be  associated  in  some  cases  with  in- 
creased peristalsis,  and  in  such  the  bromides  may  do  good,  or  preparations 
of  opium  may  be  necessary.  There  are  instances  which  prove  most  obsti- 
nate and  resist  all  forms  of  treatment,  and  the  patient  may  be  greatly  re- 
duced.    A  change  of  air  and  surroundings  may  do  more  than  medicines. 

In  a  large  group  of  the  chronic  diarrhoeas  the  mischief  is  seated  in  the 
colon  and  is  due  to  ulceration.  Medicines  by  the  mouth  are  here  of  little 
value.  The  stools  should  be  carefully  watched  and  a  diet  arranged  which 
shall  leave  the  smallest  possible  residue.  Boiled  or  peptonized  milk  may 
be  given,  but  the  stools  should  be  examined  to  see  whether  there  is  an 
excess  of  food  or  of  curds.  Meat  is,  as  a  rule,  badly  borne  in  these  cases. 
The  diarrhoea  is  best  treated  by  enemata.  The  starch  and  laudanum  should 
be  tried,  but  when  ulceration  is  present  it  is  better  to  use  astringent  injec- 
tions. From  2  to  4  pints  of  warm  water,  containing  from  half  a  drachm 
to  a  drachm  of  nitrate  of  silver,  may  be  used.  In  the  chronic  diar- 
rhoea which  follows  dysentery  this  is  particularly  advantageous.  In  giving 
large  injections  the  patient  should  be  in  the  dorsal  position,  Avith  the  hips 
elevated,  and  it  is  best  to  allow  the  injection  to  flow  in  gradually  from  a 
siphon  bag.  In  this  way  the  entire  colon  can  be  irrigated  and  the  patient 
can  retain  the  injection  for  some  time.  The  silver  injections  may  be  very 
painful,  but  they  are  invaluable  in  all  forms  of  ulcerative  colitis.  Acetate 
of  lead,  boracic  acid,  sulphate  of  copper,  sulphate  of  zinc,  and  salicylic  acid 
may  be  used  in  1-per-cent  solutions. 

In  the  intense  forms  of  choleraic  diarrhoea  in  adults  associated  with 
constant  vomiting  and  frequent  watery  discharges  the  patient  should  be 
given  at  once  a  hypodermic  of  a  quarter  of  a  grain  of  morphia,  which  should 


516  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

be  repeated  in  an  hour  if  the  pains  return  or  the  purging  persists.  This 
gives  prompt  relief^  and  is  often  the  only  medicine  needed  in  the  attack. 
The  patient  should  be  given  stimulants,  and,  when  the  vomiting  is  allayed 
by  suitable  remedies,  small  quantities  of  milk  and  lime  water. 

(c)  The  DiarrhOBa  of  CMldren. — Hygienic  management  is  of  the  first 
importance.  The  effect  of  a  change  from  the  hot,  stifling  atmosphere  of  a 
town  to  the  mountains  or  the  sea  is  often  seen  at  once  in  a  reduction  in 
the  number  of  stools  and  a  rapid  improvement  in  the  physical  condition. 
Even  in  cities  much  may  be  done  by  sending  the  child  into  the  parks  or 
for  daily  excursions  on  the  water.  However  extreme  the  condition,  fresh 
,air  is  indicated.  The  child  should  not  be  too  thickly  clad.  Many  mothers, 
even  in  the  warm  weather,  clothe  their  children  too  heavily.  Bathing  is 
of  value  in  infantile  diarrhoea,  and  when  the  fever  rises  above  102.5°  the 
child  should  be  placed  in  a  warm  bath,  the  temperature  of  which  may  be 
gradually  reduced,  or  the  child  is  kept  in  the  bath  for  twenty  minutes,  by 
which  time  the  water  is  sufficiently  cooled.  Much  relief  is  obtained  by 
the  application  of  ice-cold  cloths  or  of  the  ice-cap  to  the  head.  Irrigation 
of  the  colon  with  ice-cold  water  is  sometimes  favorable,  but  it  has  not  the 
advantage  of  the  general  bath,  the  beneficial  effect  of  which  is  seen,  not  only 
in  the  reduction  of  the  temperature,  but  in  a  general  stimulation  of  the 
nervous  system  of  the  child. 

Dietetic  Treatment. — In  the  case  of  a  hand-fed  child  it  is  important,  if 
possible,  to  get  a  wet-nurse.  T\^iile  fever  is  present,  digestion  is  sure  to  be 
much  disturbed,  and  the  amount  of  food  should  be  restricted.  If  water 
or  barley  water  be  given  the  child  will  not  feel  the  deprivation  of  food  so 
much.  When  the  vomiting  is  incessant  it  is  much  better  not  to  attempt 
to  give  milk  or  other  articles  of  food,  but  let  the  child  take  the  water  when- 
ever it  will. 

In  the  dyspeptic  diarrhoeas  of  infants,  practically  the  whole  treatment 
is  a  matter  of  artificial  feeding,  and  there  is  no  subject  in  medicine  on 
which  it  is  more  difficult  to  lay  down  satisfactory  rules.  The  studies  of 
Eotch  on  modified  milk  have  revolutionized  the  artificial  feeding  of  infants, 
and  the  establishment  of  the  Walker-Gordon  laboratories  in  various  cities 
has  been  a  great  boon  to  the  public  and  the  profession.  N"o  doubt  within 
a  few  years  the  study  of  the  bacterial  processes  going  on  in  the  intestines 
of  the  child  will  give  us  most  important  suggestions.  From  his  observa- 
tions Escherich  lays  down  the  following  rules,  recognizing  two  well-defined 
forms  of  intestinal  fermentation — the  acid  and  the  alkaline:  If  there  is 
much  decomposition,  with  foul,  offensive  stools,  the  albuminous  articles 
should  be  withheld  from  the  diet  and  the  carbohydrates  given,  such  as  dex- 
trin foods,  sugar,  and  milk,  which,  on  account  of  its  sugar,  ranks  with  the 
carbohydrates.  If  there  is  acid  fermentation,  with  sour  but  not  fetid  stools, 
an  albuminous  diet  is  given,  such  as  broths  and  ^gg  albumen.  It  is, 
however,  by  no  means  certain  whether  the  reaction  of  the  stools,  upon 
which  this  author  relies,  is  a  sufficient  test  of  the  nature  of  the  intestinal 
fermentation.  In  the  dyspeptic  diarrhoeas  of  artificially  fed  infants  it  is 
best,  as  a  rule,  to  withhold  milk  and  to  feed  the  child,  for  the  time  at  least, 
on  egg  albumen,  broths,  and  beef  juices.     To  prepare  the  egg  albumen,  the 


DISEASES  OF  THE  INTESTINES  ASSOCIATED  WITH  DIARIIHCEA.     517 

whites  of  two  or  three  eggs  may  be  stirred  in  a  pint  of  water  and  a  tea- 
spoonful  of  brandy  and  a  little  salt  mixed  with  it.  The  child  will  usually 
take  this  freely,  and  it  is  both  stimulating  and  nourishing.  It  is  some- 
times remarkable  with  what  rapidity  a  child  which  has  been  fed  on  artificial 
food  and  milk  will  pick  up  and  improve  on  this  diet  alone.  Beef-Juice  is 
obtained  by  pressing  with  a  lemon-squeezer  fresh  steak,  previously  minced 
and  either  uncooked  or  slightly  broiled.  This  may  be  given  alternately 
with  the  egg  albumen  or  it  may  be  given  alone.  Mutton  or  chicken  broth 
will  be  found  equally  serviceable,  but  it  is  prepared  with  greater  difficulty 
and  contains  more  fat.  In  the  preparation,  a  pound  of  mutton,  chicken,  or 
beef,  carefully  freed  from  fat,  is  minced  and  placed  in  a  pint  of  cold  water 
and  allowed  to  stand  in  a  glass  jar  on  ice  for  three  or  four  hours.  It  should 
then  be  cooked  over  a  slow  fire  for  at  least  three  hours,  and,  after  being 
strained,  allowed  to  cool;  the  fat  is  then  skimmed  off  and  sufficient  salt 
added;  it  may  then  be  given  either  warm  or  cold.  These  naturally  prepared 
albumin  foods  are  very  much  to  be  preferred  to  the  various  artificial  sub- 
stances. There  is  no  form  of  nourishment  so  readily  assimilated  and  apt  to 
cause  so  little  disturbance  as  egg  albumen  or  the  simple  beef  juices.  The 
child  should  be  fed  every  two  hours,  and  in  the  intervals  water  may  be  freely 
given.  It  cannot  be  expected  that,  with  the  digestion  seriously  impaired, 
as  much  food  can  be  taken  as  in  health,  and  in  many  instances  we  see  the 
diarrhoea  aggravated  by  persistent  over  feeding.  When  the  child's  stomach 
is  quieted  and  the  diarrhoea  checked  there  may  be  a  gradual  return  to  the 
milk  diet.  The  milk  should  be  sterilized,  and  in  institutions  and  in  cities 
this  simple  prophylactic  measure  is  of  the  very  first  importance  and  is 
readily  carried  out  by  means  of  the  Arnold  steam  sterilizer.  The  milk 
should  be  at  first  freely  diluted — four  parts  of  water  to  one  of  milk,  which 
is  perhaps  the  preferable  way — or  it  may  be  peptonized.  The  stools  should 
be  examined  daily,  as  important  indications  may  be  obtained  from  them. 
Milk-whey  and  forms  of  fermented  milk  are  sometimes  useful  and  may  be 
employed  when  the  stomach  is  very  irritable.  These  general  directions  as 
to  food  also  hold  good  in  cholera  infantum. 

Medicinal  Treatment. — The  first  indication  in  the  dyspeptic  diarrhoea 
of  children  is  to  get  rid  of  the  decomposing  matter  in  the  stomach  and  in- 
testines. The  diarrhoea  and  vomiting  partially  effect  this,  but  it  may  be 
more  thoroughly  accomplished,  so  far  as  the  stomach  is  concerned,  by  irri- 
gation. It  may  seem  a  harsh  procedure  in  the  case  of  young  infants,  but  in 
reality,  with  a  large-sized  soft-rubber  catheter,  it  is  practised  without  any 
difficulty.  By  means  of  a  funnel,  lukewarm  water  is  allowed  to  pass  in  and 
out  until  it  comes  aM^ay  quite  clear.  I  can  speak  in  the  very  Avarmest  man- 
ner of  the  good  results  obtained  by  this  simple  procedure  in  cases  of  the 
most  obstinate  gastro-intestinal  catarrh  in  children.  In  most  cases  the 
warm  water  is  sufficient.  In  sonie  hands  this  method  has  ])robably  been 
carried  to  excess,  but  that  does  not  detract  from  its  great  value  in  suitable 
cases.  To  remove  the  fermenting  sul)stances  from  tlie  intestines,  doses  of 
calomel  or  gray  powder  may  be  administered.  The  castor  oil  is  equally 
efficacious,  but  is  more  apt  to  be  vomited.  Irrigation  of  the  large  bowel  is 
useful,  and  not  only  thoroughly  removes  fermenting  substances,  but  cleanses 


518  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  mucosa.  The  child  should  be  placed  on  the  back  with  the  hips  ele- 
vated. A  flexible  catheter  is  passed  for  from  6  to  8  inches  and  from 
a  pint  to  2  pints  of  water  allowed  to  flow  in  from  a  fountain  syringe. 
A  pint  will  thoroughly  irrigate  the  colon  of  a  child  of  six  months  and  a 
quart  that  of  a  child  of  two  years.  The  water  may  be  lukewarm,  but  when 
there  is  high  fever  ice-cold  water  may  be  used.  In  cases  of  entero-colitis 
there  may  be  injections  with  borax,  a  drachm  to  the  pint,  or  dilute  nitrate 
of  silver,  which  may  be  either  given  in  large  injections,  as  in  the  adult,  or 
in  quantities  of  3  or  4  ounces  with  3  grains  of  nitrate  of  silver  to  the  ounce. 
These  often  cause  very  great  pain,  and  it  is  well  in  such  cases  to  follow  1;he 
silver  injection  with  irrigations  of  salt  solution,  a  drachm  to  a  pint. 

We  are  still  without  a  reliable  intestinal  antiseptic.  Neither  naphtha- 
lin,  salol,  resorcin,  the  salicylates,  nor  mercury  meets  the  indications.  As 
in  the  diarrhoea  of  adults,  bismuth  in  large  doses  is  often  very  effective, 
but  practitioners  are  in  the  habit  of  giving  it  in  doses  which  are  quite  in- 
sufiicient.  To  be  of  any  service  it  must  be  used  in  large  doses,  so  that  an 
infant  a  year  old  will  take  as  much  as  2  drachms  in  the  day.  The  gray 
powder  has  long  been  a  favorite  in  this  condition  and  may  be  given  in 
half-grain  doses  every  hour.  It  is  perhaps  preferable  to  calomel,  which 
may  be  used  in  small  doses  of  from  one  tenth  to  one  fourth  of  a  grain  every 
hour  at  the  onset  of  the  trouble.  The  sodium  salicylate  (in  doses  of  2  or 
3  grains  every  two  hours  to  a  child  a  year  old)  has  been  recommended. 

In  cholera  infantum  serious  symptoms  may  develop  with  great  rapidity, 
and  here  the  incessant  vomiting  and  the  frequent  purging  render  the  ad- 
ministration of  remedies  extremely  diflicult.  Irrigation  of  the  stomach 
and  large  bowel  is  of  great  service,  and  when  the  fever  is  high  ice-water 
injections  may  be  used  or  a  graduated  bath.  As  in  the  acute  choleraic 
diarrhoea  of  adults,  morphia  hypodermically  is  the  remedy  which  gives 
greatest  relief,  and  in  the  conditions  of  extreme  vomiting  and  purging,  with 
restlessness  and  collapse  symptoms,  this  drug  alone  commands  the  situation. 
A  child  of  one  year  may  be  given  from  y^-g-  to  -^  of  a  grain,  to  be  repeated 
in  an  hour,  and  again  if  not  better.  When  the  vomiting  is  allayed,  attempts 
may  be  made  to  give  gray  powder  in  half-grain  doses  with  ^  of  a  grain 
of  Dover's  powder.  Starch  (§  ij)  and  laudanum  (fTl  ij-iij)  injections,  if  re- 
tained, are  soothing  and  beneficial.  The  combination  of  bismuth  with 
Dover's  powder  will  also  be  found  beneficial.  No  attempt  shoiild  be  made 
to  give  food.  Water  may  be  allowed  freely,  even  when  ejected  at  once  by 
vomiting.  Small  doses  of  brandy  or  champagne,  frequently  repeated  and 
given  cold,  are  sometimes  retained.  When  the  collapse  is  extreme,  hypo- 
dermic injections  of  1-per-cent  saline  solution  may  be  used  as  recommended 
in  Asiatic  cholera,  and  hypodermic  injections  of  ether  and  brandy  may  be 
tried.  The  convalescence  requires  very  careful  management,  as  many  cases 
pass  on  into  the  condition  of  entero-colitis.  When  the  intense  symptoms 
have  subsided,  the  food  should  be  gradually  given,  beginning  with  tea- 
spoonful  doses  of  egg  albumen  or  beef -juice.  It  is  best  to  withhold  milk 
for  several  days,  and  when  used  it  should  be  at  first  completely  peptonized 
or  diluted  with  gruel.  A  teaspoonful  of  raw,  scraped  meat  three  or  four 
times  a  day  is  often  well  borne. 


APPENDICITIS.  5ig 


II.     APPENDICITIS. 

Inflammation  of  the  vermiform  appendix  is  the  most  important  of  acute 
intestinal  disorders.  Formerly  the  "  iliac  phlegmon "  was  thought  to  be 
due  to  disease  of  the  cjecum — typhlitis — and  of  the  peritonaeum  covering 
it — perityphlitis;  but  we  now  know  that  with  rare  exceptions  the  csecum 
itself  is  not  affected^  and  even  the  condition  formerly  described  as  stercoral 
typhlitis  is  in  reality  appendicitis.  The  recognition  of  the  importance  of 
appendicitis  is  due  largely  to  the  work  of  the  American  physicians  and  sur- 
geons— to  Pepper,  who  described  in  1883  the  relapsing  form;  to  Fitz, 
whose  exliaustive  article  in  1886  served  to  put  the  whole  question  on  a 
rational  basis;  to  Willard  Parker,  who  was  the  first  to  advocate  early  oper- 
ation; and  to  Sands,  Bull,  McBurney,  Weir,  Morton,  Keen,  Senn,  J.  Wil- 
liam White,  Deaver,  and  others,  who  have  done  so  much  to  improve  the  op- 
erative measures  for  its  relief.  Treves,  of  London,  has  been  foremost  in 
advocating  the  proper  surgical  treatment  of  the  disease.  The  interest  at- 
tached to  the  subject  is  manifest  from  the  appearance  within  a  few  years  of 
a  number  of  special  monographs  by  Kelynack,  Talamon,  Fowler,  Sonnen- 
berg,  Hawkins,  Deaver,  and  Mynter. 

Anatomy. — The  appendix  veriformis  is  a  functionless  relic  of  a  large 
ancestral  csecum.  It  measures  usually  about  3  inches  in  length,  but 
it  may  be  scarcely  an  inch.  The  diameter  is  about  one  fourth  of  an  inch. 
In  a  majority  of  instances  it  has  a  triangular-shaped  meso-appendix,  usually 
shorter  than  the  tube,  which  thus  becomes  a  little  curled  or  bent  upon 
itself.  There  is  often  a  small  lymph-gland  just  at  the  root  of  its  mesentery. 
The  position  of  the  appendix  is  very  variable.  The  most  common  direc- 
tion it  assumes  is  upward  and  inward,  the  tip  pointing  toward  the  spleen. 
The  position  next  in  frequency  is  behind  the  csecum,  and  next  passing  over 
the  pelvic  brim.  It  may  be  met  with,  however,  in  almost  every  region  of 
the  abdomen,  and  adherent  to  almost  every  organ  in  it.  I  have  seen  it  in 
close  contact  with  the  bladder,  adherent  to  one  ovary  and  the  broad  liga- 
ment; in  the  central  portion  of  the  abdomen  close  to  the  navel;  in  contact 
with  the  gall-bladder,  passing  out  at  right  angles  and  adherent  to  the  sig- 
moid flexure  to  the  left  of  the  middle  line  of  the  abdomen;  and  in  one  case 
it  entered  with  the  csecum  the  inguinal  canal,  curved  upon  itself,  re-entered 
the  abdomen,  and  was  adherent  to  the  wall  of  an  abscess  cavity  just  to  the 
right  of  the  promontory  of  the  sacrum.  The  structure  of  the  appendix  is 
almost  identical  with  that  of  the  caecum;  it  is  particularly  rich  in  lymphoid 
tissue.  The  blood  supply  is  derived  from  a  small  artery  which  passes 
along  the  free  edge  of  its  mesentery. 

Morbid  Anatomy  and  Etiology. — The  following  are  the  moat 
common  morbid  conditions: 

(a)  Faecal  Concretions. — The  lumen  of  the  appendix  may  contain  a 
mould  of  faeces,  which  can  readily  be  squeezed  out.  Even  while  soft  the 
contents  of  the  tube  may  be  moulded  in  two  or  three  sections  with  rounded 
ends.  Concretions — enteroliths,  coproliths — are  also  common.  The  mode 
of  formation  is  not  very  clear.     Possibly,  as  with  gall-stones,  the  micro- 


520  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

organisms  may  have  a  favoring  influence.  Of  700  cases  of  foreign  bodies 
there  were  45  per  cent  of  faecal  concretions  (J.  F.  Mitchell,  J.  H.  H.  Bul- 
letin, vol.  x).  The  enteroliths  often  resemble  in  shape  date-stones.  The 
importance  of  these  concretions  is  shown  by  the  great  frequency  with  which 
they  are  found  in  all  acute  inflammations  of  the  appendix. 

(5)  Foreign  Bodies. — Of  1,400  cases  of  appendicitis  collected  by  J.  F. 
Mitchell  these  were  present  in  seven  per  cent;  in  28  cases  pins  were 
found.  Only  two  instances  came  under  my  observation  in  ten  years' 
pathological  work  in  Montreal;  in  one  there  were  eight  snipe-shot  and 
in  another  five  apple-pips.  The  stones  and  seeds  of  various  fruits,  and 
bits  of  bone,  have  also  been  found.  It  is  well  to  bear  in  mind  tbat 
some  of  the  concretions  bear  a  very  striking  resemblance  to  cherry  and 
date  stones. 

(c)  Obliterative  Appendicitis. — The  entire  tube  is  thickened,  the  peri- 
toneal surface  smooth  or  injected,  and  either  with  adhesions  from  slight 
circumscribed  peritonitis,  or  perfectly  free.  The  mucosa  may  show  noth- 
ing more  than  a  shedding  of  epithelium  with  infiltration  of  leucocytes  in 
the  submucosa,  while  in  more  chronic  cases  there  is  almost  complete  den- 
udation of  the  mucosa,  which  is  replaced  by  granulation  tissue.  The  mus- 
cular coats  are  thickened  throughout,  and  the  entire  tube  is  firm  and  stiff, 
as  if  in  a  state  of  erection.  When  laid  open  longitudinally  it  at  once  as- 
sumes a  rolled  form  in  the  reverse  direction. 

The  term  catarrlial,  which  has  been  applied  to  this  condition,  is  scarcely 
appropriate,  since  the  changes  are  diffuse  throughout  the  whole  tube.  In 
the  majority  of  instances  the  term  appendicitis  obliterans,  used  by  Senn, 
is  in  reality  more  appropriate.  As  Hawkins  remarks,  this  condition  is 
probably  a  fertile  source  of  local  peritonitis,  and  one  may  see  in  this  stage 
fresh  adhesions  on  the  peritoneal  surface  or  more  extensive  circumscribed 
peritonitis.  It  may,  however,  be,  as  he  says,  the  precursor  of  complete  im- 
munity from  such  attacks.  "  For  if  by  the  pressure  of  the  surrounding 
parts  the  opposed  granulating  surfaces  are  brought  into  contact,  and  if  the 
whole  organ  remains  at  rest,  union  may  take  place,  and  the  appendix  as  a 
source  of  disease  then  ceases  to  exist.  In  other  cases  obliteration  of  the 
lumen  cannot  take  place  on  account  of  the  rigid  incollapsible  character  of 
the  walls,  and  it  is  this  condition  of  chronic  appendicitis  which  may  lead 
to  recurrences  of  attacks  of  colic  and  local  symptoms  in  the  right  iliac 
fossa." 

McBurney  lays  great  stress  upon  the  narrowing  of  the  lumen  as  pre- 
venting normal  drainage  of  the  tube  and  establishing  conditions  favorable 
for  the  development  of  septic  processes. 

Obliterative  appendicitis  is  met  with  in  about  2  per  cent  of  all  sub- 
jects. When  the  stricture  occurs  at  the  csecal  end  of  the  tube  the  lumen 
may  become  greatly  dilated,  forming  a  cystic  appendix  which  may  reach 
the  size  of  the  thumb,  or  even  that  of  an  ordinary  sausage.  The  con- 
tents of  the  cyst  are  either  clear  fluid  or  pus.  Ulceration  and  perforation 
are  very  apt  to  occur.  Obliterative  appendicitis  may  go  on  as  an  ordinary 
involution  process  without  causing  any  symptoms,  but  in  many  instances 
there  are  attacks  of  pain — appendicular  colic;  in  others,  exacerbations  of 


APPENDICITIS.  521 

fever  with  pain  and  swelling;  while  in  others  again  ulceration  and  perfora- 
tion may  take  place. 

(d)  Ulcerative  Appendicitis. — Local  ulceration  in  the  appendix  is  met 
with  as  a  result  of  the  presence  of  concretions  or  of  foreign  bodies,  or  as 
the  result  of  the  action  of  certain  micro-organisms,  either  those  normally 
inhabiting  the  caecum  or,  under  certain  circumstances,  the  typhoid  and 
tubercle  bacilli.  Faecal  concretions  and  foreign  bodies  are  met  with  in  the 
appendix  without  apparently  causing  the  slightest  abrasion  of  its  mucosa. 
In  other  cases  the  enterolith  has  caused  atrophy  of  the  mucous  membrane 
with  which  it  is  in  contact.  In  other  cases  again,  the  concretion  or  foreign 
body  may  be  pocketed  in  an  ulcer  at  the  tip  of  the  appendix,  from  which 
it  may  be  shelled  out.  These  conditions  may  be  present  without  adhe- 
sions and  without  reddening  of  the  serous  surface,  but  one  not  infrequently 
sees  thickening  of  the  peritonasum  with  adhesions  to  the  adjacent  parts  in 
ulcerative  appendicitis. 

Tuberculosis  of  the  appendix  is  by  no  means  uncommon.  Ulceration 
in  typhoid  fever  is  also  frequently  met  with;  in  a  series  of  80  autopsies 
there  were  3  instances  of  perforation  of  the  appendix  by  a  typhoid  ulcer. 
An  actinomycotic  ulcer  has  also  been  described. 

(e)  Necrosis  and  Sloughing  of  the  Appendix— Acute  Infective  Append!- 
Citis. — Following  upon  the  conditions  described  under  (c)  and  (d),  necrosis 
and  sloughing  may  take  place  either  in  a  limited  portion  of  the  appendix 
with  perforation,  or  en  masse  without  perforation,  in  both  cases  leading  to 
the  most  intense  peritonitis,  localized  or  general.  Most  commonly  the  gan- 
grene is  localized  to  one  spot,  either  at  the  tip  or  in  some  portion  of  the 
tube.  Usually  the  organ  is  swollen;  the  color  may  be  reddish  brown,  black, 
or  greenish  yellow.  Necrosis  may  occur  en  masse,  and  the  entire  appendix 
may  indeed  slough  off  from  the  csecum  and  lie  free  in  an  abscess  cavity. 
In  one  remarkable  case  operated  upon  by  my  colleague,  Halsted,  the  appen- 
dix, between  4  and  5  inches  in  length,  was  shrunken,  blackish  brown  in 
color,  sphacelated  throughout,  and  looked  like  a  desiccated  earthworm. 

These  active  processes  leading  to  ulceration  and  necrosis  are  due  to  the 
action  of  micro-organisms,  and  much  work  has  been  done  to  determine 
their  character.  Hodenpyl  showed  that  the  bacillus  coli  communis  was 
present  in  a  very  large  number  of  cases  of  appendicitis.  In  61  cases  of 
peritoneal  inflammation  consequent  upon  disease  of  the  appendix  the  ba- 
cillus coli  communis  was  found  in  57,  and  in  50  of  these  it  was  the  only 
organism  present.  The  streptococcus  pyogenes  and  the  staphylococcus 
pyogenes  aureus,  the  proteus  and  bacillus  pyocyaneus  have  also  been  found. 
The  streptococcus  infection  is  the  most  virulent.  Probably  too  much  stress 
has  been  laid  upon  the  bacillus  coli  communis  as  a  cause  of  infective  pro- 
cesses in  and  about  the  appendix;  In  many  cases,  with  slight  fresh  adhe- 
sion and  a  little  sero-fibrin,  the  cultures  are  negative.  As  Welch  remarks, 
"There  is  reason  to  believe  that  the  highly  resistant  colon  bacillus  may 
survive  in  an  inflamed  part  after  the  primary  organism  which  started  the 
trouble  has  died  out,  or  has  been  crowded  out  by  the  invader."  The  prone- 
ness  of  the  appendix  to  infective  inflammation  of  this  sort  lies  "in  that 
Bubtle  structure  which  determines  the  degree  of  resistance  of  a  tissue  to  dis- 


522  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ease.  One  man  differs  from  another  in  his  power  of  resistance;  the  more 
degenerate  the  man  the  less  resistance  can  he  exert.  In  like  manner,  one 
organ  in  a  man  differs  from  another.  And  in  the  appendix  we  are  dealing 
with  an  organ  which  is  degenerate  and  functionless  from  first  to  last,  and 
its  scanty  power  of  resistance  to  bacterial  invasion  is  but  another  way  of 
expressing  this  fact  "  (Hawkins). 

It  has  been  urged  that  the  anatomical  relations  of  the  meso-appendix 
and  the  adjacent  peritoneal  folds  are  such  that  distention  of  the  caecum, 
or  of  the  lower  portion  of  the  ileum,  may  cause  dragging  with  torsion  and  in- 
terfere seriously  with  the  blood  supply  of  the  tube.  The  swelling  of  the 
mucosa  so  induced  may  be  an  important  factor  in  the  infection  of  its  tissues. 

For  the  best  recent  study  of  the  morbid  anatomy  of  appendicitis  the 
student  is  referred  to  A.  0.  J.  Kelly's  section  in  the  second  edition  of 
Deaver's  work.  i 

Immediate  Effects  of  the  Perforation.  («)  Acute  General  Peritonitis.— 
If  the  appendix  is  free,  without  adhesions,  the  perforation  may  lead  at  once 
to  a  widespread  peritonitis.  The  inflammation  varies  much  in  virulence, 
depending  apparently  upon  the  infecting  organism.  The  worst  cases  are 
those  in  which  the  streptococcus  pyogenes  is  present.  A  general  peritonitis 
is  more  common  in  the  acute  infective  appendicitis  than  in  the  other  forms. 
It  probably  results  less  frequently  from  direct  perforation,  or  sloughing  of 
the  appendix,  than  from  extension  of  inflammation  from  a  local  peri-ap- 
pendicular  abscess. 

(&)  Localized  Peritonitis,  with  Abscess. — Perforation  leads  usually  to 
the  formation  of  a  circumscribed  intra-peritoneal  abscess  cavity,  which 
varies  in  situation  with  the  position  of  the  appendix,  and  in  size  from  a 
walnut  to  a  cocoanut.  Perhaps  the  most  common  situation  is  on  the  psoas 
muscle,  just  at  the  angle  between  the  ileum  and  the  cascum.  The  perfo- 
rated appendix,  however,  may  be  within  the  pelvis,  or  upon  the  promontory 
of  the  sacrum,  or  lie  between  the  coils  of  small  bowel  in  the  neighborhood 
of  the  umbilicus.  A  common  situation  for  the  large  circumscribed  intra- 
peritoneal abscess  is  in  the  iliac  region  midway  between  the  navel  and  the 
anterior  superior  spine.  Perforation,  adhesive  peritonitis,  and  the  produc- 
tion of  a  localized  abscess  may  proceed  without  causing  any  serious  symp- 
toms, and  the  condition  may  be  found  when  death  has  resulted  from  acci- 
dent or  from  some  intercurrent  affection.  The  contents  of  the  abscess 
may  be  a  grayish  yellow,  thick  pus,  usually  with  a  strong  faecal  odor;  but 
in  the  old,  limited,  small  abscesses  it  is  usually  dark  gray  in  color,  and  hor- 
ribly offensive.  The  appendix  may  be  found  free  in  the  localized  abscess; 
in  other  instances  it  is  so  covered  with  pus  and  inflammatory  exudate  that 
it  is  impossible  to  find  it.  While  in  a  majority  of  all  instances  the  abscess 
cavity,  even  when  large,  is  intra-peritoneal,  there  may  be — 

(c)  Extensive  Extra-Peritoneal  Suppuration. — When  an  appendix  perfo- 
rates, it  lies,  of  course,  in  immediate  contact  with  the  peritonaeum;  if  on 
the  iliac  fascia,  or  the  wall  of  the  pelvis,  or  behind  the  cascum,  the  adhesion 
may  take  place  in  such  a  way  that  the  perforation  occurs  into  the  retro- 
peritoneal tissue.  In  these  days  of  operation  we  do  not  so  often  see  the  ex- 
tensive retro-peritoneal  abscesses  due  to  appendix  disease.  The  pus  may 
pass  beneath  the  iliac  fascia  and  appear  at  Poupart's  ligament,  in  which 


APPENDICITIS.  523 

situation  external  perforation  may  occur  and  recovery  take  place.  The 
pus  may  be  chiefly  in  the  retro-peritoneal  tissue  in  the  flank,  forming  a 
large  perinephritic  abscess.  In  a  case  under  the  care  of  Gardner,  of  Mont- 
real, an  enormous  abscess  cavity  developed  in  this  situation,  which  con- 
tained air,  pushed  up  the  diaphragm  nearly  to  the  second  rib,  and  produced 
the  symptoms  of  pneumothorax.  Perforation  of  the  pleura  may  occur  in 
these  cases,  forming  a  faecal  pleural  fistula.  The  pus  may  extend  along 
the  psoas  muscle  and  may  perforate  the  hip  Joint,  or  pass  to  the  neighbor- 
hood of  the  rectum,  or  produce  multiple  abscesses  of  the  scrotum;  or,  pass- 
ing through  the  obturator  foramen,  form  a  large  gluteal  abscess.  Both  the 
intra-  and  extra-peritoneal  appendix  abscess  may  perforate  into  the  bladder 
or  into  the  bowel,  and  recovery  may  follow,  though  there  is  greater  danger 
in  perforation  into  the  latter.  The  appendix  has  been  discharged  per 
anum. 

Remote  Effects.— The  remote  effects  of  perforative  appendicitis  are  in- 
teresting. Hemorrhage  may  occur.  In  one  of  my  cases  the  appendix  was 
adherent  to  the  promontory  of  the  sacrum,  and  the  abscess  cavity  had  per- 
forated in  two  places  into  the  ileum.  Death  resulted  from  profuse  haemor- 
rhage. Cases  are  on  record  in  which  the  internal  iliac  artery  or  the  deep 
circumflex  iliac  artery  has  been  opened.  Suppurative  pylephlebitis  may 
result  from  inflammation  of  the  mesenteric  veins  near  the  perforated  ap- 
pendix. Two  instances  of  it  have  come  under  my  notice;  in  one  there 
was  a  small  localized  abscess  which  had  resulted  from  the  perforation  of  a 
typhoid  ulcer  of  the  appendix.  In  the  other  case,  which  I  saw  with  Ma- 
chell,  of  Toronto,  the  symptoms  were  those  of  septicaemia  and  of  suppura- 
tion of  the  liver.  The  abscess  of  the  appendix  was  small  and  had  not  pro- 
duced symptoms.  In  the  healing  of  extensive  inflammation  about  the  mar- 
gin of  the  pelvis  the  iliae  veins  may  be  greatly  compressed,  and  one  of  my 
patients  had  for  months  oedema  of  the  right  leg,  which  is  now  permanently 
enlarged. 

The  appendix  may  perforate  in  a  hernial  sac.  Several  instances  of  this 
have  been  recorded.  In  a  case  which  came  under  my  care  at  the  Uni- 
versity Hospital,  Philadelphia,  there  was  a  hernia  of  the  caecum  in  the 
inguinal  canal.  The  proximal  orifice  of  the  appendix  was  at  the  extreme 
end  of  the  hernia  in  the  inguinal  canal.  The  tube  then  curved  upon  itself, 
passed  into  the  abdomen,  and  the  terminal  three  fourths  of  an  inch  had 
sloughed  in  a  small  circumscribed  sac  situated  close  to  the  promontory  of 
the  sacrum. 

The  following  additional  facts  may  be  mentioned,  bearing  on  the  eti- 
ology: 

Age. — Appendicitis  is  a  disease  of  young  persons.  According  to  Fitz's 
statistics,  more  than  50  per  cent  of  the  cases  occur  before  the  twentieth 
year;  according  to  Einhorn's,  60  per  cent  between  the  sixteentli  and  thir- 
tieth years.  It  has  been  met  with  as  early  as  the  seventh  week,  but  it  is 
rarely  seen  prior  to  the  third  year. 

Sex. — It  is  much  more  common  in  males  than  in  females,  80  per  cent 
of  the  former  in  the  table  of  Fitz.  In  Hawkins'  series,  Ifil  were  males 
and  63  females.     Contrary  to  the  general  experience,  the  Municli  figures 


624  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

given  by  Einhorn  indicate  a  relatively  greater  number  of  women  at- 
tacked. 

Occupation, — Persons  whose  work  necessitates  the  lifting  of  heavy 
weights  seem  more  prone  to  the  disease.  Trauma  plays  a  very  definite  role, 
and  in  a  number  of  cases  the  symptoms  have  followed  very  closely  a  fall  or 
a  blow. 

Indiscretions  in  diet  are  very  prone  to  bring  on  an  attack,  particularly 
in  the  recurring  form  of  the  disease,  in  which  pain  in  the  appendix  region 
not  infrequently  follows  the  eating  of  indigestible  articles  of  food.  I  have 
been  impressed,  too,  with  the  number  of  eases  in  boys  in  which  there  has 
been  a  history  of  gorging  with  peanuts. 

Symptoms. — In  a  large  proportion  of  all  cases  of  acute  appendicitis 
the  following  symptoms  are  present:  (1)  Sudden  pain  in  the  abdomen,  usu- 
ally referred  to  the  right  iliac  fossa;  (2)  fever,  often  of  moderate  grade; 
(3)  gastro-intestinal  disturbance — nausea,  vomiting,  and  frequently  consti- 
pation; (4)  tenderness  or  pain  on  pressure  in  the  appendix  region. 

Such  a  group  of  symptoms  in  a  young  person,  particularly  following  an 
indiscretion  in  diet  or  an  injury  or  strain,  in  the  absence  of  signs  of  hernia, 
indicate  the  existence  of  appendicitis;  they  do  not  suggest  in  any  way  the 
nature  of  the  lesion,  whether  obliterative,  ulcerative,  or  an  acute  necrotic 
appendicitis.  We  may  first  consider  more  fully  these  general  symptoms  of 
the  disease. 

Pain. — A  sudden,  violent  pain  in  the  abdomen  is,  according  to  Fitz, 
the  most  constant,  first,  decided  symptom  of  perforating  inflammation  of 
the  appendix,  and  occurred  in  84  per  cent  of  the  cases  analyzed  by  him. 
In  fully  half  of  the  cases  it  is  localized  in  the  right  iliac  fossa,  but 
it  may  be  central,  diffuse,  or  indeed  in  almost  any  region  of  the  abdo- 
men. Even  in  the  cases  in  which  the  pain  is  at  first  not  in  the  appendix 
region,  it  is  usually  felt  here  within  thirty-six  or  forty-eight  hours.  It 
may  extend  toward  the  peringeum  or  testicle.  It  is  sometimes  very  sharp 
and  colic-like,  and  cases  have  been  mistaken  for  nephritic  or  for  biliary 
colic.  Some  patients  speak  of  it  as  a  sharp,  intense  pain — serous-mem- 
brane pain;  others  as  a  dull  ache — connective-tissue  pain.  While  a  very 
valuable  symptom,  pain  is  at  the  same  time  one  of  the  most  misleading. 
Some  of  the  forms  of  recurring  pain  in  the  appendix  region  Talamon 
has  called  appendicular  colic.  The  condition  is  believed  to  be  due  to 
partial  occlusion  of  the  lumen,  leading  to  violent  and  irregular  peristal- 
tic action  of  the  circular  and  longitudinal  muscles  in  the  expulsion  of  the 
mucus. 

Fever. — A  rise  in  the  temperature  follows  rapidly  upon  the  pain,  and  is 
one  of  the  most  valuable  of  the  symptoms  of  the  early  stage  of  appendi- 
citis. An  initial  chill  is  very  rare.  The  fever  may  be  moderate,  from 
100°  to  102°;  sometimes  in  children  at  the  very  outset  the  thermometer 
may  register  above  103.5°.  The  thermometer  is  one  of  the  most  trust- 
worthy guides  in  the  diagnosis  of  acute  appendicitis.  Appendicular  colic 
of  great  severity  may  occur  without  fever.  When  a  localized  abscess  has 
formed,  and  in  some  very  virulent  cases  of  general  peritonitis,  the  tempera- 
ture may  be  normal,  but  at  this  stage  there  are  other  symptoms  which  in- 


APPENDICITIS.  525 

dicate  the  gravity  of  the  situation.  The  pulse  is  quickened  in  proportion 
to  the  fever. 

Gastro-intestinal  Disturbance. — The  tongue  is  usually  furred  and  moist, 
seldom  dry.  Nausea  and  vomiting  are  symptoms  which  may  be  absent, 
but  which  are  commonly  present  in  the  acute  perforative  cases.  The  vom- 
iting rarely  persists  beyond  the  second  day  in  favorable  cases.  Constipa- 
tion is  the  rule,  but  the  attack  may  set  in  with  diarrhoea,  particularly  in 
children. 

Local  Signs. — Inspection  of  the  abdomen  is  at  first  negative;  there  is  no 
distention,  and  the  iliac  fossas  look  alike.  On  palpation  there  are  usually 
from  the  outset  two  important  signs — namely,  great  tension  of  the  right 
rectus  muscle,  and  tenderness  or  actual  pain  on  deep  pressure.  The  mus- 
cular rigidity  may  be  so  great  that  a  satisfactory  examination  cannot  be 
made  without  an  angesthetic.  McBurney  has  called  attention  to  the  value 
of  a  localized  point  of  tenderness  on  deep  pressure,  which  is  situated  at  the 
intersection  of  a  line  drawn  from  the  navel  to  the  anterior  superior  spine 
of  the  ilium,  with  a  second,  vertically  placed,  corresponding  to  the  outer 
edge  of  the  right  rectus  muscle.  Firm,  deep,  continuous  pressure  with 
one  finger  at  this  spot  causes  pain,  often  of  the  most  exquisite  character. 
In  addition  to  the  tenderness,  rigidity,  and  actual  pain  on  deep  pressure, 
there  is  to  be  felt,  in  a  majority  of  the  cases,  an  induration  or  swelling. 
In  some  cases  this  is  a  boggy,  ill-defined  mass  in  the  situation  of  the 
caecum;  more  commonly  the  swelling  is  circumscribed  and  definite,  situated 
in  the  iliac  fossa,  two  or  three  fingers'  breadth  above  Poupart's  ligament. 
Some  have  been  able  to  feel  and  roll  beneath  the  fingers  the  thickened  ap- 
pendix. The  later  the  case  comes  under  observation  the  greater  the  proba- 
bility of  the  existence  of  a  well-marked  tumor  mass.  It  is  not  to  be  for- 
gotten that  there  may  be  neither  tumor  mass  nor  induration  to  be  felt  in 
some  of  the  most  intensely  virulent  cases  of  perforative  appendicitis. 

In  addition  may  be  mentioned  great  irritability  of  the  bladder,  which 
I  have  known  to  lead  to  the  diagnosis  of  cystitis.  It  may  be  a  very  early 
symptom.  The  urine  is  scanty  and  often  contains  albumin  and  indican. 
Peptonuria  is  of  no  moment.  The  attitude  is  somewhat  suggestive,  the 
decubitus  is  dorsal,  and  the  right  leg  is  semi-flexed.  Examination  per 
rectum  in  the  early  stages  rarely  gives  any  information  of  value,  unless  the 
appendix  lies  well  over  the  brim  of  the  pelvis,  or  unless  there  is  a  large 
abscess  cavity.    Severe  cases  usually  show  a  leucocytosis  of  15,000  to  2-i,000. 

There  are  three  possibilities  in  any  case  of  appendicitis  presenting  the 
above  symptoms:  (1)  Gradual  recovery,  (2)  the  formation  of  a  local  abscess, 
and  (3)  the  development  of  a  general  peritonitis. 

Recovery  is  the  rule.  Out  of  264  cases  at  St.  Thomas's  Hospital  with 
the  above-mentioned  clinical  characters,  190  recovered.  In  one  instance 
the  appendix  was  removed,  and  in  two,  attempts  were  made  to  remove  it 
(Hawkins).  There  are  surgeons  who  claim  that  the  getting  well  in  these 
cases  does  not  mean  much;  that  the  patients  have  recurrences  and  are  con- 
stantly liable  to  the  graver  accidents  of  the  disease.  This,  I  feel  sure,  is 
an  unduly  dark  picture. 

In  a  case  which  is  proceeding  to  recovery  the  pain  lessens  at  the  end  of 


526  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  third  or  fourth  day,  the  temperature  falls,  the  tongue  becomes  cleaner, 
the  vomiting  ceases,  the  local  tenderness  is  less  marked,  and  the  bowels 
are  moved.  By  the  end  of  a  week  the  acute  symptoms  have  subsided.  The 
entire  attack  may  not  last  more  than  ten  days.  In  other  instances  slight 
fever  persists,  and  it  may  be  two  or  three  weeks  before  convalescence  is 
established.  An  induration  or  an  actual  small  tumor  mass  from  the  size 
of  a  walnut  to  that  of  an  egg  may  persist — a  condition  which  leaves  the 
patients  very  liable  to  a  recurrence. 

In  these  cases  there  is  either  a  chronic  appendicitis  without  perforation 
or  involvement  of  the  serous  surface,  or  there  is  implication  of  the  peri- 
toneal surface,  usually  from  perforation,  with  a  sero-fibrinous  exudate 
and  an  agglutination  of  the  contiguous  parts.  In  the  cases  with  a  well- 
defined  tumor,  whether  large  or  small,  there  is  almost  always  pus  forma- 
tion. 

Local  Abscess  Formation. — As  a  result  of  ulceration  and  perforation, 
sometimes  following  the  necrosis,  rarely  as  a  sequence  of  the  diffuse  ap- 
pendicitis, the  patient  has  the  train  of  symptoms  above  described;  but  at 
the  end  of  the  first  week  the  local  features  persist  or  become  aggravated. 
The  course  of  the  disease  may  be  indeed  so  acute  that  by  the  end  of  the 
fourth  or  fifth  day  there  is  an  extensive  area  of  induration  in  the  right 
iliac  fossa,  with  great  tenderness,  and  operations  have  shown  that  even  at 
this  very  early  date  an  abscess  cavity  may  have  formed.  Though  as  a  rule 
the  fever  becomes  aggravated  with  the  onset  of  suppuration,  this  is  not 
always  the  case.  The  two  most  important  elements  in  the  diagnosis  of 
abscess  formation  are  the  gradual  increase  of  the  local  tumor  and  the  aggra- 
vation of  the  general  symptoms.  Nowadays,  when  operation  is  so  frequent, 
we  have  opportunities  of  seeing  the  abscess  in  various  stages  of  develop- 
ment. Quite  early  the  pus  may  lie  between  the  caecum  and  the  coils  of 
the  ileum,  with  the  general  peritonseum  shut  off  by  fibrin,  or  there  is  a  sero- 
fibrinous exudate  with  a  slight  amount  of  pus  between  the  lower  coils  of  the 
ileum.  The  abscess  cavity  may  be  small  and  lie  on  the  psoas  muscle,  or 
at  the  edge  of  the  promontory  of  the  sacrum,  and  never  reach  a  palpable 
size.  The  sac,  when  larger,  may  be  roofed  in  by  the  small  bowel  and  pre- 
sent irregular  processes  and  pockets  leading  "in  different  directions.  In 
llirger  collections  in  the  iliac  fossa  the  roof  is  generally  formed  by  the  ab- 
dominal wall.  Some  of  the  most  important  of  the  localized  abscesses  are 
those  which  are  situated  entirely  within  the  pelvis.  The  various  directions 
and  positions  into  which  the  abscess  may  pass  or  perforate  have  already 
been  referred  to  under  morbid  anatomy,  but  it  may  be  here  mentioned 
again  that,  left  alone,  it  may  discharge  externally,  or  burrow  in  various 
directions,  or  be  emptied  through  the  rectum,  vagina,  or  bladder.  Death 
may  be  caused  by  septicaemia,  by  perforation  into  an  artery  or  vein,  or  by 
pylephlebitis. 

General  Peritonitis. — This  may  be  caused  by  direct  perforation  of  the 
appendix  and  general  infection  of  the  peritonaeum  before  any  delimiting 
inflammation  is  excited.  In  a  second  group  of  cases  there  has  been  an  at- 
tempt at  localizing  the  infective  process,  but  it  fails,  and  the  general  peri- 
tonaeum becomes  involved.    In  a  third  group  of  cases  a  localized  focus  of 


APPENDICITIS.  527 

suppuration  exists  about  an  inflamed  appendix,  and  from  this  perforation 
takes  place. 

Death  in  appendicitis  is  due  usually  to  general  peritonitis. 

We  see  at  operations  all  grades  of  the  affection,  from  the  mildest,  in 
which  the  serous  surface  is  injected,  turbid,  and  sticky,  but  without  lymph 
or  effusion,  except  in  the  immediate  neighborhood  of  the  perforated  ap- 
pendix. In  other  cases  there  is  a  fibrinous  exudate  gluing  the  coils  to- 
gether and  a  variable  amount  of  turbid  serous  fluid.  In  other  instances, 
as  the  abdomen  is  opened,  pus  wells  out,  and  there  is  a  diffuse  purulent  in- 
flammation of  the  peritonEeum.  It  is  interesting,  however,  to  note  the  com- 
parative rarity  of  fatal  peritonitis  from  appendix  disease  in  general  medical 
work.  In  450  consecutive  autopsies  on  patients  dead  in  my  wards  there 
was  not  a  single  instance  of  general  peritonitis  from  appendix  disease.  On 
the  surgical  side  there  have  been  admitted  during  the  same  period  10  cases 
of  diffuse  peritonitis  from  this  cause.  Eight  were  operated  upon;  all  died. 
In  9  cases  there  was  found  a  perforated  and  more  or  less  gangrenous  ap- 
pendix, with  little  or  no  attempt  at  localization;  in  1  case  rupture  of 
an  abscess  caused  the  general  peritonitis. 

The  gravity  of  appendix  disease  lies  in  the  fact  that  from  the  very  outset 
the  peritonceum  may  le  infected;  the  initial  symptoms  of  pain,  with  nausea 
and  vomiting,  fever,  and  local  tenderness,  present  in  all  cases,  may  indicate  a 
widespread  infection  of  this  membrane.  The  onset  is  usually  sudden,  the 
pain  diffuse,  not  always  localized  in  the  right  iliac  fossa,  but  it  is  not  so 
much  the  character  as  the  greater  intensity  of  the  symptoms  from  the  out- 
set that  makes  one  suspicious  of  a  general  peritonitis.  Abdominal  disten- 
tion, diffuse  tenderness,  and  absence  of  abdominal  movements  are  the  most 
trustworthy  local  signs,  but  they  are  not  really  so  trustworthy  as  the  gen- 
eral symptoms.  The  initial  nausea  and  vomiting  persist,  the  pulse  be- 
comes more  rapid,  the  tongue  is  dry,  the  urine  scanty.  In  very  acute 
cases,  by  the  end  of  twenty-four  hours  the  abdomen  may  be  distended.  By 
the  third  and  fourth  days  the  classical  picture  of  a  general  peritonitis  is 
well  established — a  distended  and  motionless  abdomen,  a  rapid  pulse,  a  dry 
tongue,  dorsal  decubitus  with  the  knees  drawn  up,  and  an  anxious,  pinched, 
Hippocratic  facies.    Unfortunately,  the  leucocyte  count  gives  little  aid. 

Fever  is  an  uncertain  element.  It  is  usually  present  at  first,  but  if  the 
physician  does  not  see  the  case  until  the  third  or  fourth  day  he  should 
not  be  deceived  by  a  temperature  below  100.5°.  The  pulse  is  really  a 
better  indication  than  the  temperature.  One  rarely  has  any  doubt  on  the 
third  or  fourth  day  whether  or  not  peritonitis  exists,  but  it  must  be  ac- 
knowledged that  there  are  exceptions  which  trouble  the  judgment  not  a 
little.  While  on  the  one  hand,  without  suggestive  symptoms,  a  laparotomy 
has  disclosed  an  unexpected  general  peritonitis,  on  the  other,  with  severe 
constitutional  symptoms  and  apparently  characteristic  local  signs,  the  peri- 
toneum has  been  found  smooth. 

Relapsing  Appendicitis. — Pepper,  in  1883,  called  attention  to  the  re- 
markable liability  to  relapse  in  perityphlitis.  The  patient  gets  well  and 
all  trace  of  induration  and  tenderness  disappears;  then  in  three  or  four 
months,  or  earlier,  he  again  has  fever,  pain,  and  local  signs  of  trouble. 
33 


528  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

• 
The  attacks  may  recur  for  years.  Tlie  cases  which  recover  with  the  per- 
sistence of  an  induration  or  tumor  mass  are  most  prone  to  relapse.  There 
are  more  severe  cases  in  which  the  intervals  between  the  attacks  are  very 
short,  and  the  patient  becomes  a  chronic  invalid.  After  repeated  attacks, 
however,  recovery  may  be  perfect.  The  frequency  of  recurrence  is  difficult 
to  estimate.  Fitz  places  it  at  44  per  cent,  Hawkins  at  23.6  per  cent.  The 
recent  statistics  of  operations  given  by  Deaver,  Murphy,  and  others  indi- 
cate how  common  must  be  this  type  of  the  disease.  Bull  has  collected 
443  operations  in  chronic  relapsing  appendicitis  by  eighty  surgeons,  with 
a  mortality  of  1.8  per  cent,  but  he  thinks  that  5  or  6  per  cent  would  be  a 
fairer  estimate. 

The  morbid  condition  in  this  form  is  either  a  simple  obliterative  ap- 
pendicitis with  or  without  adhesions,  or  an  adherent,  perhaps  perforated 
appendix  with  a  small  localized  abscess  circumscribed  by  dense  fibroid 
tissue. 

Diagnosis. — Appendicitis  is  by  far  the  most  common  inflammatory 
condition,  not  only  in  the  csecal  region,  but  in  the  abdomen  generally  in 
persons  under  thirty.  The  surgeons  have  taught  us  that,  almost  without 
exception,  sudden  pain  in  the  right  iliac  fossa,  with  fever  and  localized  ten- 
derness, with  or  without  tumor,  means  appendix  disease.  There  are  cer- 
tain diseases  of  the  abdominal  organs  characterized  by  pain  which  are  apt 
to  be  confounded  with  appendicitis.  Biliary  colic,  kidney  colic,  and  the 
colicky  pains  at  the  menstrual  period  in  women  have  in  some  cases  to  be 
most  carefully  considered.  I  have  not  met  with  an  instance  of  either  renal 
or  hepatic  calculus  causing  any  difficulty  in  diagnosis,  but  a  patient  was 
admitted  to  my  wards  with  a  history  of  very  sudden  onset  of  severe  pain 
three  days  previously  in  the  right  side  of  the  abdomen,  and  with  an  ill- 
defined  tumor  mass  low  in  the  right  flank.  Fortunately,  she  was  trans- 
ferred at  once  to  the  surgical  side  for  operation,  and  the  condition  proved 
to  be  an  acutely  distended  and  inflamed  gall-bladder  almost  on  the  point 
of  perforating.     A  second  very  similar  case  has  since  occurred. 

Diseases  of  the  tubes  and  pelvic  peritonitis  may  simulate  appendicitis 
very  closely,  but  the  history  and  the  local  examination  under  ether  should 
in  most  cases  enable  the  practitioner  to  reach  a  diagnosis.  I  have  seen 
several  cases  supposed  to  be  recurring  appendicitis  which  proved  to  be  tubo- 
ovarian  disease. 

The  Dietl's  crises  in  floating  kidney  have  been  mistaken  for  appendi- 
citis. 

Both  intussusception  and  internal  strangulation  may  present  very  sim- 
ilar symptoms,  and  if  the  patient  is  only  seen  at  the  later  stages,  when 
there  is  diffuse  peritonitis  and  great  tympany,  the  features  may  be  almost 
identical.  Fsecal  vomiting,  which  is  common  in  obstruction,  is  never  seen 
in  appendicitis,  and  in  children  the  marked  tenesmus  and  bloody  stools 
are  important  signs  of  intussusception.  It  is  not  often  difficult  to  decide 
when  the  cases  are  seen  early  and  when  the  history  is  clear,  but  mistakes 
have  been  made  by  surgeons  of  the  first  rank. 

Acute  haemorrhagic  pancreatitis  may  also  produce  symptoms  very  like 
those  of  appendicitis  with  general  peritonitis.     The  relation  of  typhoid 


APPENDICITIS.  529 

fever  and  appendicitis  is  interesting.  The  gastro-intestinal  symptoms,  par- 
ticularly the  pain  and  the  fever,  may  at  the  onset  suggest  appendicitis. 
Operations  have  been  comparatively  frequent.  Dr.  Bloodgood  tells  me  that 
two  cases  have  been  admitted  to  the  Johns  Hopkins  Hospital  and  have 
been  operated  upon  as  acute  appendicitis,  and  subsequently  the  diagnosis 
of  typhoid  has  been  made.  In  the  second  and  third  weeks  of  typhoid  fever 
perforation  of  the  appendix  may  occur,  and  occasionally  late  in  the  con- 
valescence perforation  of  an  unhealed  ulcer  of  the  appendix. 

There  is  a  well-marked  appendicular  hypochondriasis.  Through -the 
pernicious  influence  of  the  daily  press,  appendicitis  has  become  a  sort  of 
fad,  and  the  physician  has  often  to  deal  with  patients  who  have  almost 
a  fixed  idea  that  they  have  the  disease.  The  worst  cases  of  this  class 
which  I  have  seen  have  been  in  members  of  our  profession,  and  I  know  of 
at  least  one  instance  in  which  a  perfectly  normal  appendix  was  removed. 
The  question  really  has  its  ludicrous  side.  A  well-known  physician  in  a 
Western  city  having  one  night  a  bellyache,  and  feeling  convinced  that  his 
appendix  had  perforated,  summoned  a  surgeon,  who  quickly  removed  the 
supposed  offender! 

Hysteria  may  of  course  simulate  appendicitis  very  closely,  and  it  may 
require  a  very  keen  Judgment  to  make  a  diagnosis. 

Mucous  colitis  with  enteralgia  in  nervous  women  is  sometimes  mis- 
taken for  appendicitis.  In  two  instances  of  the  kind  I  have  prevented 
proposed  operation,  and  I  have  heard  of  cases  in  which  the  appendix  has 
been  removed. 

Perinephritic  and  pericecal  abscess  from  perforation  of  ulcer,  either 
simple  or  cancerous,  and  circumscribed  peritonitis  in  this  region  from  other 
causes,  can  rarely  be  differentiated  until  an  exploratory  incision  is  made. 

Chronic  obliterative  appendicitis  cannot  always  be  differentiated  from 
the  perforative  form,  and  in  intensity  of  pain,  severity  of  symptoms,  and,  in 
rare  instances,  even  in  the  production  of  peritonitis,  the  two  may  be  iden- 
tical. 

Briefly  stated,  localized  pain  in  the  right  iliac  fossa,  with  or  without 
induration  or  tumor,  the  existence  of  McBurney's  tender  point,  fever, 
furred  tongue,  vomiting,  with  constipation  or  diarrhoea,  indicate  appendi- 
citis. The  occurrence  of  general  peritonitis  is  suggested  by  increase  and 
diffusion  of  the  abdominal  pain,  tympanites  (as  a  rule),  marked  aggrava- 
tion of  the  constitutional  symptoms,  particularly  elevation  of  fever  and  in- 
creased rapidity  of  the  pulse.  Obliteration  of  hepatic  dulness  is  rarely 
present,  as  the  peritonaeum  in  these  cases  does  not  often  contain  gas. 

Prognosis.  — "V\liile  we  cannot  overestimate  the  gravity  of  certain 
forms  of  appendicitis,  it  is  well  to  recognize  that  a  large  proportion  of  all 
cases  recover.  It  is  the  element  of  uncertainty  in  individual  cases  which 
has  given  such  an  impetus  to  the  surgical  treatment  of  the  disease.  Tliat 
an  inflamed  appendix  may  heal  perfectly,  even  after  perforation,  is  shown 
by  instances  (post  mortem)  of  obliterated  tubes  firmly  imbedded  in'  old 
scar  tissue.  Formerly  we  had  not  a  full  knowledge  of  tlie  natural  history  of 
the  disease.  As  J.  William  WHiite  remarked  in  an  address  at  the  College 
of  Physicians,  Philadelphia,  "  We  are  in  special  need  of  reliable  medical 


530  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

statistics  as  to  this  point."  These  have  now  been  supplied  in  the  admi- 
rable monograph  of  Hawkins  (London,  1895),  in  which  he  has  analyzed  the 
cases  at  St.  Thomas's  Hospital,  264  in  number.  The  work  is  to  be  com- 
mended particularly  to  surgeons,  since,  while  written  from  the  standpoint 
of  the  physician  and  pathologist,  the  author  is  fully  alive  to  the  surgical 
aspects  of  the  disease,  and  does  ample  justice  to  the  work  of  American 
operators.  His  figures  are  as  follows:  (a)  Peritonitis,  limited  to  the  right 
iliac  fossa  and  not  proceeding  to  the  formation  of  pus,  190  cases,  no 
deaths;  (&)  peritonitis,  similarly  localized,  but  ending  in  the  formation 
of  pus  (perityphlitic  abscess),  38  cases,  with  10  deaths;  (c)  general  peri- 
tonitis, 36  cases,  with  27  deaths.  This  gives  a  total  mortality  of  14  per 
cent.  Fifty-nine  of  the  264  jaatients  had  had  one  or  more  previous  at- 
tacks; 45  of  these  had  simple  "  perityphlitis,"  and  all  recovered;  of  7  with 
abscess  formation,  3  died;  of  7  with  general  peritonitis,  3  died.  These  fig- 
ures compare  very  favorably  with  those  collected  by  Porter:  Removal  of 
appendix  during  the  attack,  19.7  per  cent  mortality;  incision  and  drain- 
age of  abscess,  18.18  per  cent  of  deaths.  The  statistics  of  individual  opera- 
tors give  a  much  more  favorable  showing,  and  we  may  say  that  in  acute 
cases  without  generalized  peritonitis,  and  in  the  localized  appendicular  ab- 
scess, the  percentage  of  deaths  in  the  hands  of  good  surgeons  is  now  very 
much  lower. 

Treatment. — So  impressed  am  I  by  the  fact  that  we  physicians  lose 
lives  by  temporizing  with  certain  cases  of  appendicitis,  that  I  prefer,  in 
hospital  work,  to  have  the  suspected  cases  admitted  directly  to  the  surgical 
side.  The  general  practitioner  does  well  to  remember — whether  his  lean- 
ings be  toward  the  conservative  or  the  radical  methods  of  treatment — ^that 
the  surgeon  is  often  called  too  late,  never  too  early. 

There  is  no  medicinal  treatment  of  appendicitis.  There  are  remedies 
which  will  allay  the  pain,  but  there  are  none  capable  in  any  way  of  con- 
trolling the  course  of  the  disease.  Rest  in  bed,  a  light  diet,  measures  di- 
rected to  allay  the  vomiting — upon  these  all  are  agreed.  There  are  two 
points  on  which  the  profession  is  very  much  divided,  namely,  the  use  of 
opium  and  of  saline  purges.  The  practice  of  giving  opium  in  some  form 
in  appendicitis  and  peritonitis  is  almost  universal  with  physicians.  Sur- 
geons, on  the  other  hand,  almost  unanimously  condemn  the  practice,  as 
obscuring  the  clinical  picture  and  tending  to  give  a  false  sense  of  security; 
and  since  they  control  the  situation,  I  think  we  should — deferring  in  this 
matter  to  their  judgment — give  less  opium,  and  trust  to  the  persistent  use 
of  ice  locally  to  relieve  the  pain. 

The  use  of  saline  purges  early  in  the  disease,  which  is  advocated  by 
some  surgeons,  is,  I  believe,  a  most  injurious  practice.  In  any  given  case 
the  pain  and  tenderness  at  the  outset  may  mean  perforation  of  the  appen- 
dix, and  the  life  of  the  patient  may  depend  upon  whether  a  limiting  adhe- 
sive inflammation  is  set  up.  Under  these  circumstances,  anything  that 
will  stimulate  active  peristalsis  of  the  bowel  wall  throughout  its  extent  is 
certainly  contra-indicated.  Surgery,  too,  has  taught  us  that  the  cfficum  is 
rarely,  if  ever,  filled  with  hardened  faeces,  so  that  it  is  really  on  theoretical 
grounds  that  a  saline  is  urged  to  clear  this  part  of  the  bowel.     I  am  glad 


INTESTINAL  OBSTRUCTION.  531 

to  see,  too^  that  some  surgeons  of  the  largest  experience,  as  McBurney, 
state  that  they  never  employ  purgatives.  They  are  also  contra-indicated,  I 
think,  when  there  are  signs  of  the  formation  of  a  local  abscess.  If  useful 
at  all,  it  is  when  general  peritonitis  has  been  established,  but  then,  as  a 
rule,  the  mischief  is  done,  and  purgatives  cannot  influence  the  result. 

Operation  is  indicated  in  all  cases  of  acute  inflammatory  trouble  in  the 
ca^cal  region,  whether  tumor  is  present  or  not,  when  the  general  symptoms 
are  severe,  and  when  by  the  third  day  the  features  of  the  case  point  to  a  pro- 
gressive lesion.  The  mortality  from  early  operation  under  these  circum- 
stances is  very  slight. 

In  recurring  appendicitis,  when  the  attacks  are  of  such  severity  and 
frequency  as  seriously  to  interrupt  the  patient's  occupation,  the  figures  al- 
ready given  show  how  slight  the  mortality  is  in  the  hands  of  capable  oper- 
ators. Unfortunately,  in  hospital  practice  too  many  cases  are  brought  in 
with  general  peritonitis — a  condition  in  which  operation  is  rarely  successful. 

Post-operative  Features  in  Appendicitis. — Unfortunately,  the  operation 
does  not  always  finish  the  victim's  troubles.  I  have  been  consulted  by  sev- 
eral patients  with  severe  pain  following  the  operation,  and  the  literature  con- 
tains a  number  of  reports  of  recurrence  of  the  pain  in  the  right  iliac  fossa. 
There  have  been  instances,  indeed,  in  which  an  indurated  cord  has  been 
felt,  and  might  have  readily  been  mistaken  for  the  appendix  had  it  not  been 
previously  removed.  In  some  instances  a  second  operation  has  been  suc- 
cessful in  freeing  the  adhesions  which  have  caused  the  pain. 


III.    INTESTINAL  OBSTRUCTION. 

Intestinal  obstruction  may  be  caused  by  strangulation,  intussusception, 
twists  and  knots,  strictures  and  tumors,  and  by  abnormal  contents. 

Etiology  and  Pathology.— («)  Strangulation. — This  is  the  most 
frequent  cause  of  acute  obstruction,  and  occurred  in  34  per  cent  of  the  295 
cases  analyzed  by  Fitz,*  and  in  35  per  cent  of  the  1,134  cases  of  Leichten- 
stern.f  Of  the  101  cases  of  strangulation  in  Fitz's  table,  which  has  the  spe- 
cial value  of  having  been  carefully  selected  from  the  literature  since  1880, 
the  following  were  the  causes:  Adhesions,  63;  vitelline  remains,  21;  adher- 
ent appendix,  6;  mesenteric  and  omental  slits,  6;  peritoneal  pouches  and 
openings,  3;  adherent  tube,  1;  peduncular  tumor,  1.  The  bands  and  adhe- 
sions result,  in  a  majority  of  cases,  from  former  peritonitis.  A  number 
of  instances  have  been  reported  following  operations  upon  the  pelvic  or- 
gans in  women.  The  strangulation  may  be  recent  and  due  to  adhesion  of 
the  bowel  to  the  abdominal  wound  or  a  coil  may  be  caught  between  the 
pedicle  of  a  tumor  and  the  pelvic  wall.  Such  cases  are  only  too  common. 
Late  occlusion  after  recovery  from  the  operation  is  due  to  bands  and  ad- 
hesions. 

*  Transactions  of  the  Congress  of  American  Physicians  and  Surgeons,  vol.  i,  1889. 
The  percentages  of  his  tables  are  used  throughout  this  section. 
f  Von  Ziemssen's  Encyclopa}dia  of  Practical  Medicine. 


532  '  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  vitelline  remains  are  represented  by  Meckel's  diverticulum,  which 
forms  a  finger-like  projection  from  the  ileum,  usually  within  eighteen 
inches  of  the  ileo-csecal  valve.  It  is  a  remnant  of  the  omphalo-mesenteric 
duct,  through  which,  in  the  early  embryo,  the  intestine  communicated  with 
the  yolk-sac.  The  end,  though  commonly  free,  may  be  attached  to  the 
abdominal  wall  near  the  navel,  or  to  the  mesentery,  and  a  ring  is  thus 
formed  through  which  the  gut  may  pass. 

Seventy  per  cent  of  the  cases  of  obstruction  from  strangulation  occur 
in  males;  40  per  cent  of  all  the  cases  occur  between  the  ages  of  fifteen  and 
thirty  years.  In  90  per  cent  of  the  cases  of  obstruction  from  these  causes 
the  site  of  the  trouble  is  in  the  small  bowel;  the  position  of  the  strangulated 
portion  was  in  the  right  iliac  fossa  in  67  per  cent  of  the  cases,  and  in  the 
lower  abdomen  in  83  per  cent. 

(h)  Intussusception. — In  this  condition  one  portion  of  the  intestine  slips 
into  an  adjacent  portion,  forming  an  invagination  or  intussusception.  The 
two  portions  make  a  cylindrical  tumor,  which  varies  in  length  from  a  half- 
inch  to  a  foot  or  more.  The  condition  is  always  a  descending  intussuscep- 
tion, and  as  the  process  proceeds,  the  middle  and  inner  layers  increase  at 
the  expense  of  the  outer  layer.  An  intussusception  consists  of  three  layers 
of  bowel:  the  outermost,  known  as  the  intussuscipiens,  or  receiving  layer; 
a  middle  or  returning  layer;  and  the  innermost  or  entering  layer.  The 
student  can  obtain  a  clear  idea  of  the  arrangement  by  making  the  end  of  a 
glove-finger  pass  into  the  lower  portion.  The  actual  condition  can  be  very 
clearly  studied  in  the  post-mortem  invaginations  which  are  so  common  in 
the  small  bowel  of  children.  In  the  statistics  of  Fitz,  93  of  295  cases 
of  acute  intestinal  obstruction  were  due  to  this  cause.  Of  these,  52  were  in 
males  and  27  in  females.  The  cases  are  most  common  in  early  life,  34 
per  cent  under  one  year  and  56  per  cent  under  the  tenth  year.  Of  103 
cases  in  children,  nearly  50  per  cent  occurred  in  the  fourth,  fifth,  and  sixth 
months  (Wiggin).  No  definite  causes  could  be  assigned  in  42  of  the  cases; 
in  the  others  diarrhoea  or  habitual  constipation  had  existed. 

The  site  of  the  invagination  varies.  We  may  recognize  (1)  an  ileo-ccecal, 
when  the  ileo-csecal  valve  descends  into  the  colon.  There  are  cases  in 
which  this  is  so  extensive  that  the  valve  has  been  felt  per  rectum.  This 
form  occurred  in  75  per  cent  of  the  cases;  in  89  per  cent  of  Wiggin's  col- 
lected cases.  In  the  ileo-colic  the  lower  part  of  the  ileum  passes  through 
the  ileo-csecal  valve.  (2)  The  ileal,  in  which  the  ileum  is  alone  involved. 
(3)  The  colic,  in  which  it  is  confined  to  the  large  intestine.  And  (4)  colico- 
rectal,  in  which  the  colon  and  rectum  are  involved. 

Irregular  peristalsis  is  the  essential  cause  of  intussusception.  Noth- 
nagel  found  in  the  localized  peristalsis  caused  by  the  faradic  current  that 
it  was  not  the  descent  of  one  portion  into  the  other,  but  the  drawing  up 
of  the  receiving  layer  by  contraction  of  the  longitudinal  coat.  Invagina- 
tion may  follow  any  limited,  sudden,  and  severe  peristalsis. 

In  the  post-mortem  examination,  in  a  case  of  death  from  intussuscep- 
tion, the  condition  is  very  characteristic.  Peritonitis  may  be  present  or 
an  acute  injection  of  the  serous  membrane.  When  death  occurs  early,  as 
it  may  do  from  shock,  there  is  little  to  be  seen.     The  portion  of  bowel 


INTESTINAL  OBSTRUCTION.  533 

affected  is  large  and  thick,  and  forms  an  elongated  tumor  with  a  curved 
outline.  The  parts  are  swollen  and  congested,  owing  to  the  constriction 
of  the  mesentery  between  the  layers.  The  entire  mass  may  be  of  a 
deep  livid-red  color.  In  very  recent  processes  there  is  only  congestion,  and 
perhaps  a  thin  layer  of  lymph,  and  the  intussusception  can  be  reduced, 
but  when  it  has  lasted  for  a  few  days,  lymph  is  thrown  out,  the  layers 
are  glued  together,  and  the  entering  portion  of  the  gut  cannot  be  with- 
drawn. 

The  anatomical  condition  accounts  for  the  presence  of  the  tumor,  which 
exists  in  two  thirds  of  all  cases;  and  the  engorgement,  which  results  from 
the  compression  of  the  mesenteric  vessels,  explains  the  frequent  occurrence 
of  blood  in  the  discharges,  which  has  so  important  a  diagnostic  value.  If 
the  patient  survives,  necrosis  and  sloughing  of  the  invaginated  portion  may 
occur,  and  if  union  has  taken  place  between  the  middle  and  outer  layer, 
the  calibre  of  the  gut  may  be  restored  and  a  cure  in  this  way  effected. 
Many  cases  of  the  kind  are  on  record.  In  the  Museum  of  the  Medical  Fac- 
ulty of  McGill  University  are  17  inches  of  small  intestine,  which  were 
passed  by  a  lad  who  had  had  symptoms  of  internal  strangulation,  and  who 
made  a  complete  recovery. 

(c)  Twists  and  Knots. — Volvulus  or  twist  occurred  in  42  of  the  295 
cases.  Sixty-eight  per  cent  were  in  males.  It  is  most  frequent  between 
the  ages  of  thirty  and  forty.  In  the  great  majority  of  all  cases  the  twist 
is  axial  and  associated  with  an  unusually  long  mesentery.  In  50  per  cent 
of  the  cases  it  was  in  the  sigmoid  flexure.  The  next  most  common  situa- 
tion is  about  the  caecum,  which  may  be  twisted  upon  its  axis  or  bent  upon 
itself.  As  a  rule,  in  volvulus  the  loop  of  bowel  is  simply  twisted  upon  its 
long  axis,  and  the  portions  at  the  end  of  the  loop  cross  each  other  and  so 
cause  the  strangulation.  It  occasionally  happens  that  one  portion  of  the 
bowel  is  twisted  about  another. 

(d)  Strictures  and  Tumors. — These  are  very  much  less  important  causes 
of  acute  obstruction,  as  may  be  judged  by  the  fact  that  there  are  only  15 
instances  out  of  the  295  cases,  in  14  of  which  the  obstruction  occurred  in 
the  large  intestine.  On  the  other  hand,  they  are  common  causes  of  chronic 
obstruction. 

The  obstruction  may  result  from:  (1)  Congenital  stricture.  These  are 
exceedingly  rare.  Much  more  commonly  the  condition  is  that  of  complete 
occlusion,  either  forming  the  imperforate  anus  or  the  congenital  defect  by 
which  the  duodenum  is  not  united  to  the  pylorus.  (2)  Simple  cicatricial 
stenosis,  which  results  from  ulceration,  tuberculous  or  syphilitic,  more 
rarely  from  dysentery,  and  most  rarely  of  all  from  typhoid  ulceration.  (3) 
New  growths.  The  malignant  strictures  are  due  chiefly  to  cylindrical  epi- 
thelioma, which  forms  an  annular  tumor,  most  commonly  met  with  in  the 
(arge  bowel,  about  the  sigmoid  flexure,  or  the  descending  colon.  Of  be- 
nign growtbs,  papillomata,  adenomata,  lipomata,  and  fibromata  occasion- 
ally induce  obstruction.  (4)  Compression  and  traction.  Tumors  of  neigh- 
boring organs,  particularly  of  the  pelvic  viscera,  may  cause  obstruction  by 
adhesion  and  traction;  more  rarely,  a  coil,  such  as  the  sigmoid  flexure, 
filled  with  fgeces,  compresses  and  obstructs  a  neighboring  coil.     In  the  heal- 


534  DISEASES  OP  THE  DiaESTIVE  SYSTEM. 

ing  of  tuberculous  peritonitis  the  contraction  of  the  thick  exudate  may 
cause  compression  and  narrowing  of  the  coils. 

(e)  Abnormal  Contents. — Foreign  bodies,  such  as  fruit  stones,  coins,  pins, 
needles,  or  false  teeth,  are  occasionally  swallowed  accidentally,  or  by  luna- 
tics on  purpose.  Eound  worms  may  become  rolled  into  a  tangled  mass 
and  cause  obstruction.  In  reality,  however,  the  majority  of  foreign  bodies, 
such  as  coins,  butt(Tns,  and  pins,  swallowed  by  children,  cause  no  incon- 
venience whatever,  but  in  a  day  or  two  are  found  in  the  stools.  Occasion- 
ally such  a  foreign  body  as  a  pin  will  pass  through  the  oesophagus  and  will 
be  found  lodged  in  some  adjacent  organ,  as  in  the  heart  (Peabody),  or  a 
barley  ear  may  reach  the  liver  (Dock). 

Medicines,  such  as  magnesia  or  bismuth,  have  been  known  to  accumu- 
late in  the  bowels  and  produce  obstruction,  but  in  the  great  majority  of 
the  cases  the  condition  is  caused  by  fseces,  gall-stones,  or  enteroliths.  Of 
44  cases,  in  23  the  obstruction  was  by  gall-stones,  in  19  by  fasces,  and  in  2 
by  enteroliths.  Obstruction  by  faces  may  happen  at  any  period  of  life. 
As  mentioned  when  speaking  of  dilatation  of  the  colon,  it  may  occur  in 
young  children  and  persist  for  weeks.  In  fgecal  accumulation  the  large 
bowel  may  reach  an  enormous  size  and  the  contents  become  very  hard. 
The  retained  masses  may  be  channeled,  and  small  quantities  of  faecal  matter 
are  passed  until  a  mass  too  large  enters  the  lumen  and  causes  obstruction. 
There  may  be  very  few  symptoms,  as  the  condition  may  be  borne  for  weeks 
or  even  for  months. 

Obstruction  by  gall-stones  is  not  very  infrequent,  as  may  be  gathered 
from  the  fact  that  23  cases  were  reported  in  the  literature  in  eight  years. 
Eighteen  of  these  were  in  women  and  5  in  men.  In  six  sevenths  of  the 
cases  it  occurred  after  the  fiftieth  year.  The  obstruction  is  usually  in  the 
ileo-caecal  region,  but  it  may  be  in  the  duodenum.  These  large  solitary 
gall-stones  ulcerate  through  the  gall-bladder,  usually  into  the  small  intes- 
tine, occasionally  into  the  colon.  In  the  latter  case  they  rarely  cause  ob- 
struction     Courvoisier  Jias  collected  131  cases  in  the  literature.  - 

Enteroliths  may  be  formed  of  masses  of  hair,  more  commonly  of  the 
phosphates  of  lime  and  magnesia,  with  a  nucleus  formed  of  a  foreign  body 
or  of  hardened  fseces.  Nearly  every  museum  possesses  specimens  of  this 
kind.  They  are  not  so  common  in  men  as  in  ruminants,  and,  as  indicated 
in  Fitz's  statistics,  are  very  rare  causes  of  obstruction. 

Symptoms. — (a)  Acute  Obstruction. — Constipation,  pain  in  the  abdo- 
men, and  vomiting  are  the  three  important  symptoms.  Pain  sets  in  early 
and  may  come  on  abruptly  while  the  patient  is  walking  or,  more  com- 
monly, during  the  performance  of  some  action.  It  is  at  first  colicky  in 
character,  but  subsequently  it  becomes  continuous  and  very  intense.  Vom- 
iting follows  quickly  and  is  a  constant  and  most  distressing  symptom.  At 
first  the  contents  of  the  stomach  are  voided,  and  then  greenish,  bile- 
stained  material,  and  soon,  in  cases  of  acute  and  permanent  obstruction, 
the  material  vomited  is  a  brownish-black  liquid,  with  a  distinctly  fsecal 
odor.  This  sequence  of  gastric,  bilious,  and,  finally,  stercoraceous  vomit- 
ing is  perhaps  the  most  important  diagnostic  feature  of  acute  obstruction. 
The  constipation  may  be  absolute,  without  the  discharge  of  either  faeces 


-       INTESTINAL  OBSTRUCTION.  535 

or  gas.  Very  often  the  contents  of  the  bowel  below  the  stricture  are  dis- 
charged. Distention  of  the  abdomen  usually  occurs,  and  when  the  large 
bowel  is  involved  it  is  extreme.  On  the  other  hand,  if  the  obstruction  is 
high  up  in  the  small  intestine,  there  may  be  very  slight  tympany.  At 
first  the  abdomen  is  not  painful,  but  subsequently  it  may  become  acutely 
tender. 

The  constitutional  symptoms  from  the  outset  are  severe.  The  face  is 
pallid  and  anxious,  and  finally  collapse  symptoms  supervene.  The  eyes 
become  sunken,  the  features  pinched,  and  the  skin  is  covered  with  a  cold, 
clammy  sweat.  The  pulse  becomes  rapid  and  feeble.  There  may  be  no 
fever;  the  axillary  temperature  is  often  subnormal.  The  tongue  is  dry 
and  parched  and  the  thirst  is  incessant.  The  urine  is  high-colored,  scanty, 
and  there  may  be  suppression,  particularly  when  the  obstruction  is  high 
up  in  the  bowel.  This  is  probably  due  to  the  constant  vomiting  and  the 
small  amount  of  liquid  which  is  absorbed.  The  case  terminates  as  a  rule 
in  from  three  to  six  days.  In  some  instances  the  patient  dies  from  shock 
or  sinks  into  coma.  A  leucocytosis  of  75,000  or  80,000  per  c.  mm.  may  be 
present. 

(b)  Symptoms  of  Chronic  Obstruction. — When  due  to  faecal  impaction, 
there  is  a  history  of  long-standing  constipation.  There  may  have  been 
discharge  of  mucus,  or  in  some  instances  the  fgecal  masses  have  been  chan- 
neled, and  so  have  allowed  the  contents  of  the  upper  portion  of  the  bowel 
to  pass  through.  In  elderly  persons  this  is  not  infrequent;  but  examina- 
tion, either  per  rectum  or  externally,  in  the  course  of  the  colon,  will  reveal 
the  presence  of  hard  scybalous  masses.  There  may  be  retention  of  faeces 
for  weeks  without  exciting  serious  symptoms.  In  other  instances  there  are 
vomiting,  pain  in  the  abdomen,  gradual  distention,  and  finally  the  ejecta 
become  faecal.  The  hardened  masses  may  excite  an  intense  colitis  or  even 
peritonitis. 

In  stricture,  whether  cicatricial  or  cancerous,  the  symptoms  of  obstruc- 
tion are  very  diverse.  Constipation  gradually  comes  on,  is  extremely  vari- 
able, and  it  may  be  months  or  even  years  before  there  is  complete  obstruc- 
tion. There  are  transient  attacks,  in  which  from  some  cause  the  fasces 
accumulate  above  the  stricture,  the  intestine  becomes  greatly  distended, 
and  in  the  swollen  abdomen  the  coils  can  be  seen  in  active  peristalsis.  In 
such  attacks  there  may  be  vomiting,  but  it  is  very  rarely  of  a  faecal  charac- 
ter. In  the  majority  of  these  cases  the  general  health  is  seriously  im- 
paired; the  patient  gradually  becomes  anaemic  and  emaciated,  and  finally, 
in  an  attack  in  which  the  obstruction  is  complete,  death  occurs  with  all 
the  features  of  acute  occlusion  or  the  case  may  be  prolonged  for  ten  or 
twelve  days. 

Diagnosis.— («)  The  Situation  of  the  Obstruction. — Hernia  must 
be  excluded,  which  is  by  no  means  always  easy,  as  fatal  obstruction  may 
occur  from  the  involvement  of  a  very  limited  portion  of  the  gut  in  the 
external  ring  or  in  the  obturator  foramen.  Mistakes  from  both  of  these 
causes  have  come  unrler  my  observation;  they  were  cases  in  which  it  was 
impossible  to  make  a  fliagnosis  other  than  acute  obstruction.  Timely  op- 
eration would  have  saved  both  lives.  A  thorough  rectal  aud,  in  women,  a 
vaginal  examination  should  be  made,  which  will  give  important  information 


536  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

as  to  the  condition  of  the  pelvic  and  rectal  contents,  particularly  in  cases  of 
intussusception,  in  which  the  descending  bowel  can  sometimes  be  felt.  In 
cases  of  obstruction  high  up  the  empty  coils  sink  into  the  pelvis  and  can 
there  be  detected.  Rectal  exploration  with  the  entire  hand  is  of  doubtful 
value.  In  the  inspection  of  the  abdomen  there  are  important  indications,  as 
the  special  prominence  in  certain  regions,  the  occurrence  of  indefinite,  Avell- 
defined  masses,  and  the  presence  of  hypertrophied  coils  in  active  peristalsis. 
John  Wyllie  has  recently  called  attention  to  the  great  value  in  diagnosis  of 
the  "  patterns  of  abdominal  tumidity."  *  In  obstruction  of  the  lower  end 
of  the  large  intestine  not  only  may  the  horseshoe  of  the  colon  stand  out 
plainly,  when  the  bowel  is  in  rigid  spasm,  but  even  the  pouches  of  the  gut 
may  be  seen.  When  the  csecum  or  lower  end  of  the  ileum  is  obstructed 
the  tumidity  is  in  the  lower  central  region,  and  during  spasm  the  coils  of 
the  small  bowel  may  stand  out  prominently,  one  above  the  other,  either 
obliquely  or  transversely  placed — the  so-called  "  ladder  pattern."  In  ob- 
struction of  the  duodenum  or  Jejunum  there  may  only  be  slight  distention 
of  the  upper  part  of  the  abdomen,  associated  usually  with  rapid  collapse 
and  anuria. 

In  the  ileum  and  csecum  the  distention  is  more  in  the  central  portion 
of  the  abdomen;  the  vomiting  is  distinctly  fgecal  and  occurs  early.  In 
obstruction  of  the  colon,  tympanites  is  much  more  extensive  and  general. 
Tenesmus  is  more  common,  with  the  passage  of  mucus  and  blood.  The 
course  is  not  so  quick,  the  collapse  does  not  supervene  so  rapidly,  and  the 
urinary  secretion  is  not  so  much  reduced. 

In  obstruction  from  stricture  or  tumor  the  situation  can  in  some  cases 
be  accurately  localized,  but  in  others  it  is  very  uncertain.  Digital  examina- 
tion of  the  rectum  should  first  be  made.  The  rectal  tube  may  then  be 
passed,  but  it  is  impossible  to  get  beyond  the  sigmoid  flexure.  In  the  use 
of  the  rigid  tube  there  is  danger  of  perforation  of  the  bowel  in  the  neigh- 
borhood of  a  stricture.  The  quantity  of  fluid  which  can  be  passed  into 
the  large  intestine  should  be  estimated.  The  capacity  of  the  large  bowel  is 
about  six  quarts.  Wiggin  advises  about  a  pint  and  a  half  from  a  height  of 
three  feet  for  an  infant.  To  thoroughly  irrigate  the  bowel  the  patient 
should  be  chloroformed  and  should  lie  on  the  back  or  on  the  side — best  on 
the  back,  with  the  hips  elevated.  Treves  suggests  that  the  c^ecal  region 
should  be  auscultated  during  the  passage  of  the  fluid.  For  diagnostic  pur- 
poses the  rectum  may  be  inflated,  either  by  the  bellows  or  by  the  use  of 
bicarbonate  of  soda  and  tartaric  acid.  In  certain  cases  these  measures  give 
important  indications  as  to  the  situation  of  the  obstruction  in  the  large 
bowel. 

(h)  Nature  of  the  Obstruction. — This  is  often  difficult,  not  infrequently 
impossible,  to  determine.  Strangulation  is  not  common  in  very  early  life. 
In  many  instances  there  have  been  previous  attacks  of  abdominal  pain,  or 
there  are  etiological  factors  which  give  a  clew,  such  as  old  peritonitis  or 
operation  on  the  pelvic  viscera.  Neither  the  onset  nor  the  character  of  the 
pain  gives  us  any  information.     In  rare  instances  nausea  and  vomiting 

*  Edinburgh  Hospital  Reports,  vol.  ii. 


INTESTINAL  OBSTRUCTION.  537 

may  be  absent.  The  vomiting  usually  becomes  fascal  from  the  third  to  the 
fifth  clay.  A  tumor  is  not  common  in  strangulation,  and  was  present  in 
only  one  fifth  of  the  cases.     Fever  is  not  of  diagnostic  value. 

Intussusceplion  is  an  affection  of  childhood,  and  is  of  all  forms  of  in- 
ternal obstruction  the  one  most  readily  diagnosed.  The  presence  of  tumor, 
bloody  stools,  and  tenesmus  are  the  important  factors.  The  tumor  is 
usually  sausage-shaped  and  felt  in  the  region  of  the  transverse  colon.  It 
existed  in  66  of  93  cases.  It  was  present  on  the  first  day  in  more  than  one 
third  of  the  cases,  on  the  second  day  in  more  than  one  fourth,  and  on  the 
third  day  in  more  than  one  fifth.  Blood  in  the  stools  occurs  in  at  least 
three  fifths  of  the  cases,  either  spontaneously  or  following  the  use  of  an 
enema.  The  blood  may  be  mixed  with  mucus.  Tenesmus  is  present  in 
one  third  of  the  cases.  Fsecal  vomiting  is  not  very  common  and  was  pres- 
ent in  only  13  of  the  93  instances.  Abdominal  tympany  is  a  symptom  of 
slight  importance,  occurring  in  only  one  third  of  the  cases. 

Volvulus  can  rarely  be  diagnosed.  The  frequency  with  which  it  in- 
volves the  sigmoid  flexure  is  to  be  borne  in  mind.  The  passage  of  a  flex- 
ible tube  or  injecting  fluids  might  in  these  cases  give  valuable  indica- 
tions. An  absolute  diagnosis  can  probably  be  made  only  by  an -abdominal 
section. 

In  f cecal  obstruction  the  condition  is  usually  clear,  as  the  faeces  can  be 
felt  per  rectum  and  also  in  the  distended  colon.  Fsecal  vomiting,  tym- 
pany, abdominal  pain,  nausea,  and  vomiting  are  late  and  are  not  so  con- 
stant. In  obstruction  by  gall-stone  a  few  of  the  cases  gave  a  previous  his- 
tory of  gall-stone  colic.  Jaundice  was  present  in  only  2  of  the  23  cases. 
Pain  and  vomiting,  as  a  rule,  occur  early  and  are  severe,  and  fsecal  vomit- 
ing is  present  in  two  thirds  of  the  cases.     A  tumor  is  rarely  evident. 

(c)  Diagnosis  from  other  Conditions. — Acute  enteritis  with  great  re- 
laxation of  the  intestinal  coils,  vomiting,  and  pain  may  be  mistaken  for 
obstruction.  In  an  autopsy  on  a  case  of  this  kind  the  small  and  large 
bowels  were  intensely  inflamed,  relaxed,  sodden,  and  enormously  distended. 
The  symptoms  were  those  of  acute  obstruction,  but  the  intestine  was  free 
from  duodenum  to  rectum.  Of  late  years  many  instances  have  been  re- 
ported in  which  peritonitis  following  disease  of  the  appendix  has  been 
mistaken  for  acute  obstruction.  The  intense  vomiting,  the  general  tym- 
pany and  abdominal  tenderness,  and  in  some  instances  the  suddenness  of 
the  onset  are  very  deceptive,  and  in  two  cases  which  have  come  under  my 
notice  the  symptoms  pointed  very  strongly  to  internal  strangulation.  In 
appendix  disease  the  temperature  is  more  frequently  elevated,  the  vomit- 
ing is  never  fascal,  and  in  many  cases  there  is  a  history  of  previous  attacks 
in  the  caeeal  region.  Acute  lia-morrliagic  pancreatitis  may  produce  symp- 
toms which  simulate  closely  intestinal  obstruction.  A  boy  was  admitted 
to  the  Johns  Hopkins  Hospital  with  a  history  of  obstinate  vomiting,  in- 
tense abdominal  pain,  gradually  increasing  tympany,  and  no  passage  for 
several  days.  His  condition  seemed  serious  and  lie  was  transferred  at  once 
to  the  surgical  wards.  At  the  operation  the  coils  were  found  uniformly 
distended  and  covered  in  places  with  the  thinnest  film  of  lymph.  No  ob- 
struction existed,  but  there  was  a  tumor-like  mass  surrounding  the  pan- 


538  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

creas,  firm,  hard,  and  deeply  infiltrated  with  blood.     The  patient  improved 
after  the  operation  and  recovered  completely. 

Treatment. — Purgatives  should  not  be  given.  For  the  pain  hypo- 
dermic injections  of  morphia  are  indicated.  To  allay  the  distressing  vomit- 
ing, the  stomach  should  be  washed  out.  Not  only  is  this  directly  beneficial, 
but  Kussmaul  claims  that  the  abdominal  distention  is  relieved,  the  pres- 
sure in  the  bowel  above  the  seat  of  obstruction  is  lessened,  and  the  violent 
peristalsis  is  diminished.  It  may  be  practised  three  or  four  times  a  day, 
and  in  some  instances  has  proved  beneficial;  in  others  curative.  Thor- 
ough irrigation  of  the  large  bowel  with  injections  should  be  practised,  the 
warm  fluid  being  allowed  to  flow  in  from  a  fountain  syringe,  and  the 
amount  carefully  estimated.  Jonathan  Hutchinson  recommends  that  the 
patient  be  placed  under  an  anaesthetic,  the  abdomen  thoroughly  kneaded, 
and  a  copious  enema  given  while  in  the  inverted  position.  Then,  with  the 
aid  of  three  or  four  strong  men,  the  patient  is  to  be  thoroughly  shaken, 
first  with  the  abdomen  held  downward,  and  subsequently  in  the  inverted 
position. 

Inflation  may  also  be  tried,  by  forcing  the  air  into  the  rectum  with  the 
bellows  or  with  a  Davidson's  syringe.  It  is  a  measure  not  without  risk, 
as  instances  of  rupture  of  the  bowel  have  been  reported.  Fitz's  figures 
show  that  in  the  first  eight  years  of  the  last  decade  there  were  33  cases  of 
recovery  after  injection  or  inflation  in  cases  of  certain  or  probable  intussus- 
ception, and  11  deaths.  Of  39  cases  in  children  treated  by  inflation  or  ene- 
mata  16  recovered  (Wiggin).  In  cases  of  acute  obstruction,  if  these  means 
do  not  prove  successful  by  the  third  day,  surgical  measures  should  be  re- 
sorted to,  and  when  the  obstruction  seems  persistent  and  the  condition 
serious,  laparotomy  should  be  performed  at  once.  Of  64  cases  in  which 
laparotomy  was  performed,  21  recovered.  The  youngest  case  operated  upon 
was  only  three  days  old. 

For  the  tympanites  turpentine  stupes  and  hot  applications  may  be  ap- 
plied; if  extreme,  the  bowel  may  be  punctured  with  a  small  aspirator  needle. 
In  cases  of  chronic  obstruction  the  diet  must  be  carefully  regulated,  and 
opium  and  belladonna  are  useful  for  the  paroxysmal  pains.  Enemata 
should  be  employed,  and  if  the  obstruction  becomes  complete,  resort  must 
be  had  to  surgical  measures. 


IV.     CONSTIPATION  (Costiveness). 

Definition. — Eetention  of  faces  from  any  cause. 

Constipation  in  Adults. — The  causes  are  varied  and  may  be  classed  as 
general  and  local. 

General  Causes. — (a)  Constitutional  peculiarities:  Torpidity  of  the 
bowels  is  often  a  family  complaint  and  is  found  more  often  in  dark  than 
in  fair  persons,  (b)  Sedentary  habits,  particularly  in  persons  who  eat  too 
much  and  neglect  the  calls  of  nature,  (c)  Certain  diseases,  such  as  anae- 
mia, neurasthenia  and  hysteria,  chronic  affections  of  the  liver,  stomach, 
and  intestines,  and  the  acute  fevers.     Under  this  heading  may  appropri- 


CONSTIPATION.  539 

ately  be  placed  that  most  injurious  of  all  habits,  drug-tahing.  (d)  Either 
a  coarse  diet,  which  leaves  too  much  residue,  or  a  diet  which  leaves  too 
little,  may  be  a  cause  of  eostiveness. 

Local  Causes. — Weakness  of  the  abdominal  muscles  in  obesity  or  from 
overdistention  in  repeated  pregnancies.  Atony  of  the  large  bowel  from 
chronic  disease  of  the  mucosa;  the  presence  of  tumors,  physiological  or 
pathological,  pressing  upon  the  bowel;  enteritis;  foreign  bodies,  large 
masses  of  scybala,  and  strictures  of  all  kinds.  An  important  local  'cause 
is  atony  of  the  colon,  particularly  of  the  muscles  of  the  sigmoid  flexure  by 
which  the  fseces  are  propelled  into  the  rectum.  By  far  the  most  obstinate 
form  is  that  associated  with  a  contracted  state  of  the  bowel,  which  is 
sometimes  spoken  of  as  spasmodic  constipation.  This  may  be  met  with 
in  three  conditions:  First,  as  a  sequence  of  chronic  dysentery  or  ulcerative 
colitis;  secondly,  in  protracted  cases  of  hysteria  and  neurasthenia  in  women, 
particularly  in  association  with  uterine  disease;  and,  thirdly,  in  very  old 
persons  often  without  any  definite  cause.  It  may  be  that  the  sigmoid 
flexure  and  lower  colon  are  in  a  condition  of  contraction  and  spasm,  while 
the  transverse  and  ascending  parts  are  in  a  state  of  atony  and  dilatation. 
The  most  characteristic  sign  of  this  variety  is  the  presence  of  hard,  globular 
masses,  or  more  rarely  small  and  sausage-like  fseces. 

Symptoms. — The  most  persistent  constipation  for  weeks  or  even 
months  may  exist  with  fair  health.  All  kinds  of  evils  have  been  attributed 
to  poisoning  by  the  resorption  of  noxious  matters  from  the  retained  fteces 
— coprsemia — but  it  is  not  likely  that  this  takes  place  to  any  extent.  Chlo- 
rosis, which  Sir  Andrew  Clark  attributes  to  fsecal  poisoning,  is  not  always 
associated  with  constipation,  and  if  due  to  this  cause  should  be  in  men, 
women,  and  children  the  most  common  of  all  disorders.  Debility,  lassi- 
tude, ^nd  a  mental  depression  are  frequent  symptoms  in  constipation, 
particularly  in  persons  of  a  nervous  temperament.  Headache,  loss  of  appe- 
tite, and  a  furred  tongue  may  also  occur.  Individuals  differ  extraordina- 
rily in  this  matter:  one  feels  wretched  all  day  without  the  accustomed 
evacuation;  another  is  comfortable  all  the  week  except  on  the  day  on 
which  by  purge  or  enema  the  bowels  are  relieved. 

"When  persistent,  the  accumulation  of  faeces  leads  to  unpleasant,  some- 
times serious  symptoms,  such  as  piles,  ulceration  of  the  colon,  distention 
of  the  sacculi,  perforation,  enteritis,  and  occlusion.  In  women,  pressure 
may  cause  pain  at  the  time  of  menstruation  and  a  sensation  of  fulness  and 
distention  in  the  pelvic  organs.  Neuralgia  of  the  sacral  nerves  may  be 
caused  by  an  overloaded  sigmoid  flexure.  The  fasces  collect  chiefly  in  the 
colon.  Even  in  extreme  grades  of  constipation  it  is  rare  to  find  dry  fasces 
in  the  caecum.  The  fseces  may  form  large  tumors  at  the  hepatic  or  splenic 
flexures,  or  a  sausage-like,  doughy  mass  above  the  navel,  or  an  irregular 
lumpy  tumor  in  the  left  inguinal  region.  In  old  persons  the  sacculi  of  the 
colon  become  distended  and  the  scybala  may  remain  in  them  and  undergo 
calcification,  forming  enteroliths. 

In  cases  with  prolonged  retention  the  faecal  masses  become  channelled 
and  diarrhoea  may  occur  for  days  before  the  true  condition  is  discovered 
by  rectal  or  external  examination.     In  women  who  have  been  habitually 


540  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

constipated;,  attacks  of  diarrlicea  with  nausea  and  vomiting  should  excite 
suspicion  and  lead  to  a  thorough  examination  of  the  large  'bowpt  Fever 
may  occur  in  these  cases,  and  Meigs  has  reported  an  instance  m  which 
the  condition  simulated  typhoid  fever. 

Constipation  in  infants  is  a  common  and  troublesome  disorder.  The 
causes  are  congenital,  dietetic,  and  local.  There  are  instances  in  which 
the  child  is  constipated  from  birth  and  may  not  have  a  natural  movement 
for  years  and  yet  thrive  and  develop.  An  instance  of  the  kind  was  in  my 
ward  recently  in  which  a  baby  of  seven  months  had  never  had  a  movement 
without  preliminary  injections.  The  abdomen  became  swollen  every  day, 
but  subsided  after  an  injection  and  the  passage  of  a  long  catheter.  No 
stricture  could  be  felt.  There  are  cases  of  enormous  dilatation  of  the  large 
bowel  with  persistent  constipation.  The  condition  appears  sometimes  to 
be  a  congenital  defect.  In  some  of  these  patients  there  may  be  constricting 
bands,  or,  as  in  a  case  of  Cheever's,  a  congenital  stricture. 

Dietetic  causes  are  more  common.  In  sucklings  it  often  arises  from 
an  unnatural  dryness  of  the  small  residue  which  passes  into  the  colon,  and 
it  may  be  very  dilfieult  to  decide  whether  the  fault  is  in  the  mother's  milk 
or  in  the  digestion  of  the  child.  Most  probably  it  is  in  the  latter,  as  some 
babies  may  be  persistently  costive  on  natural  or  artificial  foods.  Defi- 
ciency of  fat  in  the  milk  is  believed  by  some  writers  to  be  the  cause.  In 
older  children  it  is  of  the  greatest  importance  that  regular  habits  should 
be  enjoined.  Carelessness  on  the  part  of  the  mother  in  this  matter  often 
lays  the  foundation  of  troublesome  constipation  in  after  life.  Impairment 
of  the  contractility  of  the  intestinal  wall  in  consequence  of  inflammation, 
disturbance  in  the  normal  intestinal  secretions,  and  mechanical  obstruc- 
tion by  tumors,  twists,  and  intussusception  are  the  chief  local  causes. 

Treatment. — Much  may  be  done  by  systematic  habits,  particularly 
in  the  young.  The  desire  to  go  to  stool  should  always  be  granted.  Exer- 
cise in  moderation  is  helpful.  In  stout  persons  and  in  women  with  pend- 
ulous abdomens  the  muscles  should  have  the  support  of  a  bandage.  Fric- 
tion or  regularly  applied  massage  is  invaluable  in  the  more  chronic  cases. 
A  good  substitute  is  a  metal  ball  weighing  from  four  to  six  pounds,  which 
may  be  rolled  over  the  abdomen  every  morning  for  five  or  ten  minutes. 
The  diet  should  be  light,  with  plenty  of  fruit  and  vegetables,  particularly 
salads  and  tomatoes.  Oatmeal  is  usually  laxative,  though  not  to  all;  brown 
bread  is  better  than  that  made  from  fine  white  flour.  Of  liquids,  water 
and  aerated  mineral  waters  may  be  taken  freely.  A  tumblerful  of  cold 
water  on  rising,  taken  slowly,  is  efficacious  in  many  cases.  A  glass  of  hot 
water  at  night  may  also  be  tried  alone.  A  pipe  or  a  cigar  after  breakfast 
is  with  many  men  an  infallible  remedy. 

Wlien  the  condition  is  not  very  obstinate  it  is  well  to  try  to  relieve  it 
by  hygienic  and  dietetic  measures.  If  drugs  must  be  used  they  should  be 
the  milder  saline  laxatives  or  the  compound  liquorice  powder.  Enemata 
are  often  necessary,  and  it  is  much  preferable  to  employ  them  early  than 
to  constantly  use  purgative  pills.  Glycerin  either  in  the  form  of  sup- 
pository or  as  a  small  injection  is  very  vahiable.  Half  a  drachm  of  boric 
acid  placed  within  the  rectum  is  sometimes  efficacious.     The  injections  of 


ENTEROPTOSIS.  541 

tepid  water,  with  or  without  soap,  may  be  used  for  a  prolonged  period  with 
good  ejffect  and  without  damage.  The  patient  should  be  in  the  dorsal 
position  with  the  hips  elevated,  and  it  is  best  to  let  the  fluid  flow  in  slowly 
from  a  fountain  syringe. 

The  usual  remedies  employed  are  often  useless  in  the  constipation  asso- 
ciated with  contracted  bowel.  A  very  satisfactory  measure  is  the  olive-oil 
injection  as  recommended  by  Kussmaul.  The  patient  lies  on  the  back  with 
the  hips  elevated,  and  with  a  cannula  and  tube  from  15  to  20  ounces 
of  pure  oil  are  allowed  to  flow  slowly  (or  are  injected)  into  the  bowel.  The 
operation  should  take  at  least  fifteen  minutes.  This  may  be  repeated  every 
day  until  the  intestine  is  cleared,  and  subsequently  a  gmaller  injection  every 
few  days  will  suffice. 

There  are  various  drugs  which  are  of  special  service,  particularly  the 
combination  of  ipecacuanha,  nux  vomica,  or  belladonna,  with  aloes,  rhu- 
barb, colocynthj  or  podophyllin.  Meigs  recommends  particularly  the  com- 
bination of  extract  of  belladonna  (gr.  -^-^),  extract  of  nux  vomica  (gr.  \), 
and  extract  of  colocynth  (gr.  ij),  one  pill  to  be  taken  three  times  a  day. 
In  anaemia  and  chlorosis,  a  sulphur  confection  taken  in  the  morning, 
and  a  pill  of  iron,  rhubarb,  and  aloes  throughout  the  day,  are  very  service- 
able. 

In  children  the  indications  should  be  met,  as  far  as  possible,  by  hygienic 
and  dietetic  measures.  In  the  constipation  of  sucklings  a  change  in  the 
diet  of  the  mother  may  be  tried,  or  from  one  to  three  teaspoonfuls  of  cream 
may  be  given  before  each  nursing.  In  artificially  fed  children  the  top 
milk  with  the  cream  should  be  used.  Drinking  of  water,  barley  water,  or 
oatmeal  water  will  sometimes  obviate  the  difiiculty.  If  laxatives  are  re- 
quired, simple  syrup,  manna,  or  olive  oil  may  be  sufficient.  The  conical 
piece  of  soap,  so  often  seen  in  nurseries,  is  sometimes  efficacious.  Massage 
along  the  colon  may  be  tried.  Small  injections  of  cold  water  may  be  used. 
Large  injections  should  be  avoided,  if  possible.  If  it  is  necessary  to  give 
a  laxative  by  the  mouth,  castor  oil  or  the  fluid  magnesia  is  the  best.  If 
there  are  signs  of  gastro-intestinal  irritation,  rhubarb  and  soda  or  gray 
powder  may  be  given.  In  older  children  the  diet  should  be  carefully 
regulated. 

V.     ENTEROPTOSIS  (Glenard's  Disease). 

Definition. — "  Dropping  of  the  viscera,"  visceroptosis,  is  not  a  disease, 
but  a  symptom  group  characterized  by  looseness  of  the  mesenteric  and  peri- 
toneal attachments,  so  that  the  stomach,  the  intestines,  particularly  the 
transverse  colon,  the  liver,  the  kidneys,  and  the  spleen  occupy  an  abnor- 
mally low  position  in  the  abdominal  cavity. 

Symptoms  and  Physical  Signs. — It  is  important  to  recognize  two 
groups  of  cases.  In  one  the  splanchnoptosis  follows  the  loss  of  normal  sup- 
port of  the  abdominal  wall  in  consequence  of  repeated  pregnancies  or  re- 
curring ascites.  Tbe  condition  may  be  extreme  without  the  slightest  dis- 
tress on  the  part  of  the  patient. 

The  second  and  more  important  group  occurs  usually  in  young  persons. 


542  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

who  present,  with  splanchnoptosis;,  the  features  of  more  or  less  marked  neu- 
rasthenia. 

In  the  first  group  inspection  of  the  abdomen  shows  a  very  relaxed  ab- 
dominal wall,  and  as  a  rule  the  linese  albicantes  of  recurring  pregnancies. 
Peristalsis  of  the  intestines  may  be  seen,  and  in  extreme  cases  the  outlines  of 
the  stomach  itself  with  its  waves  of  peristalsis.  On  inflating  the  stomach 
with  carbonic-acid  gas  the  organ  stands  out  with  great  prominence,  and 
the  lesser  and  greater  curvatures  are  seen,  the  latter  extending  perhaps  a 
hand^s  breadth  below  the  level  of  the  navel.  The  waves  of  peristalsis  are 
feeble  and  without  the  vigor  and  force  of  those  seen  in  the  stomach  dilated 
from  stricture  of  the  pylorus.  The  condition  of  descensus  ventriculi  with 
atony  is  best  studied  in  this  group  of  cases.  An  important  point  to  remem- 
ber is  that  it  may  exist  in  an  extreme  grade  without  symptoms. 

In  the  other  group  is  embraced  a  somewhat  motley  series  of  cases,  in 
which,  with  a  pronounced  nervous,  or,  as  we  call  it  now,  neurasthenic  basis, 
there  are  displacements  of  the  viscera  with  symptoms.  The  patients  are 
usually  young,  more  frequently  women  than  men,  and  of  spare  habit.  The 
condition  may  follow  an  acute  illness  with  wasting.  They  complain,  as  a 
rule,  of  dyspepsia,  throbbing  in  the  abdomen,  and  dragging  pains  or  weak- 
ness in  the  back,  and  inability  to  perform  the  usual  duties  of  life.  A  very 
considerable  proportion  of  all  the  cases  of  neurasthenia  present  the  local 
features  of  enteroptosis.  When  preparing  for  the  examination  one  notices 
usually  an  erythematous  flushing  of  the  skin;  the  scratch  of  the  nail  is  fol- 
lowed instantly  by  a  line  of  hypersemia,  less  often  of  marked  pallor.  The 
pulsation  of  the  abdominal  aorta  is  readily  seen. 

On  examination  of  the  viscera  one  flnds  the  following:  The  stomach  is 
below  the  normal  level,  and  in  women  who  have  laced  it  may  be  vertically 
placed.  The  splashing  or  clapotage  is  unusually  distinct.  After  inflation 
with  carbonic-acid  gas  the  outlines  of  the  stomach  are  seen  through  the 
thin  abdominal  walls.  In  extreme  cases  there  may  be  great  dilatation  of 
the  stomach,  in  consequence  of  obstruction  of  the  pylorus  by  pressure  of  the 
displaced  right  kidney. 

Nephroptosis,  or  displacement  of  the  kidney,  is  one  of  the  most  constant 
phenomena  in  enteroptosis.  It  is  well,  perhaps,  to  distinguish  between 
the  kidney  which  one  can  just  touch  on  deep  inspiration — palpable  kidney, 
one  which  is  freely  movable,  and  which  on  deep  inspiration  descends  so  that 
one  can  put  the  fingers  of  the  palpating  hand  above  it  and  hold  it  down, 
and,  thirdly,  a  floating  kidney,  which  is  entirely  outside  the  costal  arch, 
is  easily  grasped  in  the  hand,  readily  moved  to  the  middle  line,  and  low 
down  toward  the  right  iliac  fossa.  It  is  held  by  some  that  the  designa- 
tion floating  kidney  should  be  restricted  to  the  cases  in  which  there  is  a 
meso-nephron,  but  this  is  excessively  rare,  while  extreme  grades  of  renal 
mobility  are  common.  Some  of  the  more  serious  sequences  of  movable 
kidney,  namely,  DietFs  crises  and  intermittent  hydronephrosis,  will  be  con- 
sidered with  diseases  of  the  kidney. 

Displacement  of  the  liver  is  very  much  less  common.  In  thin  women 
who  have  laced  the  organ  is  often  tilted  forward,  so  that  a  very  large  sur- 
face of  the  lobes  comes  in  contact  with  the  abdominal  wall;  it  is  a  very 


ENTEROPTOSIS.  543 

common  mistake  under  these  circumstances  to  think  that  the  organ  is  en- 
larged.    Dislocation  of  the  liver  itself  Mali  be  considered  later. 

Mobility  of  the  spleen  is  sometimes  very  marked  in  enteroptosis.  In 
an  extreme  grade  it  may  be  found  in  almost  any  region  of  the  abdomen.  It 
is  very  frequently  mistaken  for  a  fibroid  or  ovarian  tumor.  A  considerable 
proportion  of  the  cases  come  first  under  the  care  of  the  gynecologist. 

There  is  usually  much  relaxation  of  the  mesentery  and  of  the  peritoneal 
folds  which  support  the  intestines.  The  colon  is  displaced  downward  (co- 
loptosis),  with  consequent  kinking  at  the  flexures.  The  descent  may  be  so 
low  that  the  transverse  colon  is  at  the  brim  of  the  pelvis.  It  may  indeed 
be  fixed  or  bent  in  the  form  of  a  V.  It  is  frequently  to  be  felt,  as  Glenard 
states,  as  a  firm  cord  crossing  the  abdomen  at  or  below  the  level  of  the 
navel.  This  kinking  may  take  place  not  only  in  the  colon,  but  at  the 
pylorus,  where  the  duodenum  passes  into  the  jejunum,  and  where  the  ileum 
enters  the  caecum. 

The  explanation  of  the  phenomena  accompanying  enteroptosis  is  by  no 
means  easy.  It  has  been  suggested  by  Glenard  and  others  that  the  vascular 
disturbances  in  the  abdominal  viscera  in  consequence  of  displacements 
and  kinking  account  for  the  feelings  of  exhaustion  and  general  nervous- 
ness. In  a  large  proportion  of  the  cases,  however,  no  symptoms  develop 
until  after  an  illness  or  some  protracted  nervous  strain. 

Treatment. — In  a  majority- of  all  cases  four  indications  are  present: 
To  treat  the  existing  neurasthenia,  to  relieve  the  aervous  dyspepsia,  to 
overcome  the  constipation,  and  to  afford  mechanical  support  to  the  organs. 
Three  of  these  are  considered  under  their  appropriate  sections.  In  cases  in 
which  the  enteroptosis  has  followed  loss  in  weight  after  an  acute  illness  or 
worries  and  cares,  an  important  indication  is  to  fatten  the  patient. 

A  well  adapted  abdominal  bandage  is  one  of  the  most  important  meas- 
ures in  enteroptosis.  In  many  of  the  milder  grades  it  alone  suffices.  I 
know  of  no  single  simple  measure  which  affords  relief  to  distressing  symp- 
toms in  so  many  cases  as  the  abdominal  bandage.  It  is  best  made  of  linen, 
should  fit  snugly,  and  should  be  arranged  with  straps  so  that  it  cannot  ride 
up  over  the  hips.  A  special  form  must  be  used,  as  will  be  mentioned  later, 
for  movable  kidney.  Some  of  the  more  aggravated  types  of  enteroptosis  are 
combined  with  such  features  of  neurasthenia  that  a  rigid  Weir  Mitchell 
treatment  is  indicated.  In  a  few  very  refractory  cases  surgical  interference 
may  be  called  for.  Treves,  in  Allbutt's  System,  records  two  cases,  one  in 
which  the  laparotomy  was  resorted  to  as  a  medical  measure  with  perfect 
results.  In  the  other  the  liver  was  stitched  in  place,  and  complete  recovery 
followed. 

And  lastly,  the  physician  must  be  careful  in  dealing  with  the  subjects 
of  enteroptosis  not  to  lay  too  much  stress  on  the  disorder.  It  is  well  never 
to  tell  the  patient  that  a  kidney  is  movable;  the  symptoms  may  date  from 
a  knowledge  of  the  existence  of  the  condition. 


34 


544  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

VI.    MISCELLANEOUS  AFFECTIONS. 

I.    MUCOUS  COLITIS. 

This  affection  is  known  by  various  names,  snch  as  membranous  enteritis, 
tubular  diarrlicea,  and  mucous  colic.  It  is  a  remarkable  disease,  to  wbich 
mneh  attention  has  been  paid  for  several  centuries.  An  exhaustive  de- 
scription of  it  is  given  by  Woodward,  in  vol.  ,ii  of  the  Medical  and  Surgical 
Eeports  of  the  Civil  War.  It  is  an  affection  of  the  large  bowel,  character- 
ized by  the  production  of  a  very  tenacious  adherent  mucus,  which  may  be 
passed  in  long  strings  or  as  a  continuous,  tubular  membrane.  I  have  twice 
had  opportunities  of  seeing  this  membrane  in  situ,  closely  adherent  to  the 
mucosa  of  the  colon,  but  capable  of  separation  without  any  lesion  of  the- 
surface.  Judging  from  the  statement  of  English  authors  as  to  its  rarity, 
it  would  appear  to  be  a  more  frequent  disease  in  this  country,  in  which  it 
has  been  carefully  studied  by  Da  Costa,  Edwards,  and  others.  According 
to  Edwards,  80  per  cent  of  the  recorded  adult  cases  have  been  in  women. 
It  occurs  occasionally  in  children.  Of  111  cases  6  were  under  the  age  of 
ten.  The  cases  are  almost  invariably  seen  in  nervous  or  hysterical  women 
or  in  men  with  neurasthenia.  All  grades  of  the  affection  occur,  from  the 
passage  of  a  slimy  mucus,  like  frog-sjoawn,  to  large  tubular  casts  a  foot  or 
more  in  length.  Microscopically  the  casts  are,  as  shown  by  Sir  Andrew 
Clark,  not  fibrinous,  but  mucoid,  and  even  the  firmest  consist  of  dense, 
opaque,  transformed  mucus.  The  disease  is  a  secretion  neurosis  of  the 
colon.  There  are  two  groups  of  cases:  (1)  neurotic  and  hysterical,  in 
men  and  women;  (2)  eases  due  to  local,  uterine,  tubal,  and  ovarian  trouble. 

Symptoms. — The  disease  persists  for  years,  varying  extremely  from 
time  to  time,  and  is  characterized  by  paroxysms  of  pain  in  the  abdomen, 
tenderness,  occasionally  tenesmus,  and  the  passage  of  flakes  or  long  strings 
of  mucus,  sometimes  of  definite  casts  of  the  bowel.  There  is  frequently 
a  spot  of  great  tenderness  just  between  the  navel  and  the  left  costal  border. 
The  attacks  last  for  a  day  or,  in  some  instances,  for  ten  days  or  two  weeks. 
Mental  emotions  and  worry  of  any  sort  seem  particularly  apt  to  bring  on 
an  attack.  Occasionally  errors  in  diet  or  dyspepsia  precede  an  outbreak. 
Membranes  are  not  passed  with  every  paroxysm,  even  when  the  pains  and 
cramps  are  severe.  There  are  instances  in  which  the  morphia  habit  has 
been  contracted  on  account  of  the  severity  of  the  pain.  There  may  be 
marked  nervous  symptoms,  and  authors  mention  hysterical  outbreaks,  hypo- 
chondriasis, and  melancholia.  Blood  may  be  passed  in  rare  instances.  The 
condition  may  persist  for  years  and  lead  to  great  emaciation  and  chronic 
invalidism.  Constipation  is  a  special  feature  in  many  cases.  Herringham 
states  that  he  knew  of  three  cases  of  mucous  colitis  in  which  death  had  sud- 
denly occurred,  in  all  with  great  pain  in  the  left  side  of  the  abdomen.  In 
another  case  there  was  an  abscess  in  the  region  of  the  descending  colon. 

The  diagnosis  is  rarely  doubtful,  but  it  is  important  not  to  mistake  the 
membranes  for  other  substances;  thus,  the  external  cuticle  of  asparagus 
and  undigested  portions  of  meat  or  sausage-skins  sometimes  assume  forms 
not  unlike  mucous  casts,  but  the  microscopical  examination  will  quickly 


.     MISCELLANEOUS  AFFECTIONS.  545 

differentiate  them.     Twice  I  have  known  mucous  colitis  with  severe  pain 
to  be  mistaken  for  appendicitis. 

The  treatment  is  very  unsatisfactory.  Drugs  are  of  doubtful  benefit. 
Measures  directed  to  the  nervous  condition  are  perhaps  most  important. 
Sometimes  local  treatment  with  Kelly's  long  rectal  tubes  is  beneficial. 
Systematic  high  irrigation  of  the  colon  should  be  practiced.  Eight  inguinal 
colotomy  has  been  performed  with  success  in  several  cases  of  great  ob- 
stinacy.   The  artificial  anus  should  remain  open  for  some  time. 

II.    DILATATION  OF  THE  COLON. 

Hale  T\Tiite,  in  Allbutt's  System,  recognizes  four  groups  of  cases. 
In  the  first  the  distention  is  entirely  gaseous,  and  occurs  not  infrequently 
as  a  transient  condition.  In  many  cases  it  has  an  important  infiuence,  inas- 
much as  it  may  be  extreme,  pushing  up  the  diaphragm  and  seriously  im- 
pairing the  action  of  the  heart  and  lungs.  H.  Fenwick  has  called  attention 
to  this  as  occasionally  a  cause  of  sudden  heart-failure. 

In  the  second  group  are  the  cases  in  which  the  distention  of  the  colon 
is  caused  by  solid  substances,  as  faecal  matter,  occasionally  by  foreign  bodies 
introduced  from  without,  and  more  rarely  by  gall-stones. 

In  a  third  group  are  embraced  the  cases  in  which  the  dilatation  is  due 
to  an  organic  obstruction  in  front  of  the  dilated  gut.  Under  these  circum- 
stances the  colon  may  reach  a  very  large  size.  These  cases  are  common 
enough  in  malignant  tumors  and  sometimes  in  volvulus.  Dilatation  of  the 
sigmoid  flexure  occurs  particularly  when  this  portion  of  the  bowel  is  con- 
genitally  very  long.  In  such  cases  the  bowel  may  be  so  distended  that  it 
occupies  the  greater  part  of  the  abdomen,  pushing  up  the  liver  and  the 
diaphragm.  An  acute  condition  is  sometimes  caused  by  a  twist  in  the 
meso-colon. 

Fourthly,  there  are  the  cases  of  so-called  idiopathic  dilatation  of  the 
colon.  The  condition  has  been  very  carefully  studied  by  Eolleston,  C.  F. 
Martin,  and  others.  I  have  had  four  w^ell-marked  instances  under  my  care. 
Treves  suggests  that  the  condition  is  always  due  to  a  narrowing  low  down  in 
the  colon.  This  proved  to  be  true  in  Case  II  of  my  series,  a  boy  who  died 
at  the  age  of  about  two  and  a  half  years.  There  was  a  distinct  stricture  in 
the  sigmoid  flexure.  In  the  idiopathic  chronic  form  the  gut  reaches  an 
enormous  size.  The  coats  may  be  hypertrophied  witbout  evidence  of  any 
special  organic  change  in  the  mucosa.  The  most  remarkable  instance  has 
been  reported  by  Formad.  The  patient,  known  as  the  "  balloon-man,"  aged 
twenty-three  years  at  the  time  of  his  death,  had  had  a  distended  abdomen 
from  infancy.  Post  mortem  the  colon  was  found  as  large  as  that  of  an  ox, 
the  circumference  ranging  from  15  to  30  inches.  The  weight  with  the  con- 
tents was  47  pounds.  The  condition  is  incurable,  and  surgical  interference 
should  be  probably  the  only  measure.  In  one  of  my  cases  good  results  fol- 
lowed the  establishment  of  an  artificial  anus,  but  the  most  brilliant  case 
is  that  reported  recently  by  Treves,  who  excised  the  greater  part  of  the 
colon,  with  recovery. 


546  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

III.    INTESTINAL  SAND. 

"  8aUe  Intestinal." — Biliary  gravel  may  be  passed  in  large  amount,  and 
the  seeds  of  raspberries,  etc.,  may  occur  in  the  faeces  in  extraordinary  num- 
bers; Delepine,  Shattock,  and  others  have  described  in  the  faeces  saburrous 
matter  consisting  of  spheroidal  aggregations  of  vegetable  sclerenchymatous 
cells,  such  as  occur  in  pears.  In  Shattock's  patient  the  discharge  was  in- 
termittent, but  it  could  always  be  brought  away  by  an  aperient.  I  have  re- 
cently seen  a  case  in  which  the  patient  on  two  occasions  passed  a  consider- 
able quantity  of  sand.  The  sample  which  he  brought  consisted  of  small 
grains,  some  of  a  beautiful  garnet  color.  They  proved  to  be  vegetable 
matter. 

IV.    AFFECTIONS  OF  THE  MESENTERY. 

There  are  various  diseases  of  the  structures  embraced  in  the  mesentery, 
which  are  of  more  or  less  importance. 

(1)  HsBinorrliage  (hwrnatoma). — Instances  in  which  the  bleeding  is  con- 
fined to  the  mesenteric  tissues  are  rare;  more  commonly  the  condition  is 
associated  with  hsemorrhagic  infiltration  of  the  pancreas  and  with  retro- 
peritoneal haemorrhage.  It  occurs  in  ruptures  of  aneurisms,  either  of  the 
abdominal  aorta  or  of  the  superior  mesenteric  artery,  in  malignant  forms 
of  the  infectious  fevers,  as  small-pox,  and,  lastly,  in  individuals  in  whom 
no  predisposing  conditions  exist.  In  1887,  at  the  Philadelphia  Hospital, 
there  was  a  patient  in  the  ward  of  my  colleague,  Bruen,  who  had  obscure 
abdominal  symptoms  for  several  days  with  great  pain  and  prostration.  I 
found  at  the  post  mortem  the  greater  portion  of  the  mesentery  and  the 
retro-peritoneal  tissues  infiltrated  with  large  blood-clots.  There  was  no 
disease  of  the  aorta  or  of  the  branches  of  the  coeliac  axis  or  of  the  mesen- 
teric vessels.  Isambard  Owen  has  reported  a  case  of  sudden  death  in  a 
woman  aged  sixty-seven  from  haemorrhage  in  the  transverse  meso-colon. 

(2)  Affections  of  the  Mesenteric  Arteries. — (a)  Aneurism  (see  under 
Arteries). 

(&)  Embolism  and  Thrombosis — Infarction  of  the  Bowel. — When  the 
mesenteric  vessels  are  blocked  by  emboli  or  thrombi  the  condition  of  in- 
farction follows  in  the  territory  supplied.  Probably  the  occlusion  of  small 
vessels  does  not  produce  any  symptoms,  and  the  circulation  may  be  re- 
established. If  the  superior  mesenteric  artery  is  blocked,  a  serious  and  fatal 
condition  follows.  Three  instances  have  come  under  my  observation.  In 
one,  a  woman  aged  fifty-five  was  seized  with  nausea  and  vomiting,  which 
persisted  for  more  than  a  week.  There  was  pain  in  the  abdomen,  tym- 
panites, and  toward  the  close  the  vomiting  was  incessant  and  faecal.  The 
autopsy  showed  great  congestion,  with  swelling  and  infiltration  of  the  Jeju- 
num and  ileum.  The  superior  mesenteric  artery  was  blocked  at  its  orifice 
by  a  firm  thrombus.  In  the  second  case,  a  woman  aged  seventy-five  was 
seized  with  severe  abdominal  pain  and  frequent  vomiting.  At  first  there 
was  diarrhoea;  subsequently  the  symptoms  pointed  to  obstruction,  with 
great  distention  of  the  abdomen.  The  post  mortem  showed  the  small 
bowel,  with  the  exception  of  the  first  foot  of  the  jejunum  and  the  last  six 


MISCELLAJfEOUS  AFFECTIONS.  547 

inches  of  the  ileum,  greatly  distended  and  deeply  infiltrated  with  blood. 
The  mesentery  was  also  congested  and  infiltrated.  The  superior  mesen- 
teric artery  contained  a  firm  brownish-yellow  clot.  There  were  many  re- 
cent warty  vegetations  on  the  mitral  valve.  In  the  third  case,  a  man  aged 
forty  was  suddenly  seized  with  intense  pain  in  the  abdomen,  became  faint, 
fell  to  the  ground,  and  vomited.  For  a  week  he  had  persistent  vomiting, 
severe  diarrhoea,  tympanites,  and  great  pain  in  the  abdomen.  The  stools 
were  thin  and  at  times  blood-tinged.  The  autopsy  showed  an  aneurism 
involving  the  aorta  at  the  diaphragni.  The  superior  mesenteric  artery,  half 
an  inch  from  its  origin  on  the  sac,  was  blocked  by  a  portion  of  the  fibrinous 
clot  of  the  aneurism.  Watson  has  analyzed  the  symptoms  in  27  cases;  in 
18  there  was  pain,  usually  colicky  and  violent;  diarrhoea  occurred  in  14; 
vomiting  in  14;  and  abdominal  distention  in  12.  In  a  majority  of  the 
cases  the  heart  or  the  abdominal  aorta  was  diseased.  In  one  sixth  of  the 
cases  the  lesion  was  limited  enough  to  have  permitted  the  successful  re- 
section of  the  bowel.  J.  W.  Elliot  has  operated  upon  two  cases  of  in- 
farction of  the  bowel,  in  one  of  which  (thrombosis  of  the  mesenteric 
veins)  he  successfully  resected  forty-eight  inches.  In  the  horse,  infarction 
of  the  intestine  is  extremely  common  in  connection  with  the  verminous 
aneurisms  of  the  mesenteric  arteries,  and  is  the  usual  cause  of  colic  in  this 
animal. 

(3)  Diseases  of  the  Mesenteric  Veins. — Dilatation  and  sclerosis  occur  in 
cirrhosis  of  the  liver.  In  instances  of  prolonged  obstruction  there  may 
be  large  saccular  dilatations  with  calcification  of  the  intima,  as  in  a  case  of 
obliteration  of  the  vena  portas  described  by  me.  Suppuration  of  the  mes- 
enteric veins  is  not  rare,  and  occurs  usually  in  connection  with  pylephlebitis. 
The  mesentery  may  be  much  swollen  and  is  like  a  bag  of  pus,  and  it  is  only 
on  careful  dissection  that  one  sees  that  the  pus  is  really  within  channels 
representing  extremely  dilated  mesenteric  veins.  Two  of  the  three  cases 
I  have  seen  were  in  connection  with  local  appendix  abscess. 

(4)  Disorders  of  the  Chyle  Vessels.— Varicose,  cavernous,  and  cystic 
chylangiomata  are  met  with  in  the  mucosa  and  submucosa  of  the  small  in- 
testine, occasionally  of  the  stomach.  Extravasation  of  chyle  into  the  mes- 
enteric tissue  is  sometimes  seen.  Chylous  cysts  are  found.  I  saw  one  the 
size  of  an  egg  at  the  root  of  the  mesentery.  Bramann  records  a  case  in 
a  man  aged  sixty-three,  in  which  a  cyst  of  this  kind  the  size  of  a  child's 
head  was  healed  by  operation.  There  is  an  instance  on  record  of  a  con- 
genital malformation  of  the  thoracic  duct,  in  which  the  receptaculum 
formed  a  flattened  cyst  which  discharged  into  the  peritonaBum,  and  a  chylous 
ascitic  fluid  was  withdrawn  on  several  occasions.  Ilomans,  of  Boston,  re- 
ports an  extraordinary  case  of  a  girl,  who  from  the  third  to  the  thirteenth 
year  had  an  enlarged  abdomen.  Laparotomy  shoM^ed  a  series  of  cysts  con- 
taining clear  fluid.  They  were  supposed  to  be  dilated  lymph  vessels  con- 
nected with  the  intestines. 

(5)  Cyst's  of  the  Mesentery.— IMuch  attention  has  been  directed  of  late 
years  to  the  occurrence  of  mesenteric  cysts,  and  the  literature  which  is 
fully  given  by  Dclmez  (Paris  Thesis,  1891)  is  already  extensive.  They 
may  be  either  dermoid,  hydatid,  serous,  sanguineous,  or  chylous.     They 


548  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

occur  at  any  portion  of  the  mesentery,  and  range  from  a  few  inches  in 
diameter  to  large  masses  occupying  the  entire  abdomen.  They  are  fre- 
quently adherent  to  the  neighboring  organs,  to  the  liver,  spleen,  uterus,  and 
sigmoid  flexure. 

The  symjDtoms  usually  are  those  of  a  progressively  enlarging  tumor  in 
the  abdomen.  Sometimes  a  mass  develops  rapidly,  particularly  in  the 
hsemorrhagic  forms.  Colic  and  constipation  are  present  in  some  cases. 
The  general  health,  as  a  rule,  is  well  maintained  in  spite  of  the  progres- 
sive enlargement  of  the  abdomen,  which  is  most  prominent  in  the  um- 
bilical region.  Mesenteric  cysts  may  persist  for  many  years,  even  ten  or 
twenty. 

The  diagnosis  is  estremely  uncertain,  and  no  single  feature  is  in  any 
way  distinctive.  Augagneur  gives  three  important  signs:  the  great  mo- 
bility, the  situation  in  the  middle  line,  and  the  zone  of  tympany  in  front 
of  the  tumor.  Of  these,  the  second  is  the  only  one  which  is  at  all  con- 
stant, as  when  the  tumors  are  large  the  mobility  disappears,  and  at  this 
stage  the  intestines,  too,  are  pushed  to  one  side.  It  is  most  frequently  mis- 
taken for  ovarian  tumor.  Movable  kidney,  hydronephrosis,  and  cysts  of 
the  omentum  have  also  been  confused  with  it.  In  certain  instances  punc- 
ture may  be  made  for  diagnostic  purposes,  but  it  is  better  to  advise  lapa- 
rotomy for  the  purpose  of  drainage,  or,  if  possible,  enucleation  may  be  prac- 
tised. 


YIII.    DISEASES  OF  THE  LIYEK. 

I.     JAUNDICE  {Icterus). 

Definition. — Jaundice  or  icterus  is  a  condition  characterized  by  col- 
oration of  the  skin,  mucous  membranes,  and  fluids  of  the  body  by  the  bile- 
pigment. 

For  a  full  consideration  of  the  theories  of  jaundice  the  reader  is  referred 
to  William  Hunter's  article  in  Allbutt's  System  of  Medicine.  The  cases 
with  icterus  may  be  divided  into  two  great  groups. 

1.  Obstructive  Jaundice. 

The  following  classiflcation  of  the  causes  of  obstructive  jaundice  is  given 
by  Murchison:  (1)  Obstruction  by  foreign  bodies  within  the  ducts,  as  gall- 
stones and  parasites;  (2)  by  inflammatory  tumefaction  of  the  duodenum  or 
of  the  lining  membrane  of  the  duct;  (3)  by  stricture  or  obliteration  of  the 
duct;  (4)  by  tumors  closing  the  orifice  of  the  duct  or  growing  in  its  inte- 
rior; (5)  by  pressure  on  the  duct  from  without,  as  by  tumors  of  the  liver 
itself,  of  the  stomach,  pancreas,  kidney,  or  omentum;  by  pressure  of  en-' 
larged  glands  in  the  fissures  of  the  liver,  and,  more  rarely,  of  abdominal 
aneurism,  faecal  accumulation,  or  the  pregnant  uterus. 

To  these  causes  some  add  lowering  of  the  blood  pressure  in  the  portal 
system  so  that  the  tension  in  the  smaller  bile-ducts  is  greater  than  in  the 
blood-vessels.     For  this  view,  however,  there  is  no  positive  evidence.     In 


JAUNDICE.  549 

this  class  may  perhaps  be  placed  the  cases  of  jaundice  from  mental  shock 
or  depressed  emotions,  which  "  may  conceivably  cause  spasm  and  reversed 
peristalsis  of  the  bile-duct "  (W.  Hunter). 

General  Symptoms  of  Obstructive  Jaundice. — (1)  Icterus,  or  tinting  of 
the  skin  and  conjunctivse.  The  color  ranges  from  a  lemon-yellow  in  catar- 
rhal Jaundice  to  a  deep  olive-green  or  bronzed  hue  in  permanent  obstruc- 
tion. In  some  instances  the  color  of  the  skin  is  greenish  black,  the  so- 
called  "  black  Jaundice." 

(2)  Of  the  other  cutaneous  symptoms,  pruritus  in  the  more  chronic  forms 
may  be  intense  and  cause  the  greatest  distress.  It  may  precede  the  onset 
of  the  Jaundice,  but  as  a  rule  it  is  not  very  marked  except  in  cases  of  pro- 
longed obstruction.  Sweating  is  common,  and  may  be  curiously  localized 
to  the  abdomen  or  to  the  palms  of  the  hands.  Lichen,  urticaria,  and  boils 
may  develop,  and  the  skin  disease  known  as  xanthelasma  or  vitiligoidea. 
The  Jaundice  may  be  due  to  the  extension  of  the  xanthomata  to  the  bile- 
passages.  The  visceral  localization  of  this  disorder  has  been  chiefly  ob- 
served when  there  are  numerous  punctate  tubercles  on  the  limbs  (Hallo- 
peau).  In  very  chronic  cases  telangiectases  develop  in  the  skin,  sometimes 
in  large  numbers  over  the  body  and  face,  occasionally  on  the  mucous  mem- 
brane of  the  tongue  and  lips,  forming  patches  of  a  bright  red  color  from 
1  to  2  cm.  in  breadth. 

(3)  The  secretions  are  colored  with  bile-pigment.  The  sweat  tinges 
the  linen;  the  tears  and  saliva  and  milk  are  rarely  stained.  The  expectora- 
tion is  not  often  tinted  unless  there  is  inflammation,  as  when  pneumonia 
coexists  with  Jaundice.  The  urine  may  contain  the  pigment  before  it  is 
apparent  in  the  skin  or  conjunctiva.  The  color  varies  from  light  greenish 
yellow  to  a  deep  black-green.  Gmelin's  test  is  made  by  allowing  five  or 
six  drops  of  urine  and  a  similar  amount  of  common  nitric  acid  to  flow 
together  slowly  on  the  flat  surface  of  a  white  plate.  A  play  of  colors  is 
produced — various  shades  of  green,  yellow,  violet,  and  red.  In  cases  of 
Jaundice  of  long  standing  or  great  intensity  the  urine  usually  contains 
albumin  and  always  bile-stained  tube-casts. 

(4)  No  bile  passes  into  the  intestine.  The  stools  therefore  are  of  a 
pale  drab  or  slate-gray  color,  and  usually  very  fetid  and  pasty.  There 
may  be  constipation;  in  many  instances,  owing  to  decomposition,  there  is 
diarrhoea. 

(5)  Slow  pulse.  The  heart's  action  may  fall  to  40,  30,  or  even  to  20 
per  minute.  It  is  particularly  noticeable  in  the  cases  of  catarrhal  Jaundice, 
and  is  not  as  a  rule  an  unfavorable  symptom.  The  respirations  may  fall 
to  10  or  even  to  7  per  minute. 

(G)  Haemorrhage.  The  tendency  to  bleeding  in  chronic  icterus  is  a  se- 
rious feature  in  some  cases.  It  has  been  shown  that  the  blood  coagulation 
time  may  be  much  retarded,  and  instead  of  from  three  minutes  and  a  half 
to  four  minutes  and  a  half  we  have  found  it  in  some  cases  as  late  as  eleven 
or  twelve  minutes.  This  is  a  point  which  should  be  taken  account  of  by 
surgeons,  inasmuch  as  incontrollable  hemorrhage  is  a  well-recognized  acci- 
dent in  operating  upon  patients  with  chronic  obstructive  Jaundice.  Pur- 
pura, large  subcutaneous  extravasations,  more  rarely  htemorrhages  from  the 


550  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

mucous  membranes,  occur  in  protracted  jaundice,  and  in  the  more  severe 
forms. 

(7)  Cerebral  symptoms.  Irritability,  great  depression  of  spirits,  or  even 
melancholia  may  be  present.  In  any  case  of  persistent  jaundice  special 
nervous  phenomena  may  develop  and  rapidly  prove  fatal — such  as  sudden 
coma,  acute  delirium,  or  convulsions.  Usually  the  patient  has  a  rapid 
pulse,  slight  fever,  and  a  dry  tongue,  and  he  passes  into  the  so-called  "  ty- 
phoid state."  These  features  are  not  nearly  so  common  in  obstructive  as 
in  febrile  jaundice,  but  they  not  infrequently  terminate  a  chronic  icterus 
in  whatever  way  produced.  The  group  of  symptoms  has  been  termed 
cholcemia  or,  on  the  supposition  that  cholesterin  is  the  poison,  clwlester- 
cemia;  but  its  true  nature  has  not  yet  been  determined.  In  some  of  the 
cases  the  symptoms  may  be  due  to  uraemia. 

2.  Toxemic  jAUiNTDicE. 

In  this  form  there  is  no  obstruction  in  the  bile-passages,  but  the  jaundice 
is  associated  with  toxic  states  of  the  blood,  dependent  upon  various  poisons 
which  either  act  directly  on  the  blood  itself  or  in  some  cases  on  the  liver- 
cells  as  well.  The  term  hgematogenous  jaundice  was  formerly  applied  to 
this  group  in  contradistinction  to  the  hepatogenous  jaundice,  associated 
with  obstructive  changes  in  the  bile-passages.  Hunter  groups  the  causes 
as  follows: 

1.  Jaundice  produced  by  the  action  of  poisons,  such  as  toluylendiamin, 
phosphorus,  arsenic,  snake-venom. 

2.  Jaundice  met  with  in  various  specific  fevers  and  conditions,  such  as 
yellow  fever,  malaria  (remittent  and  intermittent),  pyaemia,  relapsing  fever, 
typhus,  enteric  fever,  scarlatina. 

3.  Jaundice  met  with  in  various  conditions  of  unknown  but  more  or 
less  obscure  infective  nature,  and  variously  designated  as  epidemic,  infec- 
tious, febrile,  malignant  jaundice,  icterus  gravis,  Weil's  disease,  acute  yel- 
low atrophy. 

The  symptoms  of  toxic  jaundice  are  not  nearly  so  striking  as  in  the  ob- 
structive variety.  The  bile  is  usually  present  in  the  stools,  sometimes  in 
excess,  causing  very  dark  movements.  The  skin  has  in  many  cases  only  a 
light  lemon  tint.  In  the  severer  forms,  as  in  acute  yellow  atrophy,  the 
color  may  be  more  intense,  but  in  malaria  and  pernicious  anemia  the  tint 
is  usually  light.  In  these  mild  cases  the  urine  may  contain  little  or  no  bile- 
pigment,  but  the  urinary  pigments  are  considerably  increased.  In  many 
cases  of  the  toxic  variety  the  constitutional  disturbance  is  very  profound, 
and  there  are  high  fever,  delirium,  convulsions,  suppression  of  urine,  black 
vomit,  and  cutaneous  haemorrhages. 

In  connection  with  the  various  fevers,  malaria,  yellow  fever,  and  "Weil's 
disease  jaundice  has  been  described.  Two  special  affections  may  here  re- 
ceive consideration,  the  icterus  of  the  new-born  and  acute  yellow  atrophy. 


ACUTE  YELLOW  ATROPHY.  551 


II.    ICTERUS   NEONATORUM. 

ISTew-born  infants  are  liable  to  jaundice,  Avhich  in  some  instances  rapidly 
proves  fatal.    A  mild  and  a  severe  form  may  be  recognized. 

The  mild  or  physiological  icterus  of  the  new-born  is  a  common  disease 
in  foundling  hospitals,  and  is  not  very  infrequent  in  private  practice.  In 
900  consecutive  birtiis  at  the  Sloane  Maternity,  icterus  was  noted  in  300 
cases  (Holt).  The  discoloration  appears  early,  usually  on  the  first  or  sec- 
ond day,  and  is  of  moderate  intensity.  The  urine  may  be  bile-stained  and 
the  fffices  colorless.  The  nutrition  of  the  child  is  not  usually  disturbed, 
and  in  the  majority  of  cases  the  jaundice  disappears  within  two  weeks. 
This  form  is  never  fatal.  The  cause  of  this  jaundice  is  not  at  all  clear. 
Some  have  attributed  it  to  stasis  in  the  smaller  bile-ducts,  which  are  com- 
pressed by  the  distended  radicals  of  the  portal  vein.  Others  hold  that  the 
jaundice  is  due  to  the  destruction  of  a  large  number  of  red  blood-corpuscles 
during  the  first  few  days  after  birth. 

The  severe  form  of  icterus  in  the  new-born  may  depend  upon  (a)  con- 
genital absence  of  the  common  or  hepatic  duct,  of  which  there  are  several 
instances  on  record;  (&)  congenital  syphilitic  hepatitis;  and  (c)  septic  poi- 
soning, associated  with  phlebitis  of  the  umbilical  vein.  This  is  a  severe 
and  fatal  form,  in  which  also  haemorrhage  from  the  cord  may  occur. 


III.     ACUTE  YELLOW  ATROPHY  (Malignant  Jaundice;  Icterus  Gravis). 

Definition. — Jaundice  associated  with  marked  cerebral  symptoms  and 
characterized  anatomically  by  extensive  necrosis  of  the  liver-cells  with  re- 
duction in  volume  of  the  organ. 

Etiology. — This  is  a  rare  disease.  ISTo  case  has  been  admitted  to  the 
Johns  Hopkins  Hospital  in  the  eleven  years  of  its  work.  Hunter  has  col- 
lected only  50  cases  betAveen  1880  and  1894  (inclusive),  which  brings  up 
the  total  number  of  recorded  cases  to  about  250.  In  a  somewhat  varied 
post-mortem  and  clinical  experience  no  instance  has  fallen  under  my  ob- 
servation. On  the  other  hand,  a  physician  may  see  several  cases  Avithin  a 
few  years,  or  even  within  a  few  months,  as  happened  to  Eeiss,  who  saw  five 
cases  within  three  months  at  the  Charite,  in  Berlin.  The  disease  seems 
to  be  rare  in  this  country.  It  is  more  common  in  Avomen  than  in  men.  Of 
the  100  cases  collected  by  Legg,  69  Avere  in  females;  and  of  Thierfelder's 
143  cases,  88  were  in  Avomen.  There  is  a  remarkable  association  between 
the  disease  and  pregnancy,  which  was  present  in  25  of  the  69  women  in 
Legg's  statistics,  and  in  33  of  the  88  women  in  Thierfelder's  collection. 
It  is  most  common  between  the  ages  of  twenty  and  thirty,  but  has  been  met 
Avith  as  early  as  the  fourth  day  and  the  tenth  month.  It  has  folloAA^ed 
fright  or  profound  mental  emotion.  In  hypertrophic  cirrhosis  the  symp- 
toms of  a  profound  icterus  gravis  may  develop,  with  all  the  clinical  features 
of  acute  yelloAv  atrophy,  including  the  presence  of  leucin  and  tyrosin  in  the 
urine,  and  convulsions.     I  have  seen  two  such  cases;  in  both  there  were 


552  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

extensive  necroses  in  the  liver-cells.  Though  the  symjDtoms  produced  by 
phosphorus  poisoning  closely  simulate  those  of  acute  yellow  atrophy,  the 
two  conditions  are  not  identical. 

Morbid  Anatomy. — The  liver  is  greatly  reduced  in  size^,  looks  thin 
and  flattened,  and  sometimes  does  not  reach  more  than  one  half  or  even 
one  third  of  its  normal  weight.  It  is  flabby  and  the  capsule  is  wrinkled. 
On  section  the  color  may  be  yellowish  brown,  yellowish  red,  or  mottled,  and 
the  outlines  of  the  lobules  are  indistinct.  The  yellow  and  dark-red  por- 
tions represent  different  stages  of  the  same  process — the  yellow  an  earlier, 
the  red  a  more  advanced  stage.  The  organ  may  cut  with  considerable  firm- 
ness. Microscopically  the  liver-cells  are  seen  in  all  stages  of  necrosis,  and 
in  spots  appear  to  have  undergone  complete  destruction,  leaving  a  fatty, 
granular  dehis  with  pigment  grains  and  crystals  of  leucin  and  tyrosin. 
The  bile-ducts  and  gall-bladder  are  empty.  Hunter  concludes  that  it  is  a 
toxsemic  catarrh  of  the  finer  bile-ducts,  similar  to  that  which  is  found  after 
poisoning  by  toluylendiamin  or  phosphorus. 

The  other  organs  show  extensive  bile-staining,  and  there  are  numerous 
haemorrhages.  The  kidneys  may  show  marked  granular  degeneration  of 
the  epithelium,  and  usually  there  is  fatty  degeneration  of  the  heart.  In  a 
majority  of  the  cases  the  spleen  is  enlarged. 

Symptoms. — In  the  initial  stage  there  is  a  gastro-duodenal  catarrh, 
and  at  first  the  jaundice  is  thought  to  be  of  a  simple  nature.  In  some  in- 
stances this  lasts  only  a  few  days,  in  others  two  or  three  weeks.  Then 
severe  symptoms  set  in — headache,  delirium,  trembling  of  the  mu.scles,  and, 
in  some  instances,  convulsions.  Vomiting  is  a  constant  symptom,  and  blood 
may  be  brought  up.  Hasmorrhages  occur  into  the  skin  or  from  the  mucous 
surfaces;  in  pregnant  women  abortion  may  occur.  With  the  development 
of  the  head  symptoms  the  jaundice  usually  increases.  Coma  sets  in  and 
gradually  deepens  until  death.  The  body  temperature  is  variable;  in  a 
majority  of  the  cases  the  disease  runs  an  afebrile  course,  though  sometimes 
just  before  death  there  is  an  elevation.  In  some  instances,  however,  there 
has  been  marked  pyrexia.  The  pulse  is  usually  rapid,  the  tongue  coated 
and  dry,  and  the  patient  is  in  a  "  typhoid  state." 

The  urine  is  bile-stained  and  often  contains  tube-casts.  Leucin  and 
tyrosin  are  not  constantly  present;  of  23  recent  cases  collected  by  Hunter, 
in  9  neith'er  was  found;  in  10  both  were  present;  in  3  tyrosin  only;  in  1 
leucin  only.  The  leucin  occurs  as  rounded  disks,  the  tj^rosin  in  needle- 
shaped  crystals,  arranged  either  in  bundles  or  in  groups.  The  tyrosin  may 
sometimes  be  seen  in  the  urine  sediment,  but  it  is  best  first  to  evaporate  a 
few  drops  of  urine  on  a  cover-glass.  In  the  majority  of  cases  no  bile  enters 
the  intestines,  and  the  stools  are  clay-colored.  The  disease  is  almost  in- 
variably fatal.  In  a  few  instances  recovery  has  been  noted.  I  saw  in 
Leube's  clinic,  at  Wiirzburg,  a  case  which  was  convalescent. 

Diagnosis. — Jaundice  with  vomiting,  diminution  of  the  liver  volume, 
delirium,  and  the  presence  of  leucin  and  tryosin  in  the  urine,  form  a  char- 
acteristic and  unmistakable  group  of  symptoms.  Leucin  and  tyrosin  are 
not,  however,  distinctive.  They  may  be  present  in  cases  of  afebrile  jaun- 
dice with  slight  enlargement  of  the  liver. 


AFFECTIONS   OF   THE   BLOOD-VESSELS   OF   THE   LIVER.  553 

It  is  not  to  be  forgotten  that  any  severe  jaundice  may  be  associated  with 
intense  cerebral  symptoms.  The  clinical  features  in  certain  cases  of  hyper- 
trophic cirrhosis  are  almost  identical,  but  the  enlargement  of  the  liver,  the 
more  constant  occurrence  of  fever,  and  the  absence  of  leucin  and  tyrosin 
are  distinguishing  signs.  Phosphorus  poisoning  may  closely  simulate  acute 
yellow  atrophy,  particularly  in  the  hgemorrhages,  jaundice,  and  the  diminu- 
tion in  the  liver  volume,  but  the  gastric  symptoms  are  usually  more  marked, 
and  leucin  and  tyrosin  are  stated  not  to  occur  in  the  urine. 

No  known  remedies  have  any  influence  on  the  course  of  the  disease. 


IV.    AFFECTIONS  OF  THE  BLOOD-VESSELS  OF  THE 

LIVER. 

(1)  Anaemia. — On  the  post-mortem  table,  when  the  liver  looks  anaemic, 
as  in  the  fatty  or  amyloid  organ,  the  blood-vessels,  which  during  life  were 
probably  well  filled,  can  be  readily  injected.  There  are  no  symptoms  in- 
dicative of  this  condition. 

(2)  Hypersemia. — This  occurs  in  two  forms,  (a)  Active  hypercemia. 
After  each  meal  the  rapid  absorption  by  the  portal  vessels  induces  transient 
congestion  of  the  organ,  which,  however,  is  entirely  physiological;  but  it 
is  quite  possible  that  in  persons  who  persistently  eat  and  drink  too  much 
this  active  hypersemia  may  lead  to  functional  disturbance  or,  in  the  case 
of  drinking  too  freely  of  alcohol,  to  organic  change.  In  the  acute  fevers 
an  acute  hypereemia  may  be  present. 

The  symptoms  of  active  hypersemia  are  indefinite.  Possibly  the  sense 
of  distress  or  fulness  in  the  right  hypochondrium,  so  often  mentioned  by 
dyspeptics  and  by  those  who  eat  and  drink  freely,  may  be  due  to  this  cause. 
There  are  probably  diurnal  variations  in  the  volume  of  the  liver.  In  cir- 
rhosis with  enlargement  the  rapid  reduction  in  volume  after  a  copious 
haemorrhage  indicates  the  important  part  which  hyperemia  plays  even  in 
organic  troubles.  It  is  stated  that  suppression  of  the  menses  or  suppression 
of  a  hemorrhoidal  flow  is  followed  by  hyperaemia  of  the  liver.  Andrew  H. 
Smith  has  described  a  case  of  periodical  enlargement  of  the  liver. 

(b)  Passive  Congestion. — This  is  much  more  common  and  results  from 
an  increase  of  pressure  in  the  efferent  vessels  or  sub-lobular  branches  of  the 
hepatic  veins.  Every  condition  leading  to  venous  stasis  in  the  right  heart 
at  once  affects  these  veins. 

In  chronic  valvular  disease,  in  emphysema,  cirrhosis  of  the  lung,  and 
in  intrathoracic  tumors  mechanical  congestion  occurs  and  finally  leads  to 
very  definite  changes.  The  liver  is  enlarged,  firm,  and  of  a  deep-red  color; 
the  hepatic  vessels  are  greatly  engorged,  particularly  the  central  vein  in 
each  lobule  and  its  adjacent  capillaries.  On  section  the  organ  presents  a 
peculiar  mottled  appearance,  owing  to  the  deeply  congested  hepatic  and 
the  ana?mic  portal  territories;  hence  the  term  nutmcrj  wliich  has  been  given 
to  this  conrlition.  Gradually  the  distention  of  the  central  capillaries  reaches 
such  a  grade  that  atrophy  of  the  intervening  liver-colls  is  induced.  Brown 
pigment  is  deposited  about  the  centre  of  the  lobules  and  the  connective 


554  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

tissue  is  greatly  increased.  In  this  cyanotic  induration  or  cardiac  liver  the 
organ  is  large  in  the  early  stage,  but  later  it  may  become  contracted.  Occa- 
sionally in  this  form  the  connective  tissue  is  increased  about  the  lobules  as 
well,  but  the  process  usually  extends  from  the  sublobular  and  central  veins. 

The  symptoms  of  this  form  are  not  always  to  be  separated  from  those 
of  the  associated  conditions.  G-astro-intestinal  catarrh  is  usually  present 
and  hgematemesis  may  occur.  The  portal  obstruction  in  advanced  cases 
leads  to  ascites,  which  may  precede  the  development  of  general  dropsy. 
There  is  often  slight  jaundice,  the  stools  may  be  clay-colored,  and  the  urine 
contains  bile-pigment. 

On  esamination  the  organ  is  found  to  be  increased  in  size.  It  may  be 
a  full  hand's  breadth  below  the  costal  margin  and  tender  on  pressure.  It 
is  in  this  condition  particularly  that  we  meet  with  pulsation  of  the  liver. 
We  must  distinguish  the  communicated  throbbing  of  the  heart,  which  is 
very  common,  from  the  heaving,  diffuse  impulse  due  to  regurgitation  into 
the  hepatic  veins,  in  which,  when  one  hand  is  upon  the  ensiform  cartilage 
and  the  other  upon  the  right  side  at  the  margin  of  the  ribs,  the  whole 
liver  can  be  felt  to  dilate  with  each  impulse. 

The  indications  for  treatment  in  passive  hypersemia  are  to  restore  the 
balance  of  the  circulation  and  to  unload  the  engorged  portal  vessels.  In 
cases  of  intense  hyperemia  18  or  20  ounces  of  blood  may  be  directly 
aspirated  from  the  liver,  as  advised  by  George  Harley  and  practised  by 
many  Anglo-Indian  physicians.  Good  results  sometimes  follow  this  he- 
pato-phlebotomy.  The  prompt  relief  and  marked  reduction  in  the  volume 
of  the  organ  which  follow  an  attack  of  hgematemesis  or  bleeding  from  piles 
suggests  this  practice.  Salts  administered  by  Matthew  Hay's  method  de- 
plete the  portal  system  freely  and  thoroughly.  As  a  rule,  the  treatment 
must  be  that  of  the  condition  with  which  it  is  associated. 

(3)  Diseases  of  the  Portal  Vein. — (a)  Thrombosis;  Adhesive  Pyle- 
phlebitis.— Coagulation  of  blood  in  the  portal  vein  is  met  with  in  cirrhosis, 
in  syphilis  of  the  liver,  invasion  of  the  vein  by  cancer,  proliferative  perito- 
nitis involving  the  gastro-hepatic  omentum,  perforation  of  the  vein  by  gall- 
stones, and  occasionally  follows  sclerosis  of  the  walls  of  the  portal  vein  or 
of  its  branches  (Borrmann).  In  rare  instances  a  complete  collateral  circula- 
tion is  established,  the  thrombus  undergoes  the  usual  changes,  and  ulti- 
mately the  vein  is  represented  by  a  fibrous  cord,  a  condition  which  has  been 
called  pylephlebitis  adhesiva.  In  a  case  of  this  kind  which  I  dissected  the 
portal  vein  was  represented  by  a  narrow  fibrous  cord;  the  collateral  circula- 
tion, which  must  have  been  completely  established  for  years,  ultimately 
failed,  ascites  and  h^matemesis  supervened  and  rapidly  proved  fatal.*  The 
diagnosis  of  obstruction  of  the  portal  vein  can  rarely  be  made.  A  sug- 
gestive symptom,  however,  is  a  sudden  onset  of  the  most  intense  engorge- 
ment of  the  branches  of  the  portal  system,  leading  to  hgematemesis,  melgena, 
ascites,  and  swelling  of  the  spleen. 

Emboli  in  the  branches  of  the  portal  vein  do  not,  as  a  rule,  produce 
infarction,  for  blood  reaches  the  lobular  capillary  plexus,  as  shown  by 

*  Joiirnal  of  Anatomy  and  Physiology,  vol.  xvii. 


DISEASES  OF  THE  BILE-PASSAGES  AND  GALL-BLADDER.        555 

Cohnlieim  and  Litteu,  through  the  free  anastomosis  with  a  hepatic  artery. 
In  rare  instances,  however,  a  condition  resembling  infarction  does  occur, 
sometimes  in  small  areas,  at  others  in  quite  extensive  territories.  Septic 
emboli,  on  the  other  hand,  may  induce  suppuration. 

(b)  Suppurative  pylepMebitis  will  be  considered  in  the  section  on  abscess. 

(4)  Affections  of  the  hepatic  vein  are  extremely  rare.  Dilatation  oc- 
curs in  cases  of  chronic  enlargement  of  the  right  heart,  from  whatever  cause 
produced.  Emboli  occasionally  pass  from  the  right  auricle  into  the  hepatic 
veins.  A  rare  and  unusual  event  is  stenosis  of  the  orifices  of  the  hejDatic 
veins,  which  I  met  in  a  case  of  fibroid  obliteration  of  the  inferior  vena  cava 
and  which  was  associated  with  a  greatly  enlarged  and  indurated  liver.* 

(5)  Hepatic  Artery. — Enlargement  of  this  vessel  is  seen  in  cases  of  cir- 
rhosis of  the  liver.  It  may  be  the  seat  of  extensive  sclerosis.  Aneurism 
of  the  hepatic  artery  is  rare,  but  instances  are  on  record,  and  will  be  re- 
ferred to  in  the  section  on  arteries. 


V.    DISEASES    OF   THE    BILE-PASSAGES   AND 
GALL-BLADDER. 

(a)  Acute  Cataerh  of  the  Bile-ducts  {GatarrTial  Jaundice). 

Definition.  — Jaundice  due  to  swelling  and  obstruction  of  the  terminal 
portion  of  the  common  duct. 

Etiology. — General  catarrhal  inflammation  of  the  bile-ducts  is  usu- 
ally associated  with  gall-stones.  The  catarrhal  process  now  under  consid- 
eration is  probably  always  an  extension  of  a  gastro-duodenal  catarrh,  and 
the  process  is  most  intense  in  the  pars  intestinalis  of  the  duct,  which  pro- 
jects into  the  duodenum.  The  mucous  membrane  is  swollen,  and  a  plug 
of  inspissated  mucus  fills  the  diverticulum  of  Vater,  and  the  narrower  por- 
tion just  at  the  orifice,  completely  obstructing  the  outflow  of  bile.  It  is  not 
known  how  widespread  this  catarrh  is  in  the  bile-passages,  and  whether 
it  really  passes  up  the  ducts.  It  would,  of  course,  be  possible  to  have  a 
catarrh  of  the  finer  ducts  within  the  liver,  which  som.e  French  writers  think 
may  initiate  the  attack,  but  the  evidence  for  this  is  not  strong,  and  it  seems 
more  likely  that  the  terminal  portion  of  the  duct  is  always  first  involved. 
In  the  only  instance  which  I  have  had  an  opportunity  to  examine  post 
mortem  the  orifice  was  plugged  with  inspissated  mucus,  the  common  and 
hepatic  ducts  were  slightly  distended  and  contained  a  bile-tinged,  not  a 
clear,  mucus,  and  there  were  no  observable  changes  in  the  mucosa  of  the 
ducts. 

This  catarrhal  or  simple  jaundice  results  from  the  following  causes: 
(1)  Duodenal  catarrh,  in  whatever  way  produced,  most  commonly  follow- 
ing an  attack  of  indigestion.  It  is  most  frequently  met  witli  in  young 
persons,  but  may  occur  at  any  age,  and  may  follow  not  only  errors  in  diet, 
but  also  cold,  exposure,  and  malaria,  as  well  as  the  conditions  associated 
with  portal  obstruction,  chronic  heart-disease,  and  Bright's  disease.     (2) 

*  Journal  of  Anatomy  and  Physiology,  vol.  xvi. 


556  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Emotional  disturbances  may  be  followed  by  jaundice,  which  is  believed  to 
be  due  to  catarrhal  swelling.  Cases  of  this  kind  are  rare  and  the  anatom- 
ical condition  is  unknown.  (3)  Simple  or  catarrhal  Jaundice  may  occur 
in  epidemic  form.  (4)  Catarrhal  jaundice  is  occasionally  seen  in  the  in- 
fectious fevers,  such  as  pneumonia,  and  typhoid  fever.  The  nature  of  acute 
catarrhal  jaundice  is  still  unknown.  It  may  possibly  be  an  acute  infection. 
In  favor  of  this  view  are  the  occurrence  in  epidemic  form  and  the  presence 
of  slight  fever.  The  spleen,  however,  is  not  often  enlarged.  In  only  4 
out  of  23  cases  was  it  palpable. 

Symptoms. — There  may  be  neither  pain  nor  distress,  and  the  pa- 
tient's friends  may  first  notice  the  yellow  tint,  or  the  patient  himself  may 
observe  it  in  the  looking-glass.  In  other  instances  there  are  dyspeptic 
symptoms  and  uneasy  sensations  in  the  hepatic  region  or  pains  in  the  back 
and  limbs.  In  the  epidemic  form,  the  onset  may  be  more  severe,  with 
headache,  chill,  and  vomiting.  Fever  is  rarely  present,  though  the  tem- 
perature may  reach  101°,  sometimes  102°.  All  the  signs  of  obstructive 
jaundice  already  mentioned  are  present,  the  stools  are  clay-colored,  and 
the  urine  contains  bile-pigment.  The  jaundice  has  a  bright-yellow  tint; 
the  greenish,  bronzed  color  is  never  seen  in  the  simple  form.  The  pulse 
may  be  normal,  but  occasionally  it  is  remarkably  slow,  and  may  fall  to  40 
or  30  beats  in  the  minute,  and  the  respirations  to  as  low  as  8  per  minute. 
Sleepiness,  too,  may  be  present.  The  liver  may  be  normal  in  size,  but  is 
usually  slightly  enlarged,  and  the  edge  can  be  felt  below  the  costal  margin. 
Occasionally  the  enlargement  is  more  marked.  As  a  rule  the  gall-bladder 
cannot  be  felt.  The  spleen  may  be  increased  in  size.  The  duration  of  the 
disease  is  from  four  to  eight  weeks.  There  are  mild  cases  in  which  the 
jaundice  disappears  within  two  weeks;  on  the  other  hand,  it  may  persist 
for  three  months.  The  stools  should  be  carefully  watched,  for  they  give 
the  first  intimation  of  removal  of  the  obstruction. 

The  diagnosis  is  rarely  difficult.  The  onset  in  young,  comparatively 
healthy  persons,  the  moderate  grade  of  icterus,  the  absence  of  emaciation 
or  of  evidences  of  cirrhosis  or  cancer,  usually  make  the  diagnosis  easy. 
Cases  which  persist  for  two  or  three  months  cause  uneasiness,  as  the  sus- 
picion is  aroused  that  it  may  be  more  than  simple  catarrh.  The  absence 
of  pain,  the  negative  character  of  the  physical  examination,  and  the  main- 
tenance of  the  general  nutrition  are  the  points  in  favor  of  simple  jaundice. 
There  are  instances  in  which  time  alone  can  determine  the  true  nature  of 
the  case.  The  possibility  of  Weil's  disease  must  be  borne  in  mind  in  anom- 
alous types. 

Treatm.ent. — As  a  rule  the  patient  can  keep  on  his  feet  from  the  out- 
set. Measures  should  be  used  to  allay  the  gastric  catarrh,  if  it  is  present. 
A  dose  of  calomel  may  be  given,  and  the  bowels  kept  open  subsequently 
by  salines.  The  patient  should  not  be  violently  purged.  Bismuth  and 
bicarbonate  of  soda  may  be  given,  and  the  patient  should  drink  freely  of  the 
alkaline  mineral  waters,  of  which  Vichy  is  the  best.  Irrigation  of  the 
large  bowel  with  cold  water  may  be  practised.  Tlie  cold  is  supposed  to  ex- 
cite peristalsis  of  the  gall-bladder  and  ducts,  and  thus  aid  in  the  expulsion 
of  the  mucus. 


DISEASES  OF  THE  BILE-PASSAGES  AND  GALL-BLADDER.        557 

(b)  Cheonic  Catarehal  Angiocholitis. 

This  may  possibly  occur  also  as  a  sequel  of  the  acute  catarrh.  I  have 
never  met  with  an  instance,  however,  in  which  a  chronic,  persistent  jaundice 
could  be  attributed  to  this  cause.  A  chronic  catarrh  always  accompanies 
obstruction  in  the  common  duct,  whether  by  gall-stones,  malignant  disease, 
stricture,  or  external  pressure.     There  are  two  groups  of  cases: 

(1)  With  Complete  Obstruction  of  the  Common  Duct. — In  this  form  the 
bile-passages  are  greatly  dilated,  the  common  duct  may  reach  the  size  of 
the  thumb  or  larger,  there  is  usually  dilatation  of  the  gall-bladder  and  of 
the  ducts  within  the  liver.  The  contents  of  the  ducts  and  of  the  gall- 
bladder are  a  clear,  colorless  mucus.  The  mucosa  may  be  everywhere 
smooth  and  not  swollen.  The  clear  mucus  is  usually  sterile.  The  patients 
are  the  subjects  of  chronic  jaundice,  usually  without  fever. 

(2)  ^Vith  Incomijlete  Ohstruction  of  the  Duct. — There  is  pressure  on  the 
duct  or  there  are  gall-stones,  single  or  multi^Dle,  in  the  common  duct  or  in 
the  diverticulum  of  Vater.  The  bile-passages  are  not  so  much  dilated,  and 
the  contents  are  a  bile-stained,  turbid  mucus.  The  gall-bladder  is  rarely 
much  dilated.     In  a  majority  of  all  cases  stones  are  found  in  it. 

The  symptoms  of  this  type  of  catarrhal  angiocholitis  are  sometimes  very 
distinctive.  With  it  is  associated  most  frequently  the  so-called  hepatic  in- 
termittent fever,  recurring  attacks  of  chills,  fever,  and  sweats.  We  need 
still  further  information  about  the  bacteriology  of  these  cases.  In  all  prob- 
ability the  febrile  attacks  are  due  distinctly  to  infection.  I  cannot  too 
strongly  emphasize  the  point  that  the  recurring  attacks  of  intermittent 
fever  do  not  necessarily  mean  suppurative  angiocholitis.  The  question  will 
be  referred  to  again  under  gall-stones. 

(c)  Suppurative  and  Ulcerative  Aitgiocholitis. 

The  condition  is  a  diffuse,  purulent  angiocholitis  involving  the  larger 
and  smaller  ducts.  In  a  large  proportion  of  all  cases  there  is  associated 
suppurative  disease  of  the  gall-bladder. 

Etiology. — It  is  the  most  serious  of  the  sequels  of  gall-stones.  Occa- 
sionally a  diffuse  suppurative  angiocholitis  follows  the  acute  infectious 
cholecystitis;  this,  however,  is  rare,  since  fortunately  in  the  latter  condi- 
tion the  cystic  duct  is  usually  occluded.  Cancer  of  the  duct,  foreign  bodies, 
such  as  lumbricoids  or  fish  bones,  are  occasional  causes.  And  lastly  there 
may  be  extension  from  a  suppurative  pylephlebitis. 

The  common  duct  is  greatly  dilated  and  may  reach  the  size  of  the  index 
finger  or  the  thumb;  the  walls  are  thickened,  and  there  may  be  fistulous 
communications  with  the  stomach,  colon,  or  duodenum.  The  hepatic  ducts 
and  their  extensions  in  the  liver  are  dilated  and  contain  pus  mixed  with  bile. 
On  section  of  the  liver  small  abscesses  are  seen,  which  correspond  to  the  di- 
lated suppurating  ducts.  The  gall-bladder  is  usually  distended,  full  of 
pus,  and  with  adhesions  to  the  neighboring  parts,  or  it  may  have  perfo- 
rated . 

Symptoms. — The  symptoms  of  suppurative  cholangitis  are  usually 
very  severe.     A  previous  history  of  gall-stones,  the  development  of  a  septic 


558  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

fever,  the  swelling  and  tenderness  of  the  liver,  the  enlargement  of  the  gall- 
bladder, and  the  leucocytosis  are  suggestive  features.  Jaundice  is  always 
present,  but  is  variable.  In  some  cases  it  is  very  intense,  in  others  it  is 
slight.  There  may  be  very  little  pain.  There  is  progressive  emaciation 
and  loss  of  strength.  In  a  recent  case  parotitis  developed  on  the  left  side, 
which  subsided  without  suppuration. 

Ulceration,  stricture,  perforation,  and  fistulse  of  the  bile-passages  will 
be  considered  with  gall-stones. 

(d)  Acute  I]srFECTious  Cholecystitis. 

Etiology. — Acute  inflammation  of  the  gall-bladder  is  usually  due  to 
bacterial  invasion,  with  or  without  the  presence  of  gall-stones.  Three  vari- 
eties or  grades  may  be  recognized:  The  catarrhal,  the  suppurative,  and  the 
phlegmonous.  The  condition  is  very  serious,  difficult  to  diagnose,  often 
fatal,  and  may  require  for  its  relief  prompt  surgical  intervention.  The 
cases  associated  with  gall-stones  have  of  course  long  been  recognized,  but 
we  now  know  that  an  acute  infection  of  the  gall-bladder  leading  to  suppura- 
tion, gangrene,  or  perforation  is  by  no  means  infrequent.  For  an  interest- 
ing series  of  cases  the  reader  is  referred  to  a  paper  by  Maurice  H.  Richard- 
son in  the  American  Journal  of  the  Medical  Sciences,  1898,  I.  In  10  of 
his  59  operations  upon  the  gall-bladder  acute  cholecystitis  was  present  with- 
out known  pre-existing  disease! 

Acute  non-calculous  cholecystitis  is  a  result  of  bacterial  invasion.  The 
colon  bacillus,  the  typhoid  bacillus,  the  pneumococcus  and  staphylococci 
and  streptococci  have  been  the  organisms  most  often  found.  The  fre- 
quency of  gall-bladder  infection  in  the  fevers  is  a  point  already  referred  to, 
particularly  in  typhoid  fever.  Two  instances  of  acute  cholecystitis  have 
occurred  within  the  past  year  at  the  Johns  Hopkins  Hospital  in  which 
typhoid  bacilli  were  isolated  from  pure  culture,  and  the  Widal  reaction  was 
present  in  the  patient's  blood,  without,  so  far  as  could  be  ascertained,  any 
history  of  typhoid  fever  (see  Gushing,  Typhoid  Cholecystitis,  J.  H.  H.  Bul- 
letin, May,  1898). 

Condition  of  the  Gall-bladder. — The  organ  is  usually  distended  and  the 
walls  tense.  Adhesions  may  have  formed  with  the  colon  or  the  omentum. 
In  other  instances  perforation  has  taken  place  and  there  is  a  localized  ab- 
scess, or  in  the  more  fulminant  forms  general  peritonitis.  The  contents  of 
the  organ  are  usually  dark  in  color,  muco-purulent,  purulent,  or  hsemorrhagic. 
In  the  cases  with  acute  phlegmonous  inflammation  there  may  be  a  very  foul 
odor.  As  Richardson  remarks,  the  cystic  duct  is  often  found  closed  even 
when  no  stone  is  impacted.  It  should  be  borne  in  mind  that  in  the  acutely 
distended  gall-bladder  the  elongation  and  enlargement  may  take  place 
chiefly  upward  and  inward,  toward  the  foramen  of  Winslow. 

Symptoms. — Severe  paroxysmal  pain  is,  as  a  rule,  the  first  indication, 
most  commonly  in  the  right  side  of  the  abdomen  in  the  region  of  the  liver. 
It  may  be  in  the  epigastrium  or  low  down  in  the  region  of  the  appendix. 
"  Nausea,  vomiting,  rise  of  pulse  and  temperature,  prostration,  distention  of 
the  abdomen,  rigidity,  general  tenderness  becoming  localized  "  usually  fol- 


DISEASES  01    THE  BILE-PASSAGES  AND  GALL-BLADDER.        559 

low  (Eichardson).  In  this  form,  without  gall-stones,  jaundice  is  not  often 
present.  The  local  tenderness  is  extreme,  but  it  may  be  deceptive  in  its 
situation.  Associated  probably  with  the  adhesion  and  inflammatory  pro- 
cesses between  the  gall-bladder  and  the  bowel  are  the  intestinal  symptoms, 
and  there  may  be  complete  stoppage  of  gas  and  fseces;  indeed,  the  opera- 
tion for  acute  obstruction  has  been  performed  in  several  cases.  The  dis- 
ended  gall-bladder  may  sometimes  be  felt. 

The  diagnosis  is  by  no  means  easy.  The  symptoms  may  not  indicate 
the  section  of  the  abdomen  involved.  In  two  of  our  cases  and  in  three  of 
Eichardson's  appendicitis  was  diagnosed;  in  two  of  his  cases  acute  intes- 
tinal obstruction  was  suspected.  This  was  the  diagnosis  in  a  case  of  acute 
phlegmonous  cholecystitis  which  I  reported  in  1881.  The  history  of  the 
cases  is  often  a  valuable  guide.  Occurring  during  the  convalescence  from 
typhoid  fever,  after  pneumonia,  or  in  a  patient  with  previous  cholecystitis, 
such  a  group  of  symptoms  as  mentioned  would  be  highly  suggestive.  The 
differentiation  of  the  variety  of  the  cholecystitis  cannot  be  made.  In  the 
acute  suppurative  and  phlegmonous  forms  the  symptoms  are  usually  more 
severe,  perforation  is  very  apt  to  occur,  with  local  or  general  peritonitis, 
and  unless  operative  measures  are  undertaken  death  ensues. 

There  is  an  acute  cholecystitis,  probably  an  infective  form,  in  which 
the  patient  has  recurring  attacks  of  pain  in  the  region  of  the  gall-bladder. 
The  diagnosis  of  gall-stones  is  made,  but  an  operation  shows  simply  an  en- 
larged gall-bladder  filled  with  mucus  and  bile,  and  the  mucous  membrane 
perhaps  swollen  and  inflamed.  In  some  of  these  cases  gall-stones  may  have 
been  present  and  have  passed  before  the  operation. 

(e)  Cancer  of  the  Bile-passages. 

The  subject  has  been  very  thoroughly  studied  of  late  years  by  Zenker, 
Musser,  Ames,  Eolleston,  and  Kelynack.  Females  suffer  in  the  propor- 
tion of  3  to  1  (Musser),  or  4  to  1  (Ames).  In  cases  of  primary  cancer  of 
the  bile-duct,  on  the  other  hand,  men  and  women  appear' to  be  about 
equally  affected.  In  Musser's  series  65  per  cent  of  the  cases  occurred  be- 
tween the  ages  of  forty  and  seventy.  The  association  of  malignant  disease 
of  the  gall-bladder  with  gall-stones  has  long  been  recognized.  The  fact  is 
well  put  by  Kelynack  as  follows:  "  While  gall-stones  are  found  in  from  6 
to  12  per  cent  of  all  general  cases  (that  is,  coming  to  autopsy),  they  occur  in 
association  with  cancer  of  the  gall-bladder  in  from  90  to  100  per  cent." 

The  exact  nature  of  the  association  is  not  very  clear,  but  it  is  usually  re- 
garded as  an  effect  of  the  chronic  irritation.  On  the  other  hand,  it  is  urged 
that  the  presence  of  tlie  malignant  disease  may  itself  favor  the  production 
of  gall-stones.  Histologically,  "  carcinoma  of  the  gall-bladder  varies  much, 
both  in  the  form  of  the  cells  and  in  their  structural  arrangement;  it  may 
be  either  columnar  or  spheroidal-celled  "  (Eolleston).  Tlie  fundus  is  usu- 
ally first  involved  in  the  gall-bladder,  and  in  the  ducts  the  ductus  communis 
choledochus. 

When  the  disease  involves  the  gall-hladder,  a  tumor  can  be  detected  ex- 
tending diagonally  downward  and  inward  toward  the  navel,  variable  in 


560  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

size,  occasionallj'  Tery  large,  due  either  to  great  distention  of  the  gall- 
bladder or  to  inTolvement  of  contiguous  parts.  It  is  usually  very  firm  and 
hard. 

Among  the  important  symptoms  are  jaundice,  which  was  present  in  69 
per  cent  of  Musser's  cases;  pain,  often  of  great  severity  and  paroxysmal  in 
character.  The  pain  and  tenderness  on  pressure  persist  in  the  intervals 
between  the  paroxysmal  attacks.  In  one  of  my  three  cases,  which  Ames 
reported,  there  was  a  very  profound  ansemia,  but  an  absence  of  jaundice 
throughout.  Gall-stones  were  present  in  two  of  the  cases,  and  a  history  of 
gall-stone  attacks  was  obtained  from  the  third. 

Primary  malignant  disease  in  the  Mle-duds  is  less  common,  and  rarely 
forms  tumors  that  can  be  felt  externally.  Kelynack  (Medical  Chronicle, 
N"ovember,  1897)  gives  very  fully  a  number  of  important  points  in  the  dif- 
ferential diagnosis  between  tumors  in  the  duct  and  tumors  in  the  gall- 
bladder. There  is  usually  an  early,  intense,  and  persistent  jaundice.  The 
dilated  gall-bladder  may  rupture.  At  best  the  diagnosis  is  very  doubtful, 
unless  cleared  up  by  an  exploratory  operation.  A  very  interesting  form 
of  malignant  disease  of  the  ducts  is  that  which  involves  the  diverticulum 
of  Vater.  Busson  has  collected  eleven  cases.  A  few  months  ago  an  elderly 
woman  was  admitted  under  my  care  with  jaundice  of  some  months'  duration, 
without  pain,  with  progressive  emaciation,  and  a  greatly  enlarged  gall- 
bladder. My  colleague,  Halsted,  operated  and  found  obstruction  at  the 
orifice  of  the  common  duct.  He  opened  the  duodenum,  removed  a  cylin- 
drical-celled epithelioma  of  the  ampulla  of  Vater,  and  stitched  the  common 
duct  to  another  portion  of  the  duodenum.  The  patient  made  an  uninter- 
rupted recovery,  and,  fourteen  weeks  after  the  operation,  had  gained  twen- 
ty-five pounds  in  weight  and  passed  bile  with  the  fseces. 

(/)    StEN"0SI8   AISTD    ObSTEUCTION   OF   THE   BiLE-DUCTS. 

stenosis  or  complete  occlusion  may  follow  ulceration,  most  commonly 
after  the  passage  of  a  gall-stone.  In  these  instances  the  obstruction  is 
usually  situated  low  down  in  the  common  duct.  Instances  are  extremely 
-rare.  Foreign  bodies,  such  as  the  seeds  of  various  fruits,  may  enter  the 
duct,  and  occasionally  round  worms  crawl  into  it.  In  the  Wistar-Horner 
Museum  of  the  I^niversity  of  Pennsylvania  there  is  a  remarkable  specimen 
showing  the  common  and  hepatic  ducts  enormously  distended  and  densely 
packed  with  a  dozen  or  more  lumbricoid  worms.  Similar  specimens  exist 
in  one  of  the  Paris  museums,  and  at  the  Royal  A'^ictoria  Hospital,  j^etley. 
Liver-flukes  and  echinococci  are  rare  causes  of  obstruction  in  man. 

Obstruction  by  pressure  from  without  is  more  frequent.  Cancer  of  the 
head  of  the  pancreas,  less  often  a  chronic  interstitial  inflammation,  may 
compress  the  terminal  portion  of  the  duct;  rarely,  cancer  of  the  pylorus. 
Secondary  involvement  of  the  lymph-glands  of  the  liver  is  a  common  cause 
of  occlusion  of  the  duct,  and  is  met  with  in  many  cases  of  cancer  of  the 
stomach  and  other  abdominal  organs.  Eare  causes  of  obstruction  are  aneu- 
rism of  a  branch  of  the  coeliac  axis  of  the  aorta,  and  pressure  of  very  large 
abdominal  tumors. 


CHOLELITHIASIS.  561 

The  sj^mptoms  produced  are  those  of  chronic  obstructive  jaundice.  At 
first,  the  liver  is  usually  enlarged,  but  in  chronic  cases  it  may  be  reduced  in 
size,  and  be  found  of  a  deeply  bronzed  color.  The  hepatic  intermittent  fever 
is  not  often  associated  with  complete  occlusion  of  the  duct  from  any  cause, 
but  it  is  most  frequently  met  with  in  chronic  obstruction  by  gall-stones. 
Permanent  occlusion  of  the  duct  terminates  in  death.  In  a  majority  of  the 
cases  the  conditions  which  lead  to  the  obstruction  are  in  themselves  fatal. 
The  liver,  which  is  not  necessarily  enlarged,  presents  a  moderate  grade  of 
cirrhosis.  Cases  of  cicatricial  occlusion  may  last  for  years.  A  patient  under 
my  care,  who  was  permanently  jaundiced  for  nearly  three  years,  had  a 
fibroid  occlusion  of  the  duct. 

The  diagnosis  of  the  nature  of  the  occlusion  is  often  very  difficult.  A 
history  of  colic,  jaundice  of  varying  intensity,  paroxysms  of  pain,  and  in- 
termittent fever  point  to  gall-stones.  In  cancerous  obstruction  the  tumor 
mass  can  sometimes  be  felt  in  the  epigastric  region.  In  cases  in  which 
the  lymph-glands  in  the  transverse  fissure  are  cancerous,  the  primary  dis- 
ease may  be  in  the  pelvic  organs  or  the  rectum,  or  there  may  be  a  limited 
cancer  of  the  stomach,  which  has  not  given  any  symptoms.  In  these  cases 
the  examination  of  the  other  lymphatic  glands  may  be  of  value.  In  a  man 
who  came  under  observation  with  a  jaundice  of  seven  weeks'  duration, 
believed  to  be  catarrhal  (as  the  patient's  general  condition  was  good  and 
he  was  not  said  to  have  lost  flesh),  a  small  nodular  mass  was  detected 
at  the  navel,  which  on  removal  proved  to  be  scirrhus.  Involvement  of  the 
clavicular  groups  of  lymph-glands  may  also  be  serviceable  in  diagnosis. 
The  gall-bladder  is  usually  enlarged  in  obstruction  of  the  common  duct, 
except  in  the  cases  of  gall-stones  (Courvoisier's  law).  Great  and  progressive 
enlargement  of  the  liver  wifh  jaundice  and  moderate  continued  fever  is  more 
commonly  met  with  in  cancer. 

Congenital  obliteration  of  the  ducts  is  an  interesting  condition,  of  which 
there  are  some  60  or  70  cases  on  record.  It  may  occur  in  several  members 
of  one  family.  Spontaneous  hfemorrhages  are  frequent,  particularly  from 
the  navel.  The  subjects  may  live  for  three  or  even  eight  weeks.  For  a 
recent  careful  consideration  of  the  subject,  see  John  Thomson's  article  in 
Allbutt's  System  of  Medicine. 


VI.    CHOLELITHIASIS. 

'No  chapter  in  medicine  is  more  interesting  than  that  which  deals  with  the 
question  of  gall-stones.  Few  affections  present  so  many  points  for  study — 
chemical,  bacteriological,  pathological,  and  clinical.  The  past  few  years 
have  seen  a  great  advance  in  our  knowledge  in  two  directions:  First,  as  to  the 
mode  of  formation  of  the  stones,  and,  secondly,  as  to  the  surgical  treatment 
of  the  cases.  The  recent  study  of  the  origin  of  stones  dates  from  Xaunyn's 
work  in  18P1.  Marion  Sims's  suggestion  tliat  gall-stones  came  within  the 
sphere  of  the  surgeon  has  been  most  fruitful.  Lawson  Tait, .  Langenbuch, 
Mayo  Robson,  Riedel,  Kehr,  and  in  this  country  Keen,  Fenger,  Murphy, 
Lange,  and  Halsted  have  not  only  revolutionized  the  treatment  of  chole- 


562  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

lithiasis,  but  from  their  work  we  physicians  have  gathered  much  of  the 
greatest  moment  in  symptomatology  and  diagnosis. 

Origin  of  Gall-stones. — Two  important  points  with  reference  to  the  for- 
mation of  calculi  in  the  bile-passages  were  brought  out  by  ISTaunyn:  (a) 
The  origin  of  the  cholesterin  of  the  bile,  as  well  as  of  the  lime  salts  from  the 
mucous  membrane  of  the  biliary  passages,  particularly  when  inflamed;  and 
(&)  the  remarkable  association  of  micro-organisms  with  gall-stones.  It  is 
stated  that  Bristowe  first  noticed  the  origin  of  cholesterin  in  the  gall-blad- 
der itself,  but  ISTaunyn's  observations  showed  that  both  the  cholesterin  and 
the  lime  were  in  great  part  a  production  of  the  mucosa  of  the  gall-bladder 
and  of  the  bile-ducts,  particularly  when  in  a  condition  of  catarrhal  inflam- 
mation excited  by  the  presence  of  microbes.  According  to  the  views  of  this 
author,  the  lithogenous  catarrh  (which,  by  the  way,  is  quite  an  old  idea) 
modifies  materially  the  chemical  constitution  of  the  bile  and  favors  the  de- 
position about  epithelial  debris  and  bacteria  of  the  insoluble  salts  of  lime 
in  combination  with  the  bilirubin,  Welch  and  others  have  demonstrated 
the  presence  of  micro-organisms  in  the  centre  of  gall-stones.  Three  addi- 
tional points  of  interest  may  be  referred  to: 

First,  the  demonstration  that  the  gall-bladder  is  a  peculiarly  favorable 
habitat  for  micro-organisms.  The  colon  bacilli,  staphylococci,  streptococci, 
pneumococci,  and  the  typhoid  bacilli  have  all  been  found  here  under  varying 
conditions  of  the  bile.  A  remarkable  fact  is  the  length  of  time  that  they 
may  live  in  the  gall-bladder,  as  was  first  demonstrated  by  Blachstein  in 
"Welch's  laboratory.  The  typhoid  bacillus  has  been  isolated  in  pure  culture 
seven  years  after  an  attack. 

Secondly,  the  experimental  production  of  gall-stones  has  been  success- 
fully accomplished  by  Gilbert  and  Fournier  by  injecting  micro-organisms 
into  the  gall-bladder  of  animals. 

Thirdly,  the  association  of  gall-stones  with  the  specific  fevers.  Bern- 
heim,  in  1889,  first  called  attention  to  the  frequency  of  gall-stone  attacks 
after  typhoid.  Since  that  time  Dufort  has  collected  a  series  of  cases,  and 
Chiari,  Mason,  and  Camac  have  called  attention  to  the  great  frequency  of 
gall-bladder  complications  during  and  after  this  disease. 

While  it  is  probable  that  a  lithogenous  catarrh,  induced  by  micro-organ- 
isms, is  the  most  important  single  factor,  there  are  other  accessory  causes  of 
great  moment. 

Age. — Nearly  50  per  cent  of  all  the  cases  occur  in  persons  above  forty 
years  of  age.  They  are  rare  under  twenty-five.  They  have  been  met  with 
in  the  new-born,  and  in  infants  (John  Thomson). 

Sex. — Three  fourths  of  the  cases  occur  in  women.  Pregnancy  has  an 
important  influence.  ISTaunyn  states  that  90  per  cent  of  women  with 
gall-stones  have  borne  children. 

All  conditions  which  favor  stagnation  of  hile  in  the  gall-bladder  predis- 
pose to  the  formation  of  stones.  Among  these  may  be  mentioned  corset- 
wearing,  enteroptosis,  nephroptosis,  and  occupations  requiring  a  ''leaning 
forward"  position.  Lack  of  exercise,  sedentary  occupations,  particularly 
when  combined  with  over-indulgence  in  food,  constipation,  depressing  men- 
tal emotions  are  also  to  be  regarded  as  favoring  circumstances.     The  belief 


CHOLELITHIASIS.  563 

prevailed  formerly  that  there  was  a  lithiac  diathesis  closely  allied  to  that 
of  gout. 

Physical  Characters  of  Gall-stones. — They  may  be  single,  in  which  case 
the  stone  is  usually  ovoid  and  may  attain  a  very  large  size.  Instances  are 
on  record  of  gall-stones  measuring  more  than  5  inches  in  length.  They  may 
be  extremely  numerous,  ranging  from  a  score  to  several  hundreds  or  even 
several  thousands,  in  which  case  the  stones  are  very  small.  When  moderately 
numerous,  they  show  signs  of  mutual  pressure  and  have  a  polygonal  form, 
with  smooth  facets;  occasionally,  however,  five  or  six  gall-stones  of  medium 
size  are  met  with  in  the  bladder  which  are  round  or  ovoid  and  without 
facets.  They  are  sometimes  mulberry-shaped  and  very  dark,  consisting 
largely  of  bile-pigments.  Again  there  are  small,  black  calculi,  rough  and 
irregular  in  shape,  and  varying  in  size  from  grains  of  sand  to  small  shot. 
These  are  sometimes  known  as  gall-sand.  On  section,  a  calculus  contains 
a  nucleus,  which  consists  of  bile-pigment,  rarely  a  foreign  body.  The 
greater  portion  of  the  stone  is  made  up  of  cholesterin,  which  may  form 
the  entire  calculus  and  is  arranged  in  concentric  lamina  showing  also  radi- 
ating lines.  Salts  of  lime  and  magnesia,  bile  acids,  fatty  acids,  and  traces 
of  iron  and  copper  are  also  found  in  them.  A  majority  of  gall-stones  con- 
sist of  from  70  to  80  per  cent  of  cholesterin,  in  either  the  amorphous  or  the 
crystalline  form.  As  above  stated,  it  is  sometimes  pure,  but  more  commonly 
it  is  mixed  with  the  bile-pigment.  The  outer  layer  of  the  stone  is  usually 
harder  and  brownish  in  color,  and  contains  a  larger  proportion  of  lime  salts. 

The  Seat  of  Formation. — Within  the  liver  itself  calculi  are  occasionally 
found,  but  are  here  usually  small  and  not  abundant,  and  in  the  form  of 
ovoid,  greenish-black  grains.  A  large  majority  of  all  calculi  are  formed 
within  the  gall-bladder.  The  stones  in  the  larger  ducts  have  usually  had 
their  origin  in  the  gall-bladder. 

Symptoms. — In  a  majority  of  the  cases,  gall-stones  cause  no  symp- 
toms. The  gall-bladder  will  tolerate  the  presence  of  large  numbers  for  an 
indefinite  period  of  time,  and  post-mortem  examinations  show  that  they 
are  present  in  25  per  cent  of  all  women  over  sixty  years  of  age  (Naunyn). 

The  French  writers  have  suggested  a  useful  division,  dealing  with  the 
main  symptoms  of  cholelithiasis,  into  (1)  the  aseptic,  mechanical  accidents 
in  consequence  of  migration  of  the  stone  or  of  obstruction,  either  in  the 
ducts  or  in  the  intestines;  (2)  the  septic,  infectious  accidents,  either  local 
(the  angiocholitis  and  cholecystitis  with  empyema  of  the  gall-bladder,  and 
the  fistulse  and  abscess  of  the  liver  and  infection  of  the  neighboring  parts) 
or  general,  the  biliary  fever  and  the  secondary  visceral  lesions. 

It  will  be  better,  perhaps,  to  consider  cholelithiasis  under  the  following 
headings:  The  symptoms  produced  by  the  passage  of  a  stone  through  the 
ducts — biliary  colic;  the  effects  of  permanent  plugging  of  the  cystic  duct; 
of  the  stone  in  the  common  duct;  and  the  more  remote  effects,  due  to 
ulceration,  perforation,  and  the  establishment  of  fistulas. 

1.  Biliary  Colic. — Gall-stoncs  may  become  engaged  in  the  cystic  or  the 
common  duct  without  producing  pain  or  severe  symptoms.  More  com- 
monly the  passage  of  a  stone  excites  the  violent  symptoms  known  as  biliary 
colic.    The  attack  sets  in  abruptly  with  agonizing  pain  in  the  right  hypo- 


564  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

chondriac  region,  which  radiates  to  the  shoulder,  or  is  very  intense  in  the 
epigastric  and  in  the  lower  thoracic  regions.  It  is  often  associated  with  a 
rigor  and  a  rise  in  temperature  from  103°  to  103°.  The  pain  is  usually  so 
intense  that  the  patient  rolls  about  in  agony.  There  are  vomiting,  pro- 
fuse sweating,  and  great  depression  of  the  circulation.  There  may  be 
marked  tenderness  in  the  region  of  the  liver,  which  may  be  enlarged,  and 
the  gall-bladder  may  become  palpable  and  very  tender.  In  other  cases  the 
fever  is  more  marked.  The  spleen  is  enlarged  (ISTaunyn)  and  the  urine  con- 
tains albumin  with  red  blood-corpuscles.  Ortner  holds  that  cholecystitis 
acuta,  occurringin  connection  with  gall-stones,  is  a  septic  (bacterial)  in- 
fection of  the  bile-passages.  The  symptoms  of  acute  infectious  cholecystitis 
and  those  of  what  we  call  gall-stone  colic  are  very  similar,  and  surgeons  have 
frequently  performed  cholecystotomy  for  the  former  condition,  believing 
calculi  were  present.  In  a  large  number  of  the  cases  jaundice  develops,  but 
it  is  not  a  necessary  symptom.  Of  course  it  does  not  occur  during  the  pas- 
sage of  the  stone  through  the  cystic  duct,  but  only  when  it  becomes 
lodged  in  the  common  duct.  The  pain  is  due  (a)  to  the  slow  progress  in 
the  cystic  duct,  in  which  the  stone  takes  a  rotary  course  owing  to  the  ar- 
rangement of  the  Heisterian  valve;  (b)  to  the  acute  inflammation  which 
usually  accompanies  an  attack;  and  (c)  to  the  stretching  and  distention  of 
the  gall-bladder  by  retained  secretions. 

The  attack  varies  in  duration.  It  may  last  for  a  few  hours,  several 
days,  or  even  a  week  or  more.  If  the  stone  becomes  impacted  in  the  orifice 
of  the  common  duct,  the  jaundice  becomes  intense;  much  more  commonly 
it  is  a  slight  transient  icterus.  The  attack  of  colic  may  be  repeated  at  in- 
tervals for  some  time,  but  finally  the  stone  passes  and  the  symptoms  rapidly 
disappear. 

Occasionally  accidents  occur,  such  as  rupture  of  the  duct  with  fatal 
peritonitis.  Fatal  syncope  during  an  attack,  and  the  occurrence  of  re- 
peated convulsive  seizures  have  come  under  my  observation.  These  are, 
however,  rare  events.  Palpitation  and  distress  about  the  heart  may  be 
present,  and  occasionally  a  mitral  murmur  develops  during  the  paroxysm; 
but  the  cardiac  conditions  described  by  some  writers  as  coming  on  acutely 
in  biliary  colic  are  possibly  pre-existent  in  these  patients. 

The  diagnosis  of  acute  hepatic  colic  is  generally  easy.  The  pain  is  in 
the  upper  abdominal  and  thoracic  regions,  whereas  the  pain  in  nephritic 
colic  is  in  the  lower  abdomen.  A  chill,  with  fever,  is  much  more  frequent 
in  biliary  colic  than  in  gastralgia,  with  which  it  is  liable,  at  times,  to  be 
confounded.  A  history  of  previous  attacks  is  an  important  guide,  and  the 
occurrence  of  jaundice,  however  slight,  determines  the  diagnosis.  To  look 
for  the  gall-stones,  the  stools  should  be  thoroughly  mixed  with  water  and 
carefully  filtered  through  a  narrow-meshed  sieve.  Pseudo-biliary  colic  is  not 
infrequently  met  with  in  nervous  women,  and  the  diagnosis  of  gall-stones 
made.  This  nervous  hepatic  colic  may  be  periodical;  the  pain  may  be  in  the 
right  side  and  radiating;  sometimes  associated  with  other  nervous  phenom- 
ena, often  excited  by  emotion,  tire,  or  excesses.  The  liver  may  be  tender, 
but  there  are  neither  icterus  nor  inflammatory  conditions.  The  combina- 
tion of  colic  and  jaundice,  so  distinctive  of  gall-stones,  is  not  always  present. 


CHOLELITHIASIS.  565 

The  pains  may  be  not  colicky,  but  more  constant  and  dragging  in  charac- 
ter. Of  50  cases  operated  upon  by  Riedel,  10  had  not  had  colic,  only  14 
presented  a  gall-bladder  tumor,  while  a  majority  had  not  had  jaundice.  A 
remarkable  xanthoma  of  the  bile-passages  has  been  found  in  association  with 
hepatic  colic.  I  have  already  spoken  of  the  diagnosis  of  acute  cholecystitis 
from  appendicitis  and  obstruction  of  the  bowels.  Eecurring  attacks  of  pain 
in  the  region  of  the  liver  may  follow  adhesions  between  the  gall-bladder 
and  adjacent  parts. 

2.  Obstruction  of  the  Cystic  Duct. — The  effects  may  be  thus  enumer- 
ated: 

(a)  Dilatation  of  the  gall-bladder — hydrops  vesicae  fellese.  In  acute  ob- 
struction the  contents  are  bile  mixed  with  much  mucous  or  muco-puruleut 
material.  In  chronic  obstruction  the  bile  is  replaced  by  a  clear  fluid  mucus. 
This  is  an  important  point  in  diagnosis,  particularly  as  a  dropsical  gall- 
bladder may  form  a  very  large  tumor.  The  reaction  is  not  always  con- 
stant. It  is  either  alkaline  or  neutral;  the  consistence  is  thin  and  mucoid. 
Albumin  is  usually  present.  A  dilated  gall-bladder  may  reach  an  enormous 
size,  and  in  one  instance  Tait  found  it  occupying  the  greater  part  of  the 
abdomen.  In  such  cases,  as  is  not  unnatural,  it  has  been  mistaken  for  an 
ovarian  tumor.  I  have  described  a  case  in  which  it  was  attached  to  the 
right  broad  ligament.  The  dilated  gall-bladder  can  usually  be  felt  below 
the  edge  of  the  liver,  and  in  many  instances  it  has  a  characteristic  outline 
like  a  gourd.  An  enlarged  and  relaxed  organ  may  not  be  palpable,  and  in 
acute  cases  the  distention  may  be  upward  toward  the  hilus  of  the  liver. 
The  dilated  gall-bladder  usually  projects  directly  downward,  rarely  to  one 
side  or  the  other,  though  occasionally  toward  the  middle  line.  It  may 
reach  below  the  navel,  and  in  persons  with  thin  walls  the  outline  can  b$ 
accurately  defined.  Eiedel  has  called  attention  to  a  tongue-like  projection 
of  the  anterior  margin  of  the  right  lobe  in  connection  with  enlarged  gall- 
bladder. It  is  to  be  remembered  that  distention  of  the  gall-bladder  may 
occur  without  jaundice;  indeed,  the  greatest  enlargement  has  been  met  with 
in  such  cases. 

Gall-stone  crepitus  may  be  felt  when  the  bladder  is  very  full  of  stones 
and  its  walls  not  very  tense.  It  is  rarely  well  felt  unless  the  abdominal  walls 
are  much  relaxed.  It  may  be  found  in  patients  who  have  never  had  any 
symptoms  of  cholelithiasis. 

(h)  Acute  cholecystitis.  The  simple  form  is  common,  and  to  it  are  due 
probably  very  many  of  the  symptoms  of  the  gall-stone  attack.  Phleg- 
monous cholecystitis  is  rare;  only  seven  instances  are  found  in  the  enor- 
mous statistics  of  Courvoisier.  It  is,  however, .  much  more  common  than 
these  figures  indicate.     Perforation  may  occur  with  fatal  peritonitis. 

(c)  Suppurative  cholecystitis,  empyema  of  the  gall-bladder,  is  much 
more  common,  and  in  the  great  majority  of  cases  is  associated  with  gall- 
stones— 41  in  55  cases  (Courvoisier).  There  may  be  enormous  dilatation, 
and  over  a  litre  of  pus  has  been  found.  Perforation  and  the  formation  of 
abscesses  in  the  neighborhood  are  not  uncommon. 

(d)  Calcification  of  the  gall-bladder  is  commonly  a  termination  of  the 
previous  condition.     There  are  two  separate  forms:  incnistation  of  the 


666  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

mucosa  with  lime  salts  and  the  true  infiltration  of  the  wall  with  lime,  the 
so-called  ossification.  A  remarkable  example  of  the  latter,  sent  to  me  by 
Groves,  of  Carp,  is  now  in  the  McGill  Medical  Museum. 

(e)  Atrophy  of  the  gall-bladder.  This  is  by  no  means  uncommon.  The 
organ  shrinks  into  a  small  fibroid  mass,  not  larger,  perhaps,  than  a  good- 
sized  pea  or  walnut,  or  even  has  the  form  of  a  narrow  fibrous  string;  more 
commonly  the  gall-bladder  tightly  embraces  a  stone.  This  condition  is 
usually  preceded  by  hydrops  of  the  bladder. 

Occasionally  the  gall-bladder  presents  diverticula,  which  may  be  cut  off 
from  the  main  portion,  and  usually  contain  calculi. 

(3)  Obstruction  of  the  Commoil  Duct. — There  may  be  a  single  stone 
tightly  wedged  in  the  duct  in  any  part  of  its  course,  or  a  series  of  stones, 
sometimes  extending  into  both  hepatic  and  cystic  ducts,  or  a  stone  lies  in 
the  diverticulum  of  Vater.  There  are  three  groups  of  cases:  {a)  In  rare 
instances  a  stone  tightly  corks  the  common  duct,  causing  permanent  occlu- 
sion; or  it  may  partly  rest  in  the  cystic  duct,  and  may  have  caused  thicken- 
ing of  the  Junction  of  the  ducts;  or  a  big  stone  may  compress  the  hepatic 
or  upper  part  of  the  common  duct.  The  jaundice  is  deep  and  enduring, 
and  there  are  no  septic  features.  The  pains,  the  previous  attacks  of  colic, 
and  the  absence  of  enlarged  gall-bladder  help  to  separate  the  condition  from 
obstruction  by  new  growths,  although  it  cannot  be  differentiated  with  cer- 
tainty. The  ducts  are  usually  much  dilated  and  everywhere  contain  a  clear 
mucoid  fluid. 

(&)  Incomplete  obstruction,  with  infective  cholangitis. 

There  may  be  a  series  of  stones  in  the  common  duct,  a  single  stone  which 
is  freely  movable,  or  a  stone  (ball-valve  stone)  in  the  diverticulum  of  Vater. 
These  conditions  may  be  met  with  at  autopsy,  without  the  subjects  having 
had  symptoms  pointing  to  gall-stones;  but  in  a  majority  of  cases  there  are 
very  characteristic  features. 

The  common  duet  may  be  as  large  as  the  thumb;  the  hepatic  duct  and 
its  branches  through  the  liver  may  be  greatly  dilated,  and  the  distention  may 
even  be  apparent  beneath  the  liver  capsule.  Great  enlargement  of  the 
gall-bladder  is  rare.  The  mucous  membrane  of  the  ducts  is  usually  smooth 
and  clear,  and  the  contents  consist  of  a  thin,  slightly  turbid  bile-stained 
mucus. 

Naunyn  has  given  the  following  as  the  distinguishing  signs  of  stone  in 
the  common  duct:  "  (1)  The  continuous  or  occasional  presence  of  bile  in 
the  faeces;  (2)  distinct  variations  in  the  intensity  of  the  jaundice;  (3) 
normal  size  or  only  slight  enlargement  of  the  liver;  (4)  absence  of  disten- 
tion of  the  gall-bladder;  (5)  enlargement  of  the  spleen;  (6)  absence  of 
ascites;  (7)  presence  of  febrile  disturbance;  and  (8)  duration  of  the  jaun- 
dice for  more  than  a  year." 

In  connection  with  the  ball-valve  stone,  which  is  most  commonly  found 
in  the  diverticulum  of  Vater,  though  it  may  be  in  the  common  duct  itself, 
I  have  tried  to  separate  a  special  symptom  group:  (a)  Ague-like  paroxysms, 
chills,  fever,  and  sweating;  the  hepatic  intermittent  fever  of  Charcot;  (&) 
jaundice  of  varying  intensity,  which  persists  for  months  or  even  years,  and 
deepens  after  each  paroxysm;  (c)  at  the  time  of  the  paroxysms,  pains  in  the 


CHOLELITHIASIS.  56Y 

region  of  the  liver  with  gastric  disturbance.  These  symptoms  may  continue 
on  and  off  for  three  or  four  years,  without  the  development  of  suppurative 
cholangitis.  In  one  of  my  cases  the  jaundice  and  recurring  hepatic  inter- 
mittent fever  existed  from  July,  1879,  until  August,  1882;  the  patient  re- 
covered and  still  lives.  The  condition  has  lasted  from  eight  months  to 
three  years.  The  rigors  are  of  intense  severity,  and  the  temperature  rises 
to  103°  or  105°.  The  chills  may  recur  daily  for  weeks,  and  present  a  tertian 
or  quartan  type,  so  that  they  are  often  attributed  to  malaria,  with  which, 
however,  they  have  no  connection.  The  jaundice  is  variable,  and  deepens 
after  each  paroxysm.  The  itching  may  be  most  intense.  Pain,  which  is 
sometimes  severe  and  colicky,  does  not  always  occur.  There  may  be  marked 
vomiting  and  nausea.  As  a  rule  there  is  no  progressive  deterioration  of 
health.     In  the  intervals  between  the  attacks  the  temperature  is  normal. 

The  clinical  history  and  the  post-mortem  examinations  in  my  cases  show 
conclusively  that  this  condition  may  persist  for  years  without  a  trace  of 
suppuration  within  the  ducts.  There  must,  however,  be  an  infection,  such 
as  may  exist  for  years  in  the  gall-bladder,  without  causing  suppuration. 
It  is  probable  that  the  toxic  symptoms  only  develop  when  a  certain  grade 
of  tension  is  reached. 

An  interesting  and  valuable  diagnostic  point  is  the  absence  of  dilatation 
of  the  gall-bladder  in  cases  of  obstruction  from  stone — Courvoisier's  rule. 
Ecklin,  who  has  recently  reviewed  this  point,  finds  that  of  172  cases  of  ob- 
struction of  the  common  duct  by  calculus  in  34  the  gall-bladder  was  normal, 
in  110  it  was  contracted,  and  in  28  it  was  dilated.  Of  139  cases  of  occlusion 
of  the  common  duct  from  other  causes  the  gall-bladder  was  normal  in  9, 
shrunken  in  9,  and  dilated  in  121. 

(c)  Incomplete  obstruction,  with  suppurative  cholangitis. 

When  suppurative  cholangitis  exists  the  mucosa  is  thickened,  often 
eroded  or  ulcerated;  there  may  be  extensive  suppuration  in  the  ducts 
throughout  the  liver,  and  even  empyema  of  the  gall-bladder.  Occasionally 
the  suppuration  extends  beyond  the  ducts,  and  there  is  localized  liver  ab- 
scess, or  there  is  perforation  of  the  gall-bladder  with  the  formation  of  ab- 
scess between  the  liver  and  stomach. 

Clinically  it  is  characterized  by  a  fever  which  may  be  intermittent,  but 
more  commonly  is  remittent  and  without  prolonged  intervals  of  apyrexia. 
The  jaundice  is  rarely  so  intense,  nor  do  we  see  the  deepening  of  the  color 
after  the  paroxysms.  There  is  usually  greater  enlargement  of  the  liver 
and  tenderness  and  more  definite  signs  of  septicemia.  The  cases  run  a 
shorter  course,  and  recovery  never  takes  place. 

(4)  The  More  Remote  Effects  of  Gall-stones. — (a)  Biliary  Fistulce. 
These  are  not  uncommon.  There  may,  for  instance,  be  abnormal  commu- 
nication between  the  gall-bladder  and  the  hepatic  duct  or  the  gall-bladder 
and  a  cavity  in  the  liver  itself.  More  rarely  perforation  occurs  between 
the  common  duct  and  the  portal  vein.  Of  this  there  are  at  least  four  in- 
stances on  record,  among  them  the  celebrated  case  of  Ignatius  Loyola. 
Perforation  into  the  abdominal  cavity  is  not  uncommon;  119  cases  exist 
in  the  literature  (Courvoisier),  in  70  of  which  the  rupture  occurred  directly 
into  the  peritoneal  cavity;  in  49  there  was  an  encapsulated  abscess.    Per- 


568  DISEASES   OF  THE  DiaESTIYE  SYSTEM. 

foration  may  take  place  from  an  intrahepatic  branch  or  from  the  hepatic, 
common,  or  cystic  ducts.  Perforation  from  the  gall-bladder  is  the  most 
common. 

Fistulous  communications  between  the  bile-passages  and  the  gastro-in- 
testinal  canal  are  frequent.  Openings  into  the  stomach  are  rare.  Between 
the  duodenum  and  bile-passages  they  are  much  more  common.  Cour- 
voisier  has  collected  10  instances  of  communication  between  the  ductus 
communis  and  the  duodenum,  and  73  cases  between  the  gall-bladder  and 
the  duodenum.  Communication  with  the  ileum  and  jejunum  is  extremely 
rare.  Of  fistulous  opening  into  the  colon  39  cases  are  on  record.  These 
communications  can  rarely  be  diagnosed;  they  may  be  present  without  any 
symptoms  whateyer.  It  is  probably  by  ulceration  into  the  duodenum  or 
colon  that  the  large  gall-stones  escape. 

Occasionally  the  urinary  passages  may  be  opened  into  and  the  stones 
may  be  found  in  the  bladder.  Many  instances  are  on  record  of  fistulas  be- 
tween the  bile-passages  and  the  lungs.  Courvoisier  has  collected  24  cases, 
to  which  list  J.  E.  Graham  has  added  10,  including  2  cases  of  his  own. 
(Trans,  of  Assoc,  of  Am.  Physicians,  xiii.)  Bile  may  be  coughed  up  with 
the  expectoration,  sometimes  in  considerable  quantities. 

Of  all  fistulous  communications  the  external  or  cutaneous  is  the  most 
common.  Courvoisier's  statistics  number  184  cases,  in  50  per  cent  of 
which  the  perforation  took  place  in  the  right  hypochondrium;  in  29  per 
cent  in  the  region  of  the  navel.  The  number  of  stones  discharged  varied 
from  one  or  two  to  many  hundreds.  Eecovery  took  place  in  78  cases;  some 
with,  some  without  operation. 

(&)  Obstruction  of  the  Bowel  ly  Gall-stones. — Eeference  has  already  been 
made  to  this;  its  frequency  appears  from  the  fact  that  of  295  cases  of 
obstruction,  occurring  during  eight  years,  analyzed  by  Fitz,  23  were  by 
gall-stone.  Courvoisier's  statistics  give  a  total  number  of  131  cases,  in  6 
of  which  the  calculi  had  a  peculiar  situation,  as  in  a  diverticulum  or  in  the 
appendix.  Of  the  remaining  125  cases,  in  70  the  stone  was  spontaneously 
passed,  usually  with  severe  symptoms.  The  post-mortem  reports  show  that 
in  some  of  these  cases  even  very  large  stones  have  passed  per  viam  naturalem, 
as  the  gall-duct  has  been  enormously  distended,  its  orifice  admitting  the 
finger  freely.  This,  however,  is  extremely  rare.  The  stones  have  been 
found  most  commonly  in  the  ileum. 

Treatment  of  Gall-stones  and  tlieir  Effects. — In  an  attack  of 
biliary  colic  the  patient  should  be  kept  under  morj^hia,  given  hypodermic- 
ally,  in  quarter-grain  doses.  In  an  agonizing  paroxysm  it  is  well  to  give 
a  whiff  or  two  of  chloroform  until  the  morphia  has  had  time  to  act.  Great 
relief  is  experienced  from  the  hot  bath  and  from  fomentations  in  the  region 
of  the  liver.  The  patient  should  be  given  laxatives  and  should  drink  co- 
piousl)""  of  alkaline  mineral  waters.  Olive  oil  has  proved  useless  in  my 
hands.  When  taken  in  large  quantities,  fatty  concretions  are  passed  with 
the  stools,  which  have  been  regarded  as  calculi;  and  concretions  due  to 
eating  pears  have  been  also  mistaken,  particularly  when  associated  with 
colic  attacks.  Since  the  days  of  Durande,  whose  mixture  of  ether  and 
turpentine  is  still  largely  used  in  France,  various  remedies  have  been  ad- 


THE   CIRRHOSES   OF   THE   LIVER.  569 

vised  to  dissolve  the  stoues  witliin  tlie  gall-bladder,  none  of  which  are 
efficacious. 

The  diet  should  be  regulated,  the  patient  should  take  regular  exercise 
and  avoid,  as  much  as  possible,  the  starchy  and  saccharine  foods.  The 
soda  salts  recommended  by  Prout  are  believed  to  prevent  the  concentra- 
tion of  the  bile  and  the  formation  of  gall-stones.  Either  the  sulphate  or 
the  phosphate  may  be  taken  in  doses  of  from  1  to  2  drachms  daily. 
For  the  intolerable  itching  McCall  Anderson's  dusting  powder  may  be  used: 
starch,  an  ounce;  camphor,  a  drachm  and  a  half;  and  oxide  of  zinc,  half 
an  ounce.  Some  of  this  should  be  finely  dusted  over  the  skin  with  a  powder- 
puff.  Powdering  with  starch,  strong  alkaline  baths  (hot),  pilocarpin  hypo- 
dermically  (gr.  ^-f ),  and  antipyrin  (gr.  viij),  may  be  tried.  Ichthyol  and 
lanolin  ointment  sometimes  gives  relief. 

Exploratory  puncture,  as  practised  by  the  elder  Pepper,  in  1857,  in  a 
case  of  empyema  of  the  gall-bladder,  and  by  Bartholow  in  1878  is  not 
now  often  done.  Aspiration  is  usually  a  safe  procedure,  though  a  fatal 
result  has  followed. 

The  surgical  treatment  of  gall-stones  has  of  late  years  made  rapid 
progress.  The  operation  of  cholecystotomy,  or  opening  the  gall-bladder 
and  removing  the  stones,  which  was  advised  by  Sims,  has  been  remark- 
ably successful.  The  removal  of  the  gall-bladder,  cholecystectomy,  has  also 
been  practised  with  success.  The  indications  for  operation  are:  (a)  Ee- 
peated  attacks  of  gall-stone  colic.  The  operation  is  now  attended  with  such 
slight  risk  that  the  patient  is  much  safer  in  the  hands  of  a  surgeon  than 
when  left  to  Nature,  with  the  feeble  assistance  of  drugs  and  mineral  waters. 
(b)  The  presence  of  a  distended  gall-bladder,  associated  with  attacks  of  pain 
or  with  fever,  (c)  Wlien  a  gall-stone  is  permanently  lodged  in  the  common 
duct,  and  the  group  of  symptoms  above  described  are  present,  the  ques- 
tion, then,  of  advising  operation  depends  largely  upon  the  personal  methods 
and  success  of  the  surgeon  who  is  available.  The  operation,  necessarily 
much  more  serious  and  difficidt  than  that  upon  the  gall-bladder,  is  now 
remarkably  successful  even  in  desperate  cases  of  years'  duration. 


VII.     THE    CIRRHOSES    OF   THE    LIVER. 

General  Considerations. ^The  many  forms  of  cirrhoses  of  the 
liver  have  one  feature  in  common — an  increase  in  the  connective  tissue  of 
the  organ.  In  fact,  we  use  the  term  cirrhosis  (by  which  Lannec  character- 
ized the  tawny,  yellow  color  of  the  common  atrophic  form)  to  indicate  simi- 
lar changes  in  other  organs. 

The  cirrhoses  may  be  classified,  etiologically,  according  to  the  supposed 
causation;  anatomically,  according  to  the  structure  primarily  involved;  or 
clinically,  according  to  certain  special  S3'mptoms. 

Etiological  Classification.— 1.  Toxic  Cirrhoses. — Alcohol  is  the  chief 
cause  of  cirrhosis  of  the  liver.  Other  poisons,  such  as  lead  and  the  toxic 
products  of  faulty  metabolism  in  gout,  diabetes,  rickets,  and  indigestion, 
play  a  minor  role. 


570  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

2.  Infectious  Cirrhoses. — With  many  of  the  specific  fevers  necrotic 
changes  occur  in  the  Hver  which,  when  widespread,  may  be  followed  by 
cirrhosis.  Possibly  the  hypertrophic  cirrhosis  of  Hanot  and  other  forms 
met  with  in  early  life  are  due  to  infection.  The  malarial  cirrhosis  is  a  well- 
recognized  variety.  The  syphilitic  poison  produces  a  very  characteristic 
form. 

3.  Cirrhosis  from  chronic  congestion  of  the  llood-vessels  in  heart-disease 
— the  cardiac  liver. 

4.  Cirrhosis  from  chronic  obstruction  of  the  tile-ducts,  a  form  of  very 
slight  clinical  interest.  In  anthracosis  the  carbon  pigment  may  reach  the 
liver  in  large  quantities  and  be  deposited  in  the  connective  tissue  about  the 
portal  canal,  leading  to  cirrhosis  (Welch). 

Anatomical  Classiflcation. — 1.  Vascular  cirrhoses,  in  which  the  new 
growth  of  connective  tissue  has  its  starting  point  about  the  finer  branches 
the  portal  or  hepatic  veins. 

2.  Biliary  cirrhoses,  in  which  the  process  is  supposed  to  begin  about 
the  finer  bile-ducts,  as  in  the  hypertrophic  cirrhosis  of  Hanot  and  in  the 
form  from  obstruction  of  the  larger  ducts. 

3.  Capsular  cirrhoses,  a  perihepatitis  leading  to  great  thickening  of  the 
capsule  and  reduction  in  the  volume  of  the  liver. 

Clinical  Classiflcation. — For  practical  purposes  we  may  recognize  the  fol- 
lowing varieties  of  cirrhosis  of  the  liver: 

1.  The  alcoholic  cirrhosis  of  Laennec,  including  with  this  the  fatty  cir- 
rhotic liver. 

2.  The  hypertrophic  cirrhosis  of  Hanot. 

3.  Syphilitic  cirrhosis. 

4.  Capsular  cirrhosis — chronic  perihepatitis. 

Other  forms,  of  slight  clinical  interest,  are  considered  elsewhere  under 
diabetes,  malaria,  tuberculosis,  and  heart-disease.  The  cirrhosis  from  ma- 
laria, upon  which  the  French  writers  lay  so  much  stress  (one  describes  thir- 
teen varieties!),  is  excessively  rare.  In  our  large  experience  with  malaria 
during  the  past  nine  years  not  a  single  case  of  advanced  cirrhosis  due  to 
this  cause  has  been  seen  in  the  wards  or  autopsy-room  of  the  Johns  Hop- 
kins Hospital. 

I.    ALCOHOLIC  CIRRHOSIS. 

Etiology.— The  disease  occurs  most  frequently  in  middle-aged  males 
who  have  been  addicted  to  drink.  Whiskey,  gin,  and  brandy  are  more  po- 
tent to  cause  cirrhoses  than  beer.  It  is  more  common  in  countries  in  which 
strong  spirits  are  used  than  in  those  in  which  malt  liquors  are  taken.  Among 
1,000  autopsies  in  my  colleague  Welch's  department  of  the  Johns  Hopkins 
Hospital  there  were  63  cases  of  small  atrophic  liver,  and  8  cases  of  the  fatty 
cirrhotic  organ.  Lancereaux  claims  that  the  vin  ordinaire  of  France  is  a 
common  cause  of  cirrhosis.  Of  210  cases,  excess  in  wine  alone  was  present 
in  68  cases.  He  thinks  it  is  the  sulphate  of  potash  in  the  plaster  of  Paris 
used  to  give  the  "  dry  "  flavor  which  damages  the  liver. 

Cirrhosis  of  the  liver  in  young  children  is  not  very  rare.  Palmer  How- 
ard collected  63  cases,  to  which  Hatfield  added  93.     In  a  certain  num- 


THE  CIRRHOSES  OF  THE  LIVER.  571 

ber  of  the  cases  there  is  an  alcoholic  history,  in  others  syphilis  has  been  pres- 
ent, while  a  third  group,  due  to  the  poisons  of  the  infectious  diseases,  em- 
braces a  certain  number  of  the  cases  of  Hanot's  hypertrophic  cirrhosis. 

Morbid  Anatomy. — Practically  on  the  post-mortem  table  we  see 
alcoholic  cirrhosis  in  two  well-characterized  forms: 

The  Atropine  Cirrhosis  of  Laennec. — The  organ  is  greatly  reduced  in 
size  and  may  be  deformed.  The  weight  is  sometimes  not  more  than  a 
pound  or  a  pound  and  a  half.  It  presents  numerous  granulations  on  the 
surface;  is  firm,  hard,  and  cuts  with  great  resistance.  The  substance  is 
seen  to  be  made  up  of  greenish-yellow  islands,  surrounded  by  grayish-white 
connective  tissue.  This  yellow  appearance  of  the  liver  induced  Laennec  to 
give  to  the  condition  the  name,  of  cirrhosis. 

The  Fatty  Cirrhotic  Liver. — Even  in  the  atrophic  form  the  fat  is  in- 
creased, but  in  typical  examples  of  this  variety  the  organ  is  not  reduced  in 
size,  but  is  enlarged,  smooth  or  very  slightly  granular,  anaemic,  yellowish 
white  in  color,  and  resembles  an  ordinary  fatty  liver.  It  is,  however,  firm, 
cuts  with  resistance,  and  microscopically  shows  a  great  increase  in  the  con- 
nective tissue.    This  form  occurs  most  frequently  in  beer-drinkers. 

The  two  essential  elements  in  cirrhosis  are  destruction  of  liver-cells  and 
obstruction  to  the  portal  circulation. 

In  an  autopsy  on  a  case  of  atrophic  cirrhosis  the  peritonaeum  is  usually 
found  to  contain  a  large  quantity  of  fluid,  the  membrane  is  opaque,  and 
there  is  chronic  catarrh  of  the  stomach  and  of  the  small  intestines.  The 
spleen  is  enlarged,  in  part,  at  least,  from  the  chronic  congestion,  possibly 
due  in  part  to  a  "  vital  reaction,"  to  a  toxic  influence  (Parkes  Weber).  The 
kidneys  are  sometimes  cirrhotic,  the  bases  of  the  lungs  may  be  much  com- 
pressed by  the  ascitic  fluid,  the  heart  often  shows  marked  degeneration, 
and  arterio-sclerosis  is  usually  present.  A  remarkable  feature  is  the  asso- 
ciation of  acute  tuberculosis  with  cirrhosis.  In  seven  cases  of  my  series 
the  patients  died  with  either  acute  tuberculous  peritonitis  or  acute  tuber- 
culous pleurisy.  Pitt  states  that  22^  per  cent  of  the  cases  of  cirrhosis  dying 
in  Guy's  Hospital  during  twelve  years  had  acute  tuberculosis.  Of  121 
autopsies  at  the  Manchester  Koyal  Infirmary  in  cirrhosis,  about  23  per  cent 
gave  evidence  of  tuberculous  infection.  Twelve  of  these  had  tuberculosis 
of  the  peritonaeum,  and  12  died  directly  from  the  tuberculous  infection 
(Kelynack). 

The  compensatory  circulation  is  usually  readily  demonstrated.  It  is 
carried  out  by  the  following  set  of  vessels:  (1)  The  accessory  portal  S3^stem 
of  Sappey,  of  which  important  branches  pass  in  the  round  and  suspensory 
ligaments  and  unite  with  the  epigastric  and  mammary  systems.  These  ves- 
sels are  numerous  and  small.  Occasionally  a  large  single  vein,  which  may 
attain  the  size  of  the  little  finger,  passes  from  the  hilus  of  the  liver,  follows 
the  round  ligament,  and  joins  the  epigastric  veins  at  tlie  navel.  Although 
this  has  the  position  of  the  umbilical  vein,  it  is  usually,  as  Sa])pey  showed, 
a  para-umbilical  vein — tbat  is,  an  enlarged  vein  by  tlie  side  of  the  obliter- 
ated umbilical  vessel.  There  may  be  produced  about  the  navel  a  large 
bunch  of  varices,  the  so-called  caput  Medusa\  Otlior  branches  of  this 
system  occur  in  the  gastro-epiploic  omentum,  about  the  gall-bladder,  and, 


572  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

most  important  of  all,  in  the  suspensory  ligament.  These  latter  form  large 
branches,  which  anastomose  freely  with  the  diaphragmatic  veins,  and  so 
unite  with  the  vena  azygos.  (2)  By  the  anastomosis  between  the  oesoph- 
ageal and  gastric  veins.  The  veins  at  the  lower  end  of  the  oesophagus  may 
be  enormously  enlarged,  producing  varices  which  project  on  the  mucous 
membrane.  (3)  The  communications  between  the  hagmorrhoidal  and  the  in- 
ferior mesenteric  veins.  The  freedom  of  communication  in  this  direction 
is  very  variable,  and  in  some  instances  the  hsemorrhoidal  veins  are  not  much 
enlarged.  (4)  The  veins  of  Eetzius,  which  unite  the  radicles  of  the  portal 
branches  in  the  intestines  and  mesentery  with  the  inferior  vena  cava  and 
its  branches.  To  this  system  belong  the  whole  group  of  retroperitoneal 
veins,  which  are  in  most  instances  enormously  enlarged,  particularly  about 
the  kidneys,  and  which  serve  to  carry  off  a  considerable  proportion  of  the 
portal  blood. 

Symptoms. — The  most  extreme  grade  of  atrophic  cirrhosis  may  exist 
without  symptoms.  So  long  as  the  compensatory  circulation  is  maintained 
the  patient  may  suffer  little  or  no  inconvenience.  The  remarkable  effi- 
ciency of  this  collateral  circulation  is  well  seen  in  those  rare  instances  of 
permanent  obliteration  of  the  portal  vein.  The  symptoms  may  be  divided 
into  two  groups — obstructive  and  toxic. 

Obstructive. — The  overfilling  of  the  blood-vessels  of  the  stomach  and 
intestine  lead  to  chronic  catarrh,  and  the  patients  suffer  with  nausea  and 
vomiting,  particularly  in  the  morning;  the  toiigue  is  furred  and  the  bowels 
are  irregular.  Haemorrhage  from  the  stomach  may  be  an  early  symptom; 
it  is  often  profuse  and  liable  to  recur.  It  seldom  proves  fatal.  The  amount 
vomited  may  be  remarkable,  as  in  a  case  already  referred  to,  in  which  ten 
pounds  were  ejected  in  seven  days.  Following  the  hgematemesis  melsena 
is  common;  but  haemorrhages  from  the  bowels  may  occur  for  several  years 
without  hai^niatemesis.  The  bleeding  very  often  comes  from  the  oesopha- 
geal varices  already  described  (p.  459).  Very  frequently  epistaxis  occurs. 
Enlargement  of  the  spleen  may,  as  Parkes  Weber  suggests,  be  due  to  a 
toxemia.  The  organ  can  usually  be  felt.  Evidences  of  the  establishment 
of  the  collateral  circulation  are  seen  in  the  enlarged  epigastric  and  mam- 
mary veins,  more  rarely  in  the  presence  of  the  caput  MedusEe  and  in  the 
development  of  haemorrhoids.  The  distended  venules  in  the  lower  thoracic 
zone  along  the  line  of  attachment  of  the  diaphragm  are  not  specially 
marked  in  cirrhosis.  The  most  striking  feature  of  failure  in  the  com- 
pensatory circulation  is  ascites,  the  effusion  of  serous  fluid  into  the  peri- 
toneal cavity.  The  conditions  under  which  this  occurs  are  still  obscure. 
The  abdomen  gradually  distends,  may  reach  a  large  size,  and  contain  as 
much  as  15  or  20  litres.  CEdema  of  the  feet  may  precede  or  develop  with 
the  ascites.    The  dropsy  is  rarely  general.     Spider  angiomata  are  common. 

Jaundice  is  usually  slight,  and  was  present  hi  only  35  of  130  cases  of 
cirrhosis  reported  by  Fagge.  The  skin  has  frequently  a  sallow,  slightly 
icteroid  tint.  The  urine  is  often  reduced  in  amount,  contains  urates  in 
abundance,  often  a  slight  amount  of  albumin,  and,  if  jaundice  is  intense, 
tube-casts.  The  disease  may  be  afebrile  throughout,  but  in  many  cases, 
as  shown  by  Carrington,  there  is  slight  fever,  from  100°  to  102.5°. 


THE  CIRRHOSES  OF  THE  LIVER.  573 

Examination  at  an  early  stage  of  the  disease  may  show  an  enlarged  and 
painful  liver.  Dreschfeld,  Foxwell,  and  others  in  England  have  of  late 
years  called  particular  attention  to  the  fact  that  in  very  many  of  the  cases 
of  alcoholic  cirrhosis  the  organ  is  "  enlarged  at  all  stages  of  the  disease,  and 
that  whether  enlarged  or  contracted  the  clinical  symptoms  and  course  are 
much  the  same  "  (Foxwell).  The  patient  may  first  come  under  observa- 
tion for  dyspepsia,  hsematemesis,  slight  jaundice,  or  nervous  symptoms. 
Later  in  the  disease,  the  patient  has  an  unmistakable  hepatic  facies;  he  is 
thin,  the  eyes  are  sunken,  the  conjunctivge  watery,  the  nose  and  cheeks 
show  distended  venules,  and  the  complexion  is  muddy  or  icteroid.  On  the 
enlarged  abdomen  the  vessels  are  distended,  and  a  bunch  of  dilated  veins 
may  surround  the  navel.  When  much  fluid  is  in  the  peritonaeum  it  is 
impossible  to  make  a  satisfactory  examination,  but  after  withdrawal  the 
area  of  liver  dulness  is  found  to  be  diminished,  particularly  in  the  middle 
line,  and  on  deep  pressure  the  edge  of  the  liver  can  be  detected,  and  occa- 
sionally the  hard,  firm,  and  even  granular  surface.  The  spleen  can  be  felt 
in  the  left  hypochondriac  region.  Examination  of  the  anus  may  reveal 
the  presence  of  haemorrhoids. 

Toxic  Symptoms. — At  any  stage  of  atrophic  cirrhosis  the  patient  may 
develop  cerebral  symptoms,  either  a  noisy,  joyous  delirium,  or  stupor, 
coma,  or  even  convulsions.  The  condition  is  not  infrequently  mistaken  for 
uraemia.  The  nature  of  the  toxic  agent  is  not  yet  settled.  The  symptoms 
may  develop  without  jaundice,  and  cannot  be  attributed  to  cholsemia,  and 
they  may  come  on  in  hospital  when  the  patient  has  not  had  alcohol  for 
weeks. 

The  fatty  cirrhotic  liver  may  produce  symptoms  similar  to  those  of  the 
atrophic  form,  but  it  more  frequently  is  latent  and  is  found  accidentally  in 
topers  who  have  died  from  various  diseases.  The  greater  number  of  the  cases 
clinically  diagnosed  as  cirrhosis  with  enlargement  come  in  this  division. 

Diagnosis. — With  ascites,  a  well-marked  history  of  alcoholism,  the 
hepatic  facies,  and  haemorrhage  from  the  stomach  or  bowels,  the  diagnosis 
is  rarely  doubtful.  If,  after  withdrawal  of  the  fluid,  the  spleen  is  found 
to  be  enlarged  and  the  liver  either  not  palpable  or,  if  it  is  enlarged,  hard 
and  regular,  the  probabilities  in  favor  of  cirrhosis  are  very  great.  In  the 
early  stages  of  the  disease,  when  the  liver  is  increased  in  size,  it  may  be 
impossible  to  say  whether  it  is  a  cirrhotic  or  a  fatty  liver.  The  differential 
diagnosis  between  common  and  syphilitic  cirrhosis  can  sometimes  be  made. 
A  marked  history  of  syphilis  or  the  existence  of  other  syphilitic  lesions,  with 
great  irregularity  in  the  surface  or  at  the  edge  of  the  liver,  are  the  points 
in  favor  of  tbe  latter.  Thrombosis  or  obliteration  of  the  portal  vein  can 
rarely  Ije  difTcrentiated.  In  a  case  of  fibroid  transformation  of  the  portal 
vein  which  came  under  my  observation,  the  collateral  circulation  had  l)een 
established  for  years,  and  the  symptoms  were  sini])ly  those  of  extreme  por- 
tal obstruction,  such  as  occur  in  cirrhosis.  Thrombosis  of  the  portal  vein 
is  frequent  in  cirrhosis  and  may  be  characterized  by  a  rapidly  developing 
ascites. 

Prognosis. — Tbe  prognosis  is  bad.  When  tlic  coll;it(M'al  circulation 
is  fully  established  the  patient  may  have  no  symptoms  whatever.     Three 


574  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cases  of  advanced  atrophic  cirrliosis  have  died  under  my  observation  oi 
other  affections  without  presenting  during  life  any  symptoms  pointing  to 
disease  of  the  liver.  There  are  instances,  too,  of  enlargement  of  the  liver, 
slight  jaundice,  cerebral  symptoms,  and  even  hsematemesis,  in  which  the 
liver  becomes  reduced  in  size,  the  symptoms  disappear,  and  the  patient  may 
live  in  comparative  comfort  for  many  years.  There  are  eases,  too,  possibly 
syphilitic,  in  which,  after  one  or  two  tappings,  the  symptoms  have  disap- 
peared and  the  patients  have  apparently  recovered.  Ascites  is  a  very  serious 
event  in  ordinary  cirrhosis.  Of  34  cases  with  ascites  10  died  before  tap- 
ping was  necessary;  14  were  tapped,  and  the  average  duration  of  life  after 
the  swelling  was  first  noticed  was  only  eight  weeks;  of  10  cases  the  diag- 
nosis was  wrong  in  4,  and  in  the  remaining  6,  who  were  tapped  oftener 
than  once,  chronic  peritonitis  and  perihepatitis  were  present  (Hale  White). 

II.    HYPERTROPHIC  CIRRHOSIS  {Eanot). 

This  well-characterized  form  was  first  described  by  Eequin  in  1846, 
but  our  accurate  knowledge  of  the  condition  dates  from  the  work  of 
the  lamented  Hanot  (1875),  whose  name  in  France  it  bears — maladie  de 
Hanoi. 

Cirrhosis  with  enlargement  occurs  in  the  early  stage  of  atrophic  cirrho- 
sis; there  is  an  enlarged  fatty  and  cirrhotic  liver  of  alcoholics,  a  pigmentary 
form  in  diabetes  has  been  described,  and  in  association  with  syphilis  the 
organ  is  often  very  large.  The  hypertrophic  cirrhosis  of  Hanot  is  easily 
distinguished  from  these  forms. 

Etiology. — Males  are  more  often  affected  than  females — in  23 
of  Schachmann's  26  cases.  The  subjects  are  young;  some  of  the  cases 
in  children  probably  belong  to  this  form.  Of  four  recent  cases  under  my 
care  the  ages  were  from  twenty  to  thirty-five.  Two  were  brothers.  Alco- 
hol plays  a  minor  part.  Not  one  of  the  four  cases  referred  to  had  been  a 
heavy  drinker.  The  absence  of  all  known  etiological  factors  is  a  remark- 
able feature  in  a  majority  of  the  cases. 

Morbid  Anatomy. — The  organ  is  enlarged,  weighing  from  2,000  to 
4,000  grammes.  The  form  is  maintained,  the  surface  is  smooth,  or  presents 
small  granulations;  the  color  in  advanced  cases  is  of  a  dark  olive  green; 
the  consistence  is  greatly  increased.  The  section  is  uniform,  greenish  yel- 
low in  color,  and  the  liver  lobules  may  be  seen  separated  by  connective 
tissue.  The  bile-passages  present  nothing  abnormal.  In  a  case  without 
much  jaundice  exploratory  operation  showed  a  very  large  red  organ,  with 
a  slightly  roughened  surface.  Microscopically  the  following  characteris- 
tics are  described  by  French  writers:  The  cirrhosis  is  mono-  or  multilobular, 
with  a  connective  tissue  rich  in  round  cells.  The  bile-vessels  are  the  seat  of 
an  angiocholitis,  catarrhal  and  productive,  and  there  is  an  extraordinary 
development  of  new  biliary  canaliculi.  The  liver-cells  are  neither  fatty 
nor  pigmented,  and  may  be  increased  in  size  and  show  karyokinetic  figures. 
From  the  supposed  origin  about  the  bile-vessels  it  has  been  called  biliary  cir- 
rhosis, but  the  histological  detail?  have  not  yet  been  worked  out  fully,  and 
the  separation  of  this  as  a  distinct  form  should,  for  the  present  at  least,  rest 


THE  CIRRHOSES  OP  THE  LI\rER.  575 

upon  clinical  rather  than  anatomical  grounds.     The  spleen  is  greatly  en- 
larged and  may  weigh  600  or  more  grammes. 

Symptoms. — Hanot's  hypertrophic  cirrhosis  presents  the  following 
very  characteristic  group  of  symptoms.  As  previously  stated,  the  cases 
occur  in  young  persons;  there  is  not,  as  a  rule,  an  alcoholic  history,  and 
males  are  usually  affected:  (a)  A  remarkably  chronic  course  of  from  four 
to  six,  or  even  ten  years,  (i)  Jaundice,  usually  slight,  often  not  more  than 
a  lemon  tint,  or  a  tinging  of  the  conjunctivae.  At  any  time  during  the 
course  an  icterus  gravis,  with  high  fever  and  delirium,  may  develop.  There 
is  bile  in  the  urine;  the  stools  are  not  clay-colored  as  in  obstructive  jaundice, 
but  may  be  very  dark  and  "  bilious."  (c)  Attacks  of  pain  in  the  region  of  the 
liver,  which  may  be  severe  and  associated  with  nausea  and  vomiting.  The 
pain  may  be  slight  and  dragging,  and  in  some  cases  is  not  at  all  a  prom- 
inent symptom.  The  jaundice  may  deepen  after  attacks  of  pain,  (d) 
Enlarged  liver.  A  fulness  in  the  upper  abdominal  zone  may  be  the  first 
complaint.  On  inspection  the  enlargement  may  be  very  marked.  In  one 
of  my  cases  the  left  lobe  was  unusually  prominent  and  stood  out  almost 
like  a  tumor.  An  exploratory  operation  showed  only  an  enlarged,  smooth 
organ  without  adhesions.  On  palpation  the  hypertrophy  is  uniform,  the 
consistence  is  increased,  and  the  edge  distinct  and  hard.  The  gall-bladder 
is  not  enlarged.  The  vertical  flatness  is  much  increased  and  may  extend 
from  the  sixth  rib  to  the  level  of  the  navel,  (e)  The  spleen  is  enlarged,  eas- 
ily palpable,  and  very  hard.  (/)  Certain  negative  features  are  of  moment — 
absence  of  ascites  and  of  dilatation  of  the  subcutaneous  veins  of  the  abdo- 
men. Among  other  symptoms  may  be  mentioned  haemorrhages.  One  of 
my  cases  had  bleeding  at  the  gums  for  a  year;  another  had  had  for  years 
most  remarkable  attacks  of  purpura  with  urticaria.  Pruritus,  xanthoma, 
lichen,  and  telangiectasies  may  be  present  in  the  skin.  In  one  of  my  cases 
the  skin  became  very  bronzed,  almost  as  deeply  as  in  Addison's  disease. 
Slight  fever  may  be  present,  which  increases  during  the  crises  of  pain. 
There  may  be  a  marked  leucocytosis.  A  curious  attitude  of  the  body  has 
been  seen,  in  which  the  right  shoulder  and  right  side  look  dragged  down. 
The  patients  die  with  the  symptoms  of  icterus  gravis,  from  haemorrhage, 
from  an  intercurrent  infection,  or  in  a  profound  cachexia.  Certain  of  the 
cases  of  cirrhosis  of  the  liver  in  children  are  of  this  type;  the  enlargement 
of  the  spleen  may  be  very  pronounced. 

III.    SYPHILITIC  CIRRHOSIS. 

This  has  already  been  considered  in  the  section  on  syphilis  (p.  249).  I 
refer  to  it  again  to  emphasize  (1)  its  frequency;  (2)  the  great  importance  of 
its  differentiation  from  the  alcoholic  form;  (3)  its  curability  in  many  cases; 
and  (-i)  the  tumor  formations  in  connection  with  it. 

lY.    CAPSULAR  CIRRHOSIS— PERIHEPATITIS. 

Local  capsulitis  is  common  in  many  conditions  of  the  liver.  The  form 
of  disease  here  described  is  characterized  by  an  enormous  thickening  of  the 
entire  capsule,  with  great  contraction  of  the  liver,  but  not  necessarily  with 


576  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

special  increase  in  the  connective  tissue  of  the  organ  itself.  Our  chief 
knowledge  of  the  disease  we  owe  to  the  Guy's  Hospital  physicians,  particu- 
larly to  Hilton  Fagge  and  to  Hale  White,  who  has  collected  from  the  rec- 
ords 22  cases.  The  liver  substance  itself  was  "never  markedly  cirrhotic; 
its  tissue  was  nearly  always  soft."  Chronic  capsulitis  of  the  spleen  and  a 
chronic  proliferative  peritonitis  are  almost  invariably  present.  In  19  of 
the  22  cases  the  kidneys  were  granular.  Hale  White  regards  it  as  a  sequel 
of  interstitial  nephritis.  The  youngest  case  in  his  series  was  twenty-nine. 
The  symptoms  are  those  of  atrophic  cirrhosis — ascites,  often  recurring  and 
requiring  many  tappings.  Jaundice  is  not  often  present.  I  have  met  with 
two  groups  of  cases — the  one  in  adults  usually  with  ascites  and  regarded 
as  ordinary  cirrhosis.  I  have  never  made  a  diagnosis  in  such  a  case.  Signs 
of  interstitial  nephritis,  recurring  ascites,  and  absence  of  jaundice  are  re- 
garded by  Hale  White  as  important  diagnostic  points.  In  the  second 
group  of  cases  the  perihepatitis,  perisplenitis,  and  proliferative  peritonitis 
are  associated  with  adherent  pericardium  and  chronic  mediastinitis.  In  one 
such  case  the  diagnosis  of  capsular  hepatitis  was  very  clear,  as  the  liver 
could  be  grasped  in  the  hand  and  formed  a  rounded,  smooth  organ  resem- 
bling the  spleen.  The  child  was  tapped  121  times  (Archives  of  Psediatrics, 
1896). 

Treatment  of  the  Cirr hoses. — Ordinary  cirrhosis  of  the  liver  is 
an  incurable  disease.  Many  writers,  speaking  of  the  curability  of  certain 
forms,  show  a  lack  of  appreciation  of  the  essential  conditions  upon  which 
the  symptoms  depend.  So  far  as  we  have  any  knowledge,  no  remedies  at 
our  disposal  can  alter  or  remove  the  cicatricial  connective  tissue  which  con- 
stitutes the  materia  peccans  in  ordinary  cirrhosis.  On  the  other  hand,  we 
know  that  extreme  grades  of  contraction  of  the  liver  may  persist  for  years 
without  symptoms  when  the  compensatory  circulation  exists.  The  so-called 
cure  of  cirrhosis  means  the  re-establishment  of  this  compensation;  and  it 
would  be  as  unreasonable  to  speak  of  healing  a  chronic  valvular  lesion  when 
with  digitalis  we  have  restored  the  circulatory  balance  as  it  is  to  speak  of 
curing  cirrhosis  of  the  liver,  when  by  tapping  and  other  measures  the  com- 
pensation has  igi  some  way  been  restored. 

The  patient  should  abstain  entirely  from  alcohol,  and,  if  possible,  should 
take  a  milk  diet,  which  has  been  highly  recommended  by  Semmola.  In 
any  case,  the  diet  should  be  nutritious,  but  not  too  rich.  Measures  should 
be  employed  to  reduce  the  gastro-intestinal  catarrh,  and  the  patient  should 
lead  a  quiet,  out-of-door  life  and  keep  the  skin  active,  the  bowels  regular, 
and  the  urine  abundant.  In  non-syphilitic  cases  it  is  useless  to  give  either 
mercury  or  iodide  of  potassium.  When  a  well-marked  history  of  syphilis 
exists  these  remedies  should  be  used,  but  neither  of  them  has  any  more 
influence  upon  the  development  of  a  new  growth  of  connective  tissue  in 
the  liver  than  it  has  upon  the  progressive  development  of  a  scar  tissue  in 
a  keloid  or  in  an  ordinary  developing  cicatrix.  The  ascites  should  be 
tapped  early,  and  the  operation  may  be  repeated  so  soon  as  the  distention 
becomes  distressing.  Tbe  continuous  drainage  with  a  Southey's  tube  may 
be  employed.  It  is  much  better  to  resort  to  tapping  early  if  after  a  few 
days'  trial  the  fluid  does  not  subside  rapidly  under  the  use  of  saline  purges. 


ABSCESS  OF  THE  LIVER.  577 

From  half  an  ounce  to  an  ounce  and  a  half  of  magnesmm  sulphate  may 
be  given  in  as  little  water  as  possible  half  an  hour  before  breakfast.  Elate- 
rium,  the  compound  Jalap  powder,  or  the  bitartrate  of  potash  may  also  be 
employed.  Digitalis  and  squills  are  often  useful.  Surgical  treatment  has 
been  advocated  of  late.  The  abdomen  is  thoroughly  drained  and  the  surface 
of  the  liver  and  spleen  and  the  parietal  peritoneum  is  then  firmly  scrubbed, 
so  as  to  promote  adhesions,  in  which  compensatory  vessels  could  develop. 
Of  three  cases  recently  treated  in  my  wards  in  this  way  one  has  recovered. 
In  the  syphilitic  cases,  or  when  syphilis  is  suspected,  iodide  of  potassium  may 
be  given  in  doses  of  from  15  to  30  drops  of  the  saturated  solution  three 
times  a  day,  and  mercury,  which  is  conveniently  given  with  squills  and 
digitalis  in  the  form  of  Addison's  or  Niemeyer's  pill.  A  patient  with  well- 
marked  syphilitic  cirrhosis  with  recurring  ascites,  in  which  tapping  was  re- 
sorted to  on  eight  or  ten  occasions,  took  this  pill  at  intervals  for  a  year  with 
the  greatest  benefit  and  subsequently  had  four  years  of  tolerably  good 
health. 

VIII.     ABSCESS    OF   THE    LIVER. 

Etiologjy. — Suppuration  within  the  liver,  either  in  the  parenchyma  or 
in  the  blood  or  bile  passages,  occurs  under  the  following  conditions: 

(1)  The  tropical  abscess.  In  hot  climates  this  form  may  develop  idio- 
pathically,  but  more  commonly  follows  dysentery.  It  frequently  occurs 
among  Europeans  in  India,  particularly  those  who  drink  alcohol  freely  and 
are  exposed  to  great  heat.  The  relation  of  this  form  of  abscess  to  dysen- 
tery is  still  under  discussion,  and  Anglo-Indian  practitioners  are  by  no 
means  unanimous  on  the  subject.  Certainly  cases  may  develop  without 
a  history  of  previous  dysentery,  and  there  have  been  fatal  cases  without 
any  affection  of  the  large  bowel.  In  this  country  the  large  solitary  tropical 
abscess  also  occurs,  oftenest  in  the  Southern  States.  In  Baltimore  it  is  not 
very  infrequent. 

The  relation  of  this  form  of  abscess  to  the  Amceha  coli  has  been  care- 
fully studied  by  Kartulis  and  exhaustively  considered  in  a  monograph  by 
Councilman  and  Lafleur.  The  descriptions  and  illustrations  of  these  au- 
thors are  most  convincing  as  to  the  direct  etiological  association  of  this 
organism  with  liver  abscess.  Clinically  the  patient  may  have  Amcehce  coli 
in  the  stools  and  well-marked  signs  of  liver  abscess  without  marked  symp- 
toms of  dysentery  and  even  with  the  fseces  well  formed. 

(2)  Traumatism  is  an  occasional  cause.  The  injury  is  generally  in  the 
hepatic  region.  Two  instances  have  come  under  my  notice  of  it  in  brake- 
men  who  were  injured  while  coupling  cars.  Injury  to  the  head  is  not  in- 
frequently followed  by  liver  abscess. 

(3)  Embolic  or  pya:>mic  abscesses  are  the  most  numerous,  and  may  de- 
velop in  a  general  pyaemia  from  any  cause  or  follow  foci  of  suppuration  in 
the  territory  of  the  portal  vessels.  The  infective  agents  may  reach  the 
liver  through  the  hepatic  artery,  as  in  those  cases  in  which  the  original 
focus  of  infection  is  in  the  area  of  the  systemic  circulation;  though  it  may 
happen  occasionally  that  the  infective  agent,  instead  of  passing  through 


5Y8  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

the  lungs,  reaches  the  liver  through  the  inferior  vena  cava  and  the  hepatic 
veins.  A  remarkable  instance  of  multiple  abscesses  of  arterial  origin  was 
afforded  by  the  case  of  aneurism  of  the  hepatic  artery  reported  by  Eoss 
and  myself.  Infection  through  the  portal  vein  is  much  more  common.  It 
results  from  dysentery  and  other  ulcerative  affections  of  the  bowels,  appen- 
dicitis, occasionally  after  typhoid  fever,  in  rectal  affections,  and  in  abscesses 
in  the  pelvis.  In  these  cases  the  abscesses  are  multiple  and,  as  a  rule,  within 
the  branches  of  the  portal  vein — suppurative  pylephlebitis. 

(4)  A  not  uncommon  cause  of  suppuration  is  inflammation  of  the  bile- 
passages  caused  by  gall-stones,  more  rarely  by  parasites — suppurative  cho- 
langitis. 

In  some  instances  of  tuberculosis  of  the  liver  the  affection  is  chiefly  of 
the  bile-ducts,  with  the  formation  of  multiple  tuberculous  abscesses  con- 
taining a  bile-stained  pus. 

(5)  Foreign  bodies  and  parasites.  In  rare  instances  foreign  bodies,  such 
as  a  needle,  may  pass  from  the  stomach  or  gullet,  lodge  in  the  liver,  and 
excite  an  abscess,  or,  as  in  several  instances  which  have  been  reported,  a 
foreign  body,  such  as  a  needle  or  a  fish-bone,  has  perforated  a  branch  or 
the  portal  vein  itself  and  induced  extensive  pylephlebitis.  Echinococcus 
cysts  frequently  cause  suppuration;  the  penetration  of  round  worms  into 
the  liver  less  commonly;  and  most  rarely  of  all  the  liver-fluke. 

Morbid  Anatomy. — (a)  Of  the  Solitary  or  Tropical  Abscess. — This 
is  not  always  single;  there  may  be  two  or  even  more  large  abscess  cavities, 
ranging  in  size  from  an  orange  to  a  child's  head.  The  largest-sized  ab- 
scess may  contain  from  3  to  6  litres  of  pus  and  involve  more  than  three 
fourths  of  the  entire  organ.  In  Waring's  statistics,  62  per  cent  of  the  cases 
were  single.  The  abscess  in  nearly  70  per  cent  of  the  cases  was  in  the 
right  lobe,  more  toward  the  convexity  than  the  concave  side.  In  long- 
standing cases  the  abscess-wall  may  be  firm  and  thick,  but,  as  a  rule,  the 
cavity  possesses  no  definite  limiting  membrane,  and  section  of  the  wall 
shows  an  internal  layer  grayish  in  color,  shreddy,  and  made  up  of  necrotic 
liver  substance,  pus-cells,  and  amoebse;  a  middle  layer,  brownish  red  in 
color;  and  an  external  zone  of  hypersemic  liver  tissue.  The  pus  is  often 
reddish  brown  in  color,  closely  resembling  anchovy  sauce.  In  other  in- 
stances it  is  grayish  white,  mucoid,  and  may  be  quite  creamy.  The  odor 
is  at  times  very  peculiar.  In  one  instance  it  had  the  sour  smell  of  chyme, 
though  no  connection  with  the  stomach  was  found.  In  amoebic  dysen- 
tery there  may  also  be  multiple  miliary  abscesses  in  the  liver,  containing 
amoebae. 

The  bacteriological  examination  of  the  contents  show  either  a  sterile  pus 
or,  in  some  cases,  staphylococci,  streptococci,  or  the  colon  bacillus.  The 
termination  of  'this  form  of  abscess  may  be  as  follows,  as  noted  in  Waring's 
300  cases:  Eemained  intact,  56  per  cent;  opened  by  operation,  16  per  cent; 
perforated  the  right  pleura,  nearly  5  per  cent;  ruptured  into  the  right  lung, 
9  per  cent;  ruptured  into  the  peritonaeum,  5  per  cent;  ruptured  into  the 
colon,  nearly  3  per  cent;  and  there  were,  in  addition,  instances  wliich  rup- 
tured into  the  hepatic  and  bile-vessels  and  into  the  gall-bladder.  Flexner 
has  reported  two  cases  of  perforation  into  the  inferior  vena  cava.     For  a  full 


ABSCESS  OF  THE  LIVER.  579 

consideration  of  the  subject  of  amcebic  abscess  of  the  liver  the  reader  is 
referred  to  Lafleur's  article  in  Allbutt's  System  of  Medicine. 

(&)  Of  Septic  and  Pycemic  Abscesses. — These  are  usually  multiple,  though 
occasionally,  following  injury,  there  may  be  a  large  solitary  collection  of  pus. 

In  suppurative  ijylephlebitis  the  liver  is  uniformly  enlarged.  The  cap- 
sule may  be  smooth  and  the  external  surface  of  the  organ  of  normal  ap- 
pearance. In  other  instances,  numerous  yellowish-^hite  points  appear  be- 
neath the  capsule.  On  section  there  are  isolated  pockets  of  pus,  either 
having  a  round  outline  or  in  some  places  distinctly  dendritic,  and  from 
these  the  pus  may  be  squeezed.  They  look  like  small,  solitary  abscesses, 
but,  on  probing,  are  found  to  communicate  with  the  portal  vein  and  to 
represent  its  branches,  distended  and  suppurating.  The  entire  portal  sys- 
tem within  the  liver  may  be  involved;  sometimes  territories  are  cut  oft:  by 
thrombi.  The  suppuration  may  extend  into  the  main  branch  or  even  into 
the  mesenteric  and  gastric  veins.  The  pus  may  be  fetid  and  is  often  bile- 
stained;  it  may,  however,  be  thick,  tenacious,  and  laudable.  In  suppura- 
tive cholangitis  there  is  usually  obstruction  by  gall-stones,  the  ducts  are 
greatly  distended,  the  gall-bladder  enlarged  and  full  of  pus,  and  the  branches 
within  the  liver  are  extremely  distended,  so  that  on  section  there  is  an  ap- 
pearance not  unlike  that  described  in  pylephlebitis. 

Suppuration  about  the  echinococcus  cysts  may  be  very  extensive,  forming 
enormous  abscesses,  the  characters  of  which  are  at  once  recognized  by  the 
remnants  of  the  cysts. 

Symptoms. — (a)  Of  the  Large  Solitary  Abscess. — In  the  tropics  there 
are  instances  in  which  the  abscess  appears  to  be  latent  and  to  run  a  course 
without  definite  symptoms; .  death  may  occur  suddenly  from  rupture. 

Fever,  pain,  enlargement  of  the  liver,  and  the  development  of  a  septic 
condition  are  the  important  symptoms  of  hepatic  abscess.  The  tempera- 
ture is  elevated  at  the  outset  and  is  of  an  intermittent  or  septic  type.  It 
is  irregular,  and  may  remain  normal  or  even  subnormal  for, a  few  days; 
then  the  patient  has  a  rigor  and  the  temperature  rises  to  103°  or  higher. 
Owing  to  this  intermittent  character  of  the  fever  the  cases  are  usually,  in 
this  latitude,  mistaken  for  malaria.  The  fever  may  rise  every  afternoon 
without  a  rigor.  Profuse  sweating  is  common,  particularly  when  the  pa- 
tient falls  asleep.  In  chronic  cases  there  may  be  little  or  no  fever.  One 
of  my  patients,  with  a  liver  abscess  which  had  perforated  the  lung,  coughed 
up  pus  after  his  temperature  had  been  normal  for  weeks.  The  pain  is 
variable,  and  is  usually  referred  to  the  back  or  shoulder;  or  there  is  a  dull 
aching  sensation  in  the  right  hypochondrium.  When  turned  on  the  left 
side,  the  patient  often  complains  of  a  heavy,  dragging  sensation,  so  that 
he  usually  prefers  to  lie  on  the  right  side;  at  least,  this  has  been  the  case 
in  a  majority  of  the  instances  which  have  come  under  my  observation.  Pain 
on  pressure  over  the  liver  is  usually  present,  particularly  on  deep  pressure 
at  the  costal  margin  in  the  nipple  line. 

The  enlargement  of  the  liver  is  most  marked  in  the  right  lobe,  and,  as 
the  abscess  cavity  is  usually  situated  more  toward  the  upper  than  the  un- 
der surface,  the  increase  in  volume  is  upward  and  to  the  riglit,  not  down- 
ward, as  in  cancer  and  the  other  affections  producing  enlargement.     Per- 


580  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

cussion  in  the  mid-sternal  and  parasternal  lines  may  slio\\'  a  normal  limit. 
At  the  nipple-line  the  curve  of  liver  dulness  begins  to  rise,  and  in  the  mid- 
axillary  it  may  reach  the  fifth  rib,  while  behind,  near  the  spine,  the  area 
of  dulness  may  be  almost  on  a  level  with  the  angle  of  the  scapula.  Of 
course  there  are  instances  in  which  this  characteristic  feature  is  not  present, 
as  when  the  abscess  occupies  the  left  lobe.  The  enlargement  of  the  liver 
may  be  so  great  as  to  cause  bulging  of  the  right  side,  and  the  edge  may 
project  a  hand's-breadth  or  more  below  the  costal  margin.  In  such  in- 
stances the  surface  is  smooth.  Palpation  is  painful,  and  there  may  be 
fremitus  on  deep  inspiration.  In  some  instances  fluctuation  may  be  de- 
tected. Adhesions  may  form  to  the  abdominal  wall  and  the  abscess  may 
point  below  the  margin  of  the  ribs,  or  even  in  the  epigastric  region.  In 
many  cases  the  appearance  of  the  patient  is  suggestive.  The  skin  has  a 
sallow,  slightly  icteroid  tint,  the  face  is  pale,  the  complexion  muddy,  the 
conjunctivae  are  infiltrated,  and  often  slightly  bile-tinged.  There  is  in  the 
facies  and  in  the  general  appearance  of  the  patient  a  strong  suggestion  of 
the  existence  of  abscess.  There  is  no  internal  affection  associated  with  sup- 
puration which  gives,  I  think,  just  the  same  hue  as  certain  instances  of 
abscess  of  the  liver.  Marked  jaundice  is  rare.  Diarrhoea  may  be  present 
and  may  give  an  important  clew  to  the  nature  of  the  case,  particularly  if 
amoebae  are  found  in  the  stools.     Constipation  may  occur. 

Eemarkable  and  characteristic  symptoms  arise  when  the  abscess  invades 
the  lung.  The  extension  may  occur  through  the  diaphragm,  without  actual 
rupture,  and  with  the  production  of  a  purulent  pleurisy  and  invasion  of 
the  lung.  The  patients  gradually  develop  a  severe  cough,  usually  of  an 
aggravated  and  convulsive  character,  there  are  signs  of  involvement  at  the 
base  of  the  right  lung,  defective  resonance,  feeble  tubular  breathing,  and 
increase  in  the  tactile  fremitus;  but  the  most  characteristic  feature  is  the 
presence  of  a  reddish-brown  expectoration  of  a  brick-dust  color,  resembling 
anchovy  sai^pe.  This,  which  was  noted  originally  by  Budd,  was  present 
in  our  cases,  and  in  addition  Eeese  and  Lafleur  found  the  amcebce  coli  iden- 
tical with  those  which  exist  in  the  liver  abscess  and  in  the  stools.  They 
are  present  in  variable  numbers  and  display  active  amoeboid  movements. 
The  brownish  tint  of  the  expectoration  is  due  to  blood-pigment  and  blood- 
eorpuscles,  and  there  may  be  orange-red  cr3'stals  or  hsmatoidin. 

The  abscess  may  perforate  externally,  as  mentioned  already,  or  into  the 
stomach  or  bowel;  occasionally  into  the  pericardium.  The  duration  of  this 
form  is  very  variable.  It  may  run  its  course  and  prove  fatal  in  six  or  eight 
weeks  or  may  persist  for  several  years. 

The  prognosis  is  serious,  as  the  mortality  is  more  than  50  per  cent. 
The  death-rate  has  been  lowered  of  late  years,  owing  to  the  greater  fearless- 
ness with  which  surgeons  now  attack  these  cases. 

(&)  Of  the  Pycemic  Abscess  and  Siippurative  Pylephlehitis. — Clinically 
these  conditions  cannot  be  separated.  Occurring  in  a  general  pygemia,  no 
special  features  may  be  added  to  the  case.  When  there  is  suppuration 
within  the  portal  vein  the  liver  is  uniforml}  enlarged  and  tender,  though 
pain  may  not  be  a  marked  feature.  There  is  an  irregular,  septic  fever,  and 
the  complexion  is  muddy,  sometimes  distinctly  icteroid.     The  features  are 


ABSCESS  OF  THE  LIVER.  581 

indeed  those  of  pygemia,  plus  a  slight  icteroid  tinge,  and  an  enlarged  and 
painful  liver.  The  latter  features  alone  are  peculiar.  The  sweats,  chills, 
prostration,  and  fever  have  nothing  distinctive. 

Diagnosis. — Abscess  of  the  liver  may  be  confounded  with  intermit- 
tent fever,  a  common  mistake  in  malarial  regions.  Practically  an  intermit- 
tent fever  which  resists  quinine  is  not  malarial.  Laveran's  organisms  are 
also  absent  from  the  blood.  When  the  abscess  bursts  into  the  pleura  a 
right-sided  empyema  is  produced  and  perforation  of  the  lung  usually  fol- 
lows. When  the  liver  abscess  has  been  latent  and  dysenteric  symptoms  have 
not  been  marked,  the  condition  may  be  considered  empyema  or  abscess  of 
the  lung.  In  such  cases  the  anchovy-sauce-like  color  of  the  pus  and  the. 
presence  of  the  amoebae  will  enable  one  to  make  a  definite  diagnosis,  as  has 
been  done  in  cases  by  Lafleur.  Perforation  externally  is  readily  recognized, 
and  yet  in  an  abscess  cavity  in  the  epigastric  region  it  may  be  difficult  to  say 
whether  it  has  proceeded  from  the  liver  or  is  in  the  abdominal  wall.  When 
the  abscess  is  large,  and  the  adhesions  are  so  firm  that  the  liver  does  not  de- 
scend during  inspiration,  the  exploratory  needle  does  not  make  an  up-and- 
down  movement  during  aspiration.  In  an  instance  of  this  kind  which  I 
saw  with  Hearn  at  the  Philadelphia  Hospital,  all  the  features,  local  and 
general,  seemed  to  point  to  abscess  in  the  abdominal  wall,  but  the  operation 
revealed  a  large  perforating  abscess  cavity  in  the  left  lobe  of  the  liver.  The 
diagnosis  of  suppurating  echinococcus  cyst  is  rarely  possible,  except  in 
Australia  and  Iceland,  where  hydatids  are  so  common. 

•Perhaps  the  most  important  affection  from  which  suppuration  within 
the  liver  is  to  be  separated  is  the  intermittent  hepatic  fever  associated  with 
gall-stones.  Of  the  cases  reported  a  majority  have  been  considered  due  to 
suppuration,  and  in  two  of  my  cases  the  liver  had  been  repeatedly  aspirated. 
Post-mortem  examinations  have  shown  conclusively  that  the  high  fever  and 
chills  may  recur  at  intervals  for  years  without  suppuration  in  the  ducts. 
The  distinctive  features  of  this  condition  are  paroxysms  of  fever  with 
rigors  and  sweats — which  may  occur  with  great  regularity,  but  which  more 
often  are  separated  by  long  intervals — the  deepening  of  the  jaundice  after 
the  paroxysms,  the  entire  apyrexia  in  the  intervals,  and  the  maintenance 
of  the  general  nutrition.  The  time  element  also  is  important,  as  in  some 
of  these  cases  the  disease  has  lasted  for  several  years.  Finally,  it  is  to  be 
remembered  that  abscess  of  the  liver,  in  temperate  climates  at  least,  is  in- 
variably secondary,  and  the  primary  source  must  be  carefully  sought  for, 
either  in  dysentery,  slight  ulceration  of  the  rectum,  suppurating  haemor- 
rhoids, ulcer  of  the  stomach,  or  in  suppurative  diseases  of  other  parts  of  the 
body,  particularly  in  the  skull  or  in  the  bones. 

Leucocytosis  may  be  absent  in  the  amoebic  abscess  of  the  liver,  in  sep- 
tic cases  it  may  be  very  high.  , 

In  suspected  cases,  whether  the  liver  is  enlarged  or  not,  exploratory 
aspiration  may  be  performed  without  risk.  The  needle  may  be  entered  in 
the  anterior  axillary  line  in  the  lowest  interspace,  or  in  the  seventh  inter- 
space in  the  mid-axillary  line,  or  over  the  centre  of  the  area  of  dulness 
behind.  The  patient  should  be  placed  under  ether,  for  it  may  be  neces- 
sary to  make  several  deep  punctures.     It  is  not  well  to  use  too  small  an 


582  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

aspirator.  No  ill  effects  follow  this  procedure,  even  though  blood  may 
leak  into  the  peritoneal  cavity.  Extensive  suppuration  may  exist,  and  yet 
be  missed  in  the  aspiration,  particularly  when  the  branches  of  the  portal 
vein  are  distended  with  pus. 

Treatment.— Pysemic  abscess  and  suppurative  pylephlebitis  are  in- 
variably fatal.  Treves,  however,  reports  a  case  of  pysemic  abscess  following 
appendicitis  in  which  the  patient  recovered  after  an  exploratory  operation. 
Surgical  measures  are  not  justified  in  these  cases,  unless  an  abscess  shows 
signs  of  pointing.  As  the  abscesses  associated  with  dysentery  are  often  single, 
they  afford  a  reasonable  hope  of  benefit  from  operation.  If,  however,  the 
patient  is  expectorating  the  pus,  if  the  general  condition  is  good  and  the 
hectic  fever  not  marked,  it  is  best  to  defer  operation,  as  many  of  these  in- 
stances recover  spontaneously.  The  large  single  abscesses  are  the  most 
favorable  for  operation.  The  general  medical  treatment  of  the  cases  is  that 
of  ordinary  septicaemia. 


IX.     NEW   GROWTHS    IN    THE    LIVER. 

These  may  be  cancer,  either  primary  or  secondary,  sarcoma,  or  angioma. 

Etiology. — Cancer  of  the  liver  is  third  in  order  of  frequency  of  in- 
ternal cancer.  It  is  rarely  primary,  usually  secondary  to  cancer  in  other 
organs.  It  is  a  disease  of  late  adult  life.  According  to  Leichtenstern, 
over  50  per  cent  of  the  cases  occur  between  the  fortieth  and  the  sixtieth 
years.  It  occasionally  occurs  in  children.  Women  are  attacked  less 
frequently  than  men.  It  is  stated  by  some  authors  that  secondary  can- 
cer is  more  common  in  women,  owing  to  the  frequency  of  cancer  of  the 
uterus.  Heredity  is  believed  to  have  an  influence  in  from-  15  to  20  per 
cent. 

In  many  cases  trauma  is  an  antecedent,  and  cancer  of  the  bile-passages 
is  associated  in  many  instances  with  gall-stones.  Cancer  is  stated  to  be  less 
common  in  the  tropics.  Its  relative  proportion  to  other  diseases  may  be 
judged  from  the  fact  that  among  the  first  3,000  patients  admitted  to  the 
wards  of  the  Johns  Hopkins  Hospital  there  were  seven  cases  of  cancer  of 
the  liver. 

Morbid  Anatomy. — The  following  forms  of  new  growths  occur  in 
the  liver  and  have  a  clinical  importance: 

Cancer. — (1)  Primary  cancer,  of  which  three  forms  may  be  recognized.* 

(a)  The  massive  cancer,  which  causes  great  enlargement  and  on  section 
shows  a  uniform  mass  of  new  growth,  which  occupies  a  large  portion  of 
the  organ.  It  is  grayish  white,  usually  not  softened,  and  is  abruptly  out- 
lined from  the  contiguous  liver  substance. 

(&)  Nodular  cancer,  in  which  the  liver  is  occupied  by  nodular  masses, 
some  large,  some  small,  irregularly  scattered  throughout  the  organ.  Usu- 
ally in  one  region  there  is  a  larger,  perhaps  firmer,  older-looking  mass,  which 
indicates  the  primary  seat,  and  the  numerous  nodules  are  secondary  to  it. 


*  Hanot  and  Gilbert,  :6tudes  sur  les  Maladies  du  Foie,  Paris,  1888. 


NEW  GROWTHS  IN  THE  LIVER.  583 

This  form  is  much  like  the  secondary  cancerous  involvement,  except  that 
it  seldom  reaches  a  large  size. 

(c)  The  third  is  the  remarkable  and  rare  variety,  cancer  with  cirrhosis, 
which  forms  an  anatomical  picture  perfectly  unique  and  at  first  very  puz- 
zling. The  liver  is  not  much  enlarged,  rarely  weighing  more  than  2^  or 
3  kilogrammes.  The  surface  is  grayish  yellow,  studded  over  with  nodular 
yellowish  masses,  resembling  the  projections  in  an  ordinary  cirrhotic  liver. 
On  section  the  cancerous  nodules  are  seen  scattered  throughout  the  entire 
organ,  varying  in  diameter  from  3  to  10  or  more  millimetres  and  sur- 
rounded with  fibrous  tissue. 

Histologically,  the  primary  cancers  are  epitheliomata — alveolar  and 
trabecular.  The  character  of  the  cells  varies  greatly.  In  some  varieties  they 
are  polymorphous;  in  others  small  polyhedral;  in  others,  again,  giant  cells 
are  found.  In  rare  instances,  as  in  one  described  by  Greenfield,  the  cells  are 
cylindrical.  The  trabecular  form  of  epithelioma  is  also  known  as  adenoma 
or  adeno-carcinoma. 

(3)  Secondary  Cancer. — The  organ  may  be  enormous.  The  largest  I 
have  known  was  30^  pounds.  The  cancerous  nodules  project  beneath 
the  capsule,  and  can  be  felt  during  life  or  even  seen  through  the  thin  ab- 
dominal walls.  They  are  usually  disseminated  equally,  though  in  rare  in- 
stances they  may  be  confined  to  one  lobe.  The  consistence  of  the  nodules 
varies;  in  some  cases  they  are  firm  and  hard  and  those  on  the  surface  show 
a  distinct  umbilication,  due  to  the  shrinking  of  the  fibrous  tissue  in  the 
centre.  These  superficial  cancerous  masses  are  still  sometimes  spoken  of 
as  "  Farre's  tubercles."  More  frequently  the  masses  are  on  section  grayish 
white  in  color,  or  hasmorrhagic.  Kupture  of  blood-vessels  is  not  uncommon 
in  these  cases.  In  one  specimen  there  was  an  enormous  clot  beneath  the 
capsule  of  the  liver,  together  with  haemorrhage  into  the  gall-bladder  and 
into  the  peritonseum.  The  secondary  cancer  shows  the  same  structure  as 
the  initial  lesion,  and  is  usually  either  an  alveolar  or  cylindrical  carcinoma. 
Degeneration  is  common  in  these  secondary  growths;  thus  the  hyaline 
transformation  may  convert  large  areas  into  a  dense,  dry,  grayish-yellow 
mass.  Extensive  areas  of  fatty  degeneration  may  occur,  sclerosis  is  not 
imcommon,  and  haemorrhages  are  frequent.  Suppuration  sometimes 
follows. 

(3)  Cancer  of  the  tile-passages  which  has  been  already  considered. 

Sarcoma. — Of  primary  sarcoma  of  the  liver  very  few  cases  have  been 
reported.  Secondary  sarcoma  is  more  frequent,  and  many  examples  of 
lympho-sarcoma  and  myxo-sarcoma  are  on  record,  less  frequently  glio-sar- 
coma  or  the  smooth  or  striped  myoma. 

The  most  important  form  is  the  melano-sarcoma,  which  develops  in  the 
liver  secondarily  to  sarcoma  of  the  eye  or  of  the  skin.  Very  rarely  melano- 
sarcoma  develops  primarily  in  the  liver.  Of  the  reported  cases  Ilanot  ex- 
cludes all  but  one.  In  this  form  the  liver  is  greatly  enlarged,  is  either  uni- 
formly infiltrated  with  the  cancer,  which  gives  the  cut  surface  the  appear- 
ance of  dark  granite,  or  there  are  large  nodular  masses  of  a  deep  black  or 
marbled  color.  There  are  usually  extensive  metnstases,  and  in  some  in- 
stances every  organ  of  the  body  is  involved.     Nodules  of  melano-sarcoma 


584  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  the  skin  may  give  a  clew  to  the  diagnosis.  Hamburger  (J.  H.  H.  Bulle- 
tin, 1898)  has  reported  the  cases  which  have  been  in  my  wards. 

Other  Forms  of  Liver  Tumor. — One  of  the  commonest  tumors  in  the 
liver  is  the  angioma,  which  occurs  as  a  small,  reddish  body  the  size  of  a 
walnut,  and  consists  simply  of  a  series  of  dilated  vessels.  Occasionally  in 
children  angiomata  have  developed  and  produced  large  tumors. 

Cysts  are  occasionally  found  in  the  liver,  either  single,  which  are  not 
very  uncommon,  or  multiple,  when  they  usually  coexist  with  congenital 
cystic  kidneys. 

Symptoms. — It  is  often  impossible  to  differentiate  primary  and  sec- 
ondary cancer  of  the  liver  unless  the  primary  seat  of  the  disease  is  evident, 
as  in  the  case  of  scirrhus  of  the  breast,  or  cancer  of  the  rectum,  or  of  a 
tumor  in  the  stomach,  which  can  be  felt.  As  a  rule,  cancer  of  the  liver  is 
associated^  with  progressive  enlargement;  but  there  are  cases  of  primary 
nodular  cancer,  and  in  the  cancer  with  cirrhosis  the  organ  may  not  be  en- 
larged. Gastric  disturbance,  loss  of  appetite,  nausea,  and  vomiting  are  fre- 
quent. Progressive  loss  of  flesh  and  strength  may  be  the  first  symptoms. 
Pain  or  a  sensation  of  uneasiness  in  the  right  hypochondriac  region  may 
be  present,  but  enormous  enlargement  of  the  liver  may  occur  without  the 
slightest  pain.  Jaundice,  which  is  present  in  at  least  one  half  of  the  cases, 
is  usually  of  moderate  extent,  unless  the  common  duct  is  occluded.  As- 
cites is  rare,  except  in  the  form  of  cancer  with  cirrhosis,  in  which  the  clinical 
picture  is  that  of  the  atrophic  form.  Pressure  by  nodules  on  the  portal 
vein  or  extension  of  the  cancer  to  the  peritonaeum  may  also  induce  ascites. 

Inspection  shows  the  abdomen  to  be  distended,  particularly  in  the  upper 
zone.  In  late  stages  of  the  disease,  when  emaciation  is  marked,  the  can- 
cerous nodules  can  be  plainly  seen  beneath  the  skin,  and  in  rare  instances 
even  the  umbilications.  The  superficial  veins  are  enlarged.  On  palpation 
the  liver  is  felt,  a  hand's-breadth  or  more  below  the  costal  margin,  de- 
scending with  each  inspiration.  The  surface  is  usually  irregular,  and  may 
present  large  masses  or  smaller  nodular  bodies,  either  rounded  or  with  cen- 
tral depressions.  In  instances  of  diffuse  infiltration  the  liver  may  be  greatly 
enlarged  and  present  a  perfectly  smooth  surface.  The  growth  is  progres- 
sive, and  the  edge  of  the  liver  may  ultimately  extend  below  the  level  of  the 
navel.  Although  generally  uniform  and  producing  enlargement  of  the 
whole  organ,  occasionally,  when  the  tumor  develops  from  the  left  lobe,  it 
may  form  a  solid  mass,  which  occupies  the  epigastric  region.  By  percussion 
the  outline  can  be  accurately  limited  and  the  progressive  growth  of  the 
tumor  estimated.  The  spleen  is  rarely  enlarged.  Pyrexia  is  present  in  many 
cases,  usually  a  continuous  fever,  ranging  from  100°  to  102°;  it  may  be  in- 
termittent, with  rigors.  This  may  be  associated  with  the  cancer  alone,  or, 
as  in  one  of  my  cases,  with  suppuration.  CEdema  of  the  feet,  from  anaemia, 
usually  supervenes.  Cancer  of  the  liver  kills  in  from  three  to  fifteen  months. 
One  patient  lived  for  more  than  two  years. 

Diagnosis. — The  diagnosis  is  easy  when  the  liver  is  greatly  enlarged 
and  the  surface  nodular.  The  smoother  forms  of  diffuse  carcinoma  may 
at  first  be  mistaken  for  fatty  or  amyloid  liver,  but  the  presence  of  jaun- 
dice, the  rapid  enlargement,  and  the  more  marked  cachexia  will  usually 


FATTY  LIVER.  585 

suffice  to  differentiate  it.  Perhaps  the  most  puzzling  conditions  occur  in 
the  rare  cases  of  enlarged  amyloid  liver  with  irregular  gummata.  The 
large  echinococcus  liver  may  present  a  striking  similarity  to  carcinoma,  but 
the  projecting  nodules  are  usually  softer,  the  disease  lasts  much  longer,  and 
the  cachexia  is  not  marked. 

Hypertrophic  cirrhosis  may  at  first  be  mistaken  for  carcinoma,  as  the 
jaundice  is  usually  deep  and  the  liver  very  large;  but  the  absence  of  a 
marked  cachexia  and  wasting,  and  the  painless,  smooth  character  of  the 
enlargement  are  points  against  cancer.  When  in  doubt  in  these  cases, 
aspiration  may  be  safely  performed,  and  positive  indication  may  be  gained 
from  the  materials  so  obtained.  In  large,  rapidly  growing  secondary  can- 
cers the  superficial  rounded  masses  may  almost  fluctuate  and  these  soft 
tumor-like  projections  may  contain  blood.  The  form  of  cancer  with  cir- 
rhosis can  scarcely  be  separated  from  atrophic  cirrhosis  itself.  Perhaps 
the  wasting  is  more  extreme  and  more  rapid,  but  the  jaundice  and  the 
ascites  are  identical.  Melano-sarcoma  causes  great  enlargement  of  the 
organ.  There  are  frequently  symptoms  of  involvement  of  other  viscera, 
as  the  lungs,  kidneys,  or  spleen.  Secondary  tumors  may  develop  on  the 
skin.  A  very  important  symptom,  not  present  in  all  cases,  is  melanuria, 
the  passage  of  a  very  dark-colored  urine,  which  may,  however,  when  first 
voided,  be  quite  normal  in  color.  The  existence  of  a  melano-sarcoma  of 
the  eye,  or  the  history  of  blindness  in  one  eye,  with  subsequent  extirpa- 
tion, may  indicate  at  once  the  true  nature  of  the  hepatic  enlargement. 
The  secondary  tumors  may  develop  some  time  after  the  extirpation  of 
the  eye,  as  in  a  case  under  the  care  of  J.  C.  Wilson,  at  the  Philadelphia 
Hospital,  or,  as  in  a  case  under  Tyson  at  the  same  institution,  the  pa- 
tient may  have  a  sarcoma  of  the  choroid  which  had  never  caused  any  symp- 
toms. 

The  treatment  must  be  entirely  symptomatic.  The  question  of  surgical 
interference  may  be  discussed.  Keen  has  collected  reports  of  76  cases  of 
resection  of  tumors  of  the  liver,  63  of  which  recovered. 


X.    FATTY    LIVER. 

Two  different  forms  of  this  condition  are  recognized — the  fatty  infil- 
tration and  fatty  degeneration. 

Fatty  infiltration  occurs,  to  a  certain  extent,  in  normal  livers,  since 
the  cells  always  contain  minute  globules  of  oil. 

In  fatty  degeneration,  which  is  a  much  less  common  condition,  the 
protoplasm  of  the  liver-cells  is  destroyed  and  the  fat  takes  its  place,  as  seen 
in  cases  of  malignant  jaundice  and  in  phosphorus  poisoning. 

Fatty  liver  occurs  under  the  following  conditions:  (a)  In  association 
with  general  obesity,  in  which  case  the  liver  appears  to  be  one  of  the  store- 
houses of  the  excessive  fat.  (h)  In  conditions  in  which  the  oxidation  pro- 
cesses are  interfered  with,  as  in  cachexia,  profound  anaemia,  and  in  phthisis. 
The  fatty  infiltration  of  the  liver  in  heavy  drinkers  is  to  be  attributed  to 
the  excessive  demand  made  by  the  alcohol  upon  the  oxygen,  (c)  Certain 
poisons,  of  which  phosphorus  is  the  most  characteristic,  produce  an  intense 


586  DISEASES   OF   THE  DiaESTIVE  SYSTEM. 

fatty  degeneration  ^dth.  necrosis  of  the  liver-cells.  The  poison  of  acute 
yellow  atrophy,  whatever  its  nature,  acts  in  the  same  way. 

The  fatty  liver  is  uniformly  increased  in  size.  The  edge  may  reach 
below  the  level  of  the  navel.  It  is  smooth,  looks  pale  and  bloodless;  on 
section  it  is  dry,  and  renders  the  surface  of  the  knife  greasy.  The  liver 
may  weigh  many  pounds,  and  yet  the  specific  gravity  is  so  low  that  the 
entire  organ  floats  in  water. 

The  symptoms  of  fatty  liver  are  not  definite.  Jaundice  is  never  pres- 
ent; the  stools  may  be  light-colored,  but  even  in  the  most  advanced  grades 
the  bile  is  still  formed.  Signs  of  portal  obstruction  are  rare.  Hgemor- 
rhoids  are  not  very  infrequent.  Altogether,  the  symptoms  are  ill-defined, 
and  chiefly  those  of  the  disease  with  which  the  degeneration  is  associated. 
In  cases  of  great  obesity,  the  physical  examination  is  uncertain;  but  in 
phthisis  and  cachectic  conditions,  the  organ  can  be  felt  to  be  greatly  en- 
larged, though  smooth  and  painless.  Fatty  livers  are  among  the  largest 
met  with  at  the  bedside. 


XI.     AMYLOID    LIVER. 

The  waxy,  lardaeeous,  or  amyloid  liver  occurs  as  part  of  a  general  de- 
generation, associated  with  cachexias,  particularly  when  the  result  of  long- 
standing suppuration. 

In  practice,  it  is  found  oftenest  in  the  prolonged  suppuration  of  tuber- 
culous disease,  either  of  the  lungs  or  of  the  bones.  Next  in  order  of  fre- 
quency are  the  cases  associated  with  syphilis.  Here  there  may  be  ulcera- 
tion of  the  rectum,  with  which  it  is  often  connected,  or  chronic  disease  of 
the  bone,  or  it  may  be  present  when  there  are  no  suppurative  changes.  It 
is  found  occasionally  in  rickets,  in  prolonged  convalescence  from  the  infec- 
tious fevers,  and  in  the  cachexia  of  cancer. 

The  amyloid  liver  is  large,  and  may  attain  dimensions  equalled  only 
by  those  of  the  cancerous  organ.  Wilks  speaks  of  a  liver  weighing  four- 
teen pounds.  It  is  solid,  firm,  resistant,  on  section  antemic,  and  has  a 
semitranslucent,  infiltrated  appearance.  vStained  with  a  dilute  solution  of 
iodine,  the  areas  infiltrated  with  the  amyloid  matter  assume  a  rich  mahog- 
any-brown color.  The  precise  nature  of  this  change  is  still  in  question. 
It  first  attacks  the  capillaries,  usually  of  the  median  zone  of  the  lobules, 
and  subsequently  the  interlobular  vessels  and  the  connective  tissue.  The 
cells  are  but  little  if  at  all  affected. 

There  are  no  characteristic  symptoms  of  this  condition.  Jaundice 
does  not  occur;  the  stools  may  be  light-colored,  but  the  secretion  of  bile 
persists.  The  physical  examination  shows  the  organ  to  be  uniformly  en- 
larged and  painless,  the  surface  smooth,  the  edges  rounded,  and  the  con- 
sistence greatly  increased.  Sometimes  the  edge,  even  in  very  great  enlarge- 
ment, is  sharp  and  hard.  The  spleen  also  may  be  involved,  but  there  are 
no  evidences  of  portal  obstruction. 

The  dinrjnosis  of  the  condition  is,  as  a  rule,  easy.  Progressive  and  great 
enlargement  in  connection  with  suppuration  of  long  standing  or  with 


ANOMALIES  IN  FORM  AND  POSITION  OP  THE  LIVER.  587 

syphilis,  is  almost  always  of  this  nature.      In  rare  instances,  however,  the 
amyloid  liver  is  reduced  in  size. 

In  hukcemia  the  liver  may  attain  considerahle  size  and  be  smooth  and 
uniform,  resembling,  on  physical  examination,  the  fatty  organ.  The  blood 
condition  at  once  indicates  the  true  nature  of  the  case. 


Xn.     ANOMALIES    IN    FORM    AND    POSITION    OF   THE 

LIVER. 

In  transposition  of  the  viscera  the  right  lobe  of  the  organ  may  occupy 
the  left  side.  A  common  and  important  anomaly  is  the  tilting  forward  of 
the  organ,  so  that  the  long  axis  is  vertical,  not  transverse.  Instead  of  the 
edgfe  of  the  right  lobe  presenting  just  below  the  costal  margin,  a  consider- 
able portion  of  the  surface  of  the  lobe  is  in  contact  with  the  abdominal 
parietes,  and  the  edge  may  be  felt  as  low,  perhaps,  as  the  navel.  This  an- 
teversion  is  apt  to  be  mistaken  for  enlargement  of  the  organ. 

The  "  lacing  "  liver  is  met  with  in  two  chief  types.  In  one,  the  anterior 
portion,  chiefly  of  the  right  lobe,  is  greatly  prolonged,  and  may  reach  the 
transverse  navel  line,  or  even  lower.  A  shallow  transverse  groove  sepa- 
rates the  thin  extension  from  the  main  portion  of  the  organ.  The  peri- 
toneal coating  of  this  groove  may  be  fibroid,  and  in  rare  instances  the  de- 
formed portion  is  connected  with  the  organ  by  an  almost  tendinous  mem- 
brane. The  liver  may  be  compressed  laterally  and  have  a  pyramidal  shape, 
and  the  extreme  left  border  and  the  hinder  margin  of  the  left  lobe  may  be 
much  folded  and  incurved.  The  projecting  portion  of  the  liver,  extending 
low  in  the  right  flank,  may  be  mistaken  for  a  tumor,  or  more  frequently 
for  a  movable  right  kidney.  Its  continuity  with  the  liver  itself  may  not 
be  evident  on  palpation  or  on  percussion,  as  coils  of  intestine  may  lie  in 
front.  It  descends,  however,  with  inspiration,  and  usually  the  margin 
can  be  traced  continuously  with  that  of  the  left  lobe  of  the  liver.  The 
greatest  difficulty  arises  when  this  anomalous  lappet  of  the  liver  is  either 
naturally  very  thick  and  united  to  the  liver  by  a  very  thin  membrane,  or 
when  it  is  swollen  in  conditions  of  great  congestion  of  the  organ. 

The  other  principal  type  of  lacing  liver  is  quite  different  in  shape.  It 
is  thick,  broader  above  than  below,  and  lies  almost  entirely  above  the  trans- 
verse line  of  the  cartilages.  There  is  a  narrow  groove  just  above  the  anterior 
border,  which  is  placed  more  transversely  than  normal.* 

Movable  Liver. — This  rare  condition  has  received  much  attention  of 
late,  anrl  J.  E.  Graham,  in  a  recent  paper,  has  collected  70  reported  cases 
from  the  literature.  In  a  very  considerable  number  of  these  there  has  been 
a  mistaken  diagnosis.  A  slight  grade  of  mobility  of  the  organ  is  found 
in  the  pendulous  abdomen  of  enteroptosis,  and  after  repeated  ascites. 

The  organ  is  so  connected  at  its  posterior  margin  with  the  inferior 
vena  cava  and  diaphragm  that  any  great  mobility  from  this  point  is  im- 

*  See  p.  Hertz,  Abnormitiiten  in  der  Lage  und  Form  dor  Bauchnrtrane,  Beriin,  1894. 


588  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

possible^  except  on  the  theory  of  a  meso-hepar  or  congenital  ligamentous 
union  between  these  structures.  The  ligaments,  however,  may  show  an 
extreme  grade  of  relaxation  (the  suspensory  7.5  cm.,  and  the  triangular 
ligament  4  cm.,  in  one  of  Leube's  cases);  and  when  the  patient  is  in  the 
erect  posture  the  organ  may  drop  down  so  far  that  its  upper  surface  is 
entirely  below  the  costal  margin.  The  condition  is  rarely  met  with  in  men; 
56  of  the  cases  were  in  women.  ■*• 


IX.    DISEASES   OF  THE  PAJSTCEEAS. 

The  importance  of  diseases  of  the  pancreas  has  been  emphasized,  par- 
ticularly through  studies  made  in  this  country  by  F.  W.  Draper  on  haemor- 
rhage and  by  Fitz  on  acute  pancreatitis,  while  those  of  Senn  have  created 
a  surgery  of  the  gland.  An  additional  interest  has  been  given  to  the  organ 
by  the  work  of  v.  Mering  and  Minkowski  on  pancreatic  diabetes.  The  works 
of  Claessen  (1842)  and  of  Ancelet  (1866)  give  the  older  literature.  The 
modern  study  of  the  subject  dates  from  Senn's  paper  in  the  American 
Journal  of  the  Medical  Sciences,  1885,  and  Fitz's  Middleton  Goldsmith 
Lecture  for  1889.  In  rewriting  this  section  I  have  drawn  freely  on 
Korte's  recent  monograph. 


I.     H>EMORRHAGE. 

Both  Spiess  (1866)  and  Zenker  (1874)  were  acquainted  with  haemor- 
rhage into  the  pancreas  as  a  cause  of  sudden  death,  but  the  great  medico- 
legal importance  of  the  subject  was  first  fully  recognized  by  F.  W.  Draper, 
of  Boston,  whose  townsmen,  Harris,  Fitz,  Whitney,  and  others  have  con- 
tributed additional  studies.  In  4,000  autopsies  Draper  met  with  19  cases 
of  pancreatic  hemorrhage,  in  9  or  10  of  Avhich  no  other  cause  of  death  was 
found.  When  the  bleeding  is  extensive  the  entire  tissue  of  the  gland  is 
destroyed  and  the  blood  invades  the  retro-peritoneal  tissue.  In  other  in- 
stances the  peritoneal  covering  is  broken  and  the  blood  fills  the  lesser  peri- 
toneum (see  hsemo-peritonseum).  The  hsemorrhage  may  be  in  connection 
with  an  acute  pancreatitis  or  with  necrotic  inflammation  of  the  gland.  In 
an  instance  in  which  there  was  a  small  growth  in  the  tail  of  the  pancreas  I 
found  hemorrhage  into  the  gland  and  into  the  retro-peritoneum,  forming 
a  blood  sac  which  surrounded  the  left  kidney. 

Zenker  suggests  that  the  sudden  death  in  these  cases  is  due  to  shock 
through  the  solar  plexus. 

The  symptoms  are  thus  briefly  summarized  by  Prince:  "  The  patient, 
who  has  previously  been  perfectly  well,  is  suddenly  taken  with  the  illness 
which  terminates  his  life.  .  .  .  When  the  hemorrhage  occurs  the  patient 
may  be  quietly  resting  or  pursuing  his  usual  occupation.  The  pain  which 
ushers  in  the  attack  is  usually  very  severe  and  located  in  the  upper  part  of 
the  abdomen.     It  steadily  increases  in  severity,  is  sharp  or  perhaps  colicky 


ACUTE  PANCREATITIS.  689 

in  character.  It  is  almost  from  the  first  accompanied  by  nausea  and  vom- 
iting; the  latter  becomes  frequent  and  obstinate,  but  gives  no  relief.  The 
patient  soon  becomes  anxious,  restless,  and  depressed;  he  tosses  about,  and 
only  with  difficulty  can  he  be  restrained  in  bed.  The  surface  is  cold  and 
the  forehead  is  covered  with  a  cold  sweat.  The  pulse  is  weak,  rapid,  and 
sooner  or  later  imperceptible.  The  abdomen  .becomes  tender,  the  tender- 
ness being  located  in  the  upper  part  of  the  abdomen  or  epigastrium.  Tym- 
panites is  sometimes  marked.  The  temperature  in  most  cases  is  either 
normal  or  below  normal.  The  bowels  are  apt  to  be  constipated.  These 
symptoms  continue  without  relief,  those  which  are  most  striking  being 
the  pain,  vomiting,  anxiousness,  restlessness,  and  the  state  of  collapse  into 
which  the  patient  soon  falls." 

It  has  been  suggested  in  such  cases  to  open  the  abdomen,  expose  the 
pancreas,  and  relieve  the  tension,  since  the  fatal  result  is  often  due  to  the 
pressure  and  not  to  the  loss  of  blood. 


II.    ACUTE    PANCREATITIS. 

(a)  Acute  Hsemorrhagic  Pancreatitis. — In  this  form  the  inflammation 
is  combined  with  haemorrhage,  and  it  is  difficult  to  separate  clearly  the  two 
processes. 

Etiology. — Korte  has  collected  41  instances,  of  which  only  4  were  in 
women.  A  large  majority  of  the  cases  occur  in  adult  males.  McPhedran 
has  reported  one  in  a  nine  months'  old  child.  Many  of  the  patients  had 
been  addicted  to  alcohol;  others  had  suffered  occasionally  with  severe  pains 
and  vomiting  or  with  gall-stone  colic. 

The  pancreas  is  found  enlarged,  and  the  interlobular  tissue  infiltrated 
with  blood,  and  perhaps  with  clots.  The  relation  of  gall-stones  to  the 
condition  has  been  demonstrated  in  a  recent  case  (Opie).  A  small  calculus 
had  lodged  in  the  diverticulum  of  Vater,  closing  its  duodenal  orifice  and 
converting  the  common  bile  duct  and  the  duct  of  Wirsung  into  a  closed 
channel.  Bile  finding  its  way  into  the  pancreas  had  caused  hsemorrhagic 
inflammation.  Injection  of  bile  into  the  pancreatic  ducts  of  dogs  repro- 
duces the  lesion.  The  gland  cells  have  undergone  more  or  less  widespread 
necrosis,  and  at  the  margin  of  the  necrotic  areas  are  accumulations  of 
inflammatory  products,  red  blood-corpuscles,  polynuclear  leucocytes,  and 
fibrin.  There  can  be  seen  about  the  lobules  and  upon  the  omentum  and 
mesentery  opaque  white  specks,  the  fat  necroses  of  Baker. 

Symptoms. — One  of  the  most  characteristic  features  is  the  sudden- 
ness of  the  onset,  usually  with  violent  colicky  pain  in  the  upper  part  of  the 
abdomen.  Nausea  and  vomiting  follow,  with  collapse  symptoms,  more  or 
less  severe  according  to  the  intensity  of  the  attack.  The  abdomen  becomes 
swollen  and  tense  and  there  is  constipation.  The  temperature  at  first  may 
be  low;  subsequently  fever  sets  in,  sometimes  initiated  by  a  chill.  There 
may  be  early  delirium.  Collapse  symptoms  supervene,  and  death  occuru 
usually  from  the  second  to  the  fourth  day,  or  even  earlier.  The  swelling 
and  infiltration  in  the  region  of  the  pancreas  necessarily  involve  the  coeliac 
plexus,  and  the  stretching  of  the  nerves  may  account  for  the  agonizing  pain 


590  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  the  sudden  collapse.  In  a  case  whicli  I  have  reported  tlie  semilunar 
ganglia  •^'ere  swollen,  the  nerve-cells  indistinct,  and  there  was  an  intersti- 
tial infiltration  of  round  cells.  The  Pacinian  corpuscles  in  the  neighbor- 
hood of  the  pancreas  were  enormously  swollen  and  oedematous. 

Deep  pressure  on  the  upper  part  of  the  abdomen  may  give  evidence  of 
circumscribed  resistance. 

Diagnosis. — Intestinal  obstruction  or  acute  perforating  peritonitis 
is  usually  suspected.  Now  that  the  condition  has  become  better  known 
the  diagnosis  intra  vitam  has  been  made  (by  Fitz  and  by  Thayer).  "  Acute 
pancreatitis  is  to  be  suspected  when  a  previously  healthy  person  or  a  suf- 
ferer from  occasional  attacks  of  indigestion  is  suddenly  seized  with  a  violent 
pain  in  the  epigastrium  followed  by  vomiting  and  collapse,  and  in  the  course 
of  twenty-four  hours  by  a  circumscribed  epigastric  swelling,  tympanitic 
or  resistant,  with  slight  elevation  of  temperature.  Circumscribed  tender- 
ness in  the  course  of  the  pancreas  and  tender  spots  throughout  the  abdomen 
are  valuable  diagnostic  signs  ''  (Fitz).  An  interesting  case  admitted  to  the 
Johns  Hopkins  Hospital  illustrates  a  common  mistake.  The  young  man 
had  had  symptoms  of  obstruction  of  the  bowels  for  three  or  four  days.  The 
abdomen  was  distended,  tender,  and  very  painful.  I  saw  him  on  admission, 
agreed  in  the  diagnosis  of  probable  obstruction,  and  ordered  him  to  be 
transferred  at  once  to  the  operating-room.  Halsted  found  no  evidence  of 
obstruction,  but  in  the  region  of  the  pancreas  and  at  the  root  of  the  mesen- 
tery there  was  a  dense,  thick,  indurated  mass,  and  there  were  areas  of  fat- 
necrosis  in  both  mesentery  and  omentum.  Oddly  enough  this  patient  re- 
turned four  years  afterward  with  another  attack,  but  he  refused  to  be 
operated  upon  and  was  taken  away  by  his  friends. 

(i)  Acute  Suppurative  Pancreatitis — Pancreatic  Abscess.— Fitz,  in  his 
monograph  in  1889,  reported  22  cases.  To  this  list  Korte  has  added  24. 
Of  the  cases,  32  were  in  males. 

The  etiology  in  a  majority  of  cases  is  doubtful.  Dyspeptic  disturbances 
and  trauma  have  preceded  the  onset  in  some  instances.  In  2-i  cases  there 
was  a  single  abscess;  in  14  there  were  numerous  small  abscesses.  In  other 
instances  there  was  a  diffuse  purulent  infiltration.  Some  of  the  sequels 
are  peri-pancreatic  abscess,  perforation  into  the  stomach,  the  duodenum,  or 
the  peritongeum,  and  thrombosis  of  the  portal  vein. 

The  symptoms  of  suppurative  pancreatitis  are  not  always  well  defined. 
In  one  case  in  my  wards  Thayer  made  a  correct  diagnosis.  The  patient, 
aged  thirty-four,  had  had  occasional  attacks  of  severe  pain  and  vomiting. 
This  was  followed  by  fever  and  delirium.  A  deep-seated  mass  was  felt  in 
the  median  line  just  above  the  umbilicus.  Finney  operated  and  found 
disseminated  fat-necrosis  and  a  deep-seated  abscess  with  necrotic  pancre- 
atic tissue.  The  patient  recovered.  The  course  of  the  suppurative  form 
is  much  more  chronic.  Icterus,  fatty  diarrhoea,  and  sugar  in  the  urine 
have  been  met  with  in  some  cases.  The  presence  of  a  tumor  mass  in  the 
epigastrium  is  of  tbe  greatest  moment. 

(c)  Gangrenous  Pancreatitis. — Complete  necrosis  of  the  gland,  or  part 
of  it,  may  follow  either  haemorrhage  or  h^emorrhagic  inflammation,  and  in 
exceptional  cases  may  occur  after  suppurative  infiltration  or  after  injury 


ACUTE  PANCREATITIS.  591 

or  the  perforation  of  an  ulcer  of  the  stomach.  In  Fitz's  monograph  15 
eases  are  reported.  Korte  has'increased  this  number  to  40.  Symptoms  of 
hsemorrhagic  pancreatitis  may  precede  or  be  associated  with  it.  Death 
usually  follows  in  from  ten  to  twenty  days,  with  symptoms  of  collapse. 

Anatomically  the  pancreas  may  present  a  dry  necrotic  appearance,  but 
as  a  rule  the  organ  is  converted  into  a  dark  slaty-colored  mass  lying  nearly 
free  in  the  omental  cavity  or  attached  by  a  few  shreds.  In  other  instances 
the  totally  or  partially  sequestrated  organ  may  lie  in  a  large  abscess  cavity, 
forming  a  palpable  tumor  in  the  epigastric  region.  In  two  cases,  reported 
by  Chiari,  the  necrotic  pancreas  was  discharged  per  rectum,  with  recovery. 

Relation  of  Fat-necrosis  to  Pancreatic  Disease. — In  connection  with  all 
forms  of  pancreatic  disease  small  yellowish  areas,  to  which  Balser  first  di- 
rected attention,  may  be  found  in  the  interlobular  pancreatic  tissue,  in  the 
mesentery,  in  the  omentum,  in  the  abdominal  fatty  tissue  generally,  and 
occasionally  in  the  pericardial  and  subcutaneous  fat.  It  is  stated  that  they 
may  be  present  without  disease  of  the  gland,  but  this  is  doubtful.  They 
are -most  frequent  in  the  hsemorrhagic  and  necrotic  forms  of  pancreatitis, 
less  common  in  the  suppurative.  In  the  pancreas  the  lobules  are  seen  to  be 
separated  by  a  dead-white  necrotic  tissue,  which  gives  a  remarkable  appear- 
ance to  the  section.  In  the  abdominal  fat  the  areas  are  usually  not  larger 
than  a  pin's  head;  they  at  once  attract  attention,  and  may  be  mistaken,  on 
superficial  examination,  for  miliary  tubercles  or  neoplasms.  They  may  be 
larger;  instances  have  been  reported  in  which  they  were  the  size  of  a  hen's 
egg.  On  section  they  have  a  soft,  tallowy  consistence.  E.  Langerhans  has 
shqwn  that  this  substance  is  a  combination  of  lime  with  certain  fatty  acids. 
They  may  be  crusted  with  lime,  and  in  a  man,  aged  eighty,  who  died  of 
Bright's  disease,  I  found  the  lobules  of  the  pancreas  entirely  isolated  by 
areas  of  fatty  necrosis  with  extensive  deposition  of  lime  salts.  There  is  no 
necessary  etiological  relation  between  disease  of  the  pancreas  and  dissemi- 
nated fatty  necroses  of  the  abdomen  at  the  time  the  latter  are  discovered. 
They  have  been  found  accidentally  in  laparotomy  for  ovarian  tumor  and  in 
instances  in  which  the  pancreas  has  been  normal.  They  may  be  present  in 
thin  persons  or  in  association  with  gall-stones.  The  bacterium  coli  com- 
mune was  present  in  two  insta,nces,  with  diphtheritic  colitis,  examined  by 
Welch,  though  in  most  cases  tllfe  areas  of  necrosis  are  sterile.  Langerhans 
produced  fat-necrosis  by  injecting  extract  of  pancreas  into  the  peri-renal 
fatty  tissue  of  a  dog;  and  Hildebrand  and  Dettmer  have  shown  experi- 
mentally that  the  fat-necroses  are  caused  by  certain  constituents  of  the  pan- 
creatic juice,  but  not  by  trypsin.  Flexner  has  demonstrated  by  chemical 
tests  the  existence  of  the  fat-splitting  ferment  in  peritoneal  fat-necroses  in 
recent  human  and  experimental  cases.  The  ferment  (steapsin)  disappears 
after  five  or  six  days  in  experimental  necroses,  and  can  not  be  demonstrated 
in  the  limc-incrusted  human  ones.  H.  U.  Williams  has  produced  similar 
lesions  in  the  subcutaneous  fat  by  inserting  bits  of  sterile  pancreas  beneath 
the  skin.  By  ligating  the  pancreatic  ducts  of  cats  Opie  produced  at  the 
end  of  several  weeks  necrosis  of  almost  the  entire  abdominal  fat,  together 
with  foci  in  the  subcutaneous  tissue  and  in  the  pericardium.  Flexner 
has  produced  acute  hnomnrrhagic  pancreatitis  by  injecting  artificial  gastric 
37 


592  DISEASES  OF  THE  DIGESTIVE  SYSTEM.    - 

juice  into  the  duct  of  Wirsung.  Opie  has  recently  made  the  interesting 
observation  that  hsemorrhagic  pancreatitis  "and  fat-necrosis  may  be  pro- 
duced by  injecting  bile  into  the  pancreatic  duct  of  dogs,  and  has  also  shown 
that  the  penetration  of  bile  into  the  pancreas  may  be  the  cause  of  these 
conditions  in  human  cases.  _ 

It  is  well  for  surgeons  to  remember  that  in  two  cases  at  least  the  most 
serious  symptoms  of  acute  pancreatic  disease  have  been  found  in  association 
with  only  widespread  fat-necrosis  of  the  gland.  In  a  case  reported  by 
Stockton  and  Williams  a  man,  on  his  return  journey  from  Europe,  was 
seized  with  vomiting  and  pain,  without  fever,  but  with  a  very  small  pulse. 
The  patient  died  soon  after  his  arrival  in  America.  The  post  mortem 
showed  a  pancreas  18  cm.  long,  at  first  sight  normal,  but  on  section  most 
extensive  fatty  infiltration  with  fat-necrosis  was  demonstrable. 

III.    CHRONIC    PANCREATITIS. 

Sclerosis  follows  obstruction  of  the  duct  of  Wirsung  by  pancreatic  -cal- 
culi, by  gall-stones  lodged  near  the  orifice  of  the  common  duct,  and  by 
neoplasm.  Opie  has  distinguished  two  histological  types  of  chronic  in- 
flammation: (a)  interlobular,  including  that  caused  by  occlusion  of  the 
duct,  and  (h)  interacinar,  a  more  diffuse  process  invading  the  islands  of 
Langerhans  which  are  spared  by  the  interlobular  form.  These  varieties 
have  much  correspondence  to  the  atrophic  and  hypertrophic  cirrhosis  of 
the  liver.  As  already  mentioned,  it  is  probable  that  there  is  a  close  rela- 
tionship between  disease  of  the  islands  of  Langerhans  and  diabetes.  Ogca- 
sionally  the  gland  is  larger  than  normal,  and  may  form  a  tumor  readily 
palpable  in  the  upper  part  of  the  abdomen.  In  haemochromatosis  there 
may  be  pigmentary  changes  in  association  with  a  similar  condition  in  the 
liver  and  pigmentation  of  the  skin. 

The  interest  in  atrophy  of  the  pancreas  relates  first  to  the  association 
with  it  of  diabetes,  which  has  been  already  considered;  and  secotidly  to  the 
possibility  of  a  chronic  interstitial  pancreatitis,  particularly  at  the  head  of 
the  organ,  blocking  the  terminal  part  of  the  common  bile-duct.  Eiedel 
refers  to  severe  cases  in  which  he  found  during  operation  for  gall-stones 
the  head  of  the  pancreas  enlarged  and  hard  as  stone,  so  that  he  dreaded  the 
possibility  of  new  growth;  but  two  of  his  patients  recovered  and  were  well 
for  years,  and  in  the  third  the  post  mortem  showed  that  the  condition  was 
one  of  chronic  pancreatitis.  Similar  cases  are  described  by  Mayo-Eobson. 
In  one  of  Korte's  cases  a  small  nodule  of  the  gland  involved  in  a  chronic 
pancreatitis  had  pressed  directly  upon  the  ductus  communis  choledochus 
and  caused  the  jaundice. 

IV.    PANCREATIC    CYSTS. 

Of  121  cases  operated  upon  by  surgeons  60  were  in  males  and  56  in 
females;  in  5  the  sex  was  not  given  (Korte).  Sixty-six  of  the  cases  oc- 
curred in  the  fourth  decade.  T.  C.  Eailton's  case  (which  is  not  in  Korte's 
series),  an  infant  aged  six  months,  and  Shattuck's  case  in  a  child  of  thir- 


PANCREATIC  CYSTS.  593 

teen  and  a  half  months,  are  the  youngest  in  the  literature.    According  to 
the  origin  Korte  recognizes  three  varieties. 

(1)  Traumatic  Cases. — In  this  list  of  33  cases  30  were  in  men  and  only 
3  in  women.  Blows  on  the  abdomen  or  constantly  repeated  pressure  are  the 
most  common  forms  of  trauma.  One  case  followed  severe  massage.  Usu- 
ally with  the  onset  there  are  inflammatory  symptoms,  pain,  and  vomiting, 
sometimes  suggestive  of  peritonitis.  The  contents  of  the  cyst  are  usually 
bloody,  though  in  13  of  the  traumatic  cases  it  was  clear  or  yellowish. 

(2)  Cysts  following  Inflammatory  Conditions. — In  51  cases  the  trouble 
began  gradually  after  attacks  of  dyspepsia  with  colic,  simulating  somewhat 
that  of  gall-stones.  Occasionally  the  attack  set  in  with  very  severe  symp- 
toms, suggestive  of  obstruction  of  the  bowel.  In  this  group  the  tumor  ap- 
peared in  19  cases  soon  after  the  onset  of  the  pain;  in  others  it  was  delayed 
for  a  period  of  from  a  few  weeks  to  two  or  three  years.  McPhedran  has  re- 
ported a  remarkable  instance  in  which  the  tumor  developed  in  the  epigas- 
trium with  signs  of  severe  inflammation.  It  was  opened  and  drained  and 
believed  to  be  a  hydrops  of  the  lesser  peritoneal  cavity.  Three  months 
later  a  second  cyst  developed,  which  appeared  to  spring  directly  from  the 
pancreas. 

(3)  Cysts  without  any  Inflammatory  or  Traumatic  Etiology.— Of  33 
cases  in  this  group  26  were  in  women.  A  remarkable  feature  is  the  pro- 
longed period  of  their  existence — in  one  case  for  forty-seven  years,  in  one 
for  between  sixteen  and  twenty  years,  in  others  for  sixteen,  nine,  and  eight 
years,  in  the  majority  for  from  two  to  four  years. 

Anatomically  Korte  recognizes  (1)  retention  cysts  due  to  plugging  of 
the  main  duct;  (2)  proliferation  cysts  of  the  pancreatic  tissue — the  cysto- 
adenoma;  (3)  retention  cysts  arising  from  the  alveoli  of  the  gland  and  of  the 
smaller  ducts,  which  become  cut  off  and  dilate  in  consequence  of  chronic 
interstitial  pancreatitis;  (4)  pseudo-cysts  following  inflammatory  or  trau- 
matic affections  of  the  pancreas,  usually  the  result  of  injury,  causing 
haemorrhage  and  hydrops  of  the  lesser  peritoneum. 

Situation. — In  its  growth  the  cyst  may  (1)  develop  in  the  lesser  peri- 
tonaeum, push  the  stomach  upward,  and  reach  the  abdominal  wall  between 
the  stomach  and  the  transverse  colon;  (2)  more  rarely  the  cyst  appears 
above  the  lesser  curvature  and  pushes  the  stomach  downward;  in  both  of 
these  cases  the  situation  of  the  tumor  is  high  in  the  abdomen,  but  in  (3) 
it  may  develop  between  the  leaves  of  the  transverse  meso-colon  and  lie 
below  both  the  colon  and  the  stomach.  The  relation  of  these  two  organs 
to  the  tumor  is  variable,  but  in  the  majority  of  cases  the  stomach  lies 
above  and  the  transverse  colon  below  the  cyst.  Occasionally,  too,  as  in  T. 
C.  Eailton's  case,  the  cyst  may  develop  from  the  tail  of  the  pancreas  and 
project  far  over  in  the  left  hypochondrium  in  the  position  of  the  spleen 
or  of  a  renal  tumor. 

General  Symptoms. — Apart  from  the  features  of  onset  already  re- 
ferred to,  the  patient  may  complain  of  no  trouble  whatever,  particularly  in 
the  very  chronic  cases,  unless  tlie  cyst  reaches  a  very  large  size.  Painful 
colicky  attacks,  with  nausea  and  vomiting  and  progressive  enlargement  of 
the  abdomen,  have  frequently  been  noted.     Fatty  diarrhoea  from  disturb- 


594  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ance  of  the  function  of  the  pancreas  is  rare.  Sugar  in  the  urine  has  been 
present  in  a  number  of  cases.  Increased  secretion  of  the  saliva,  the  so-called 
pancreatic  salivation,  is  also  rare.  Pressure  of  the  cyst  may  sometimes 
cause  jaundice,  and  in  rare  instances  dyspnoea.  Very  marked  loss  of  flesh 
has  been  present  in  a  number  of  cases.  A  remarkable  feature  often  noticed 
has  been  the  transitory  disappearance  of  the  cyst.  In  one  of  Halsted's  cases 
the  girth  of  the  abdomen  decreased  from  43  to  31  inches  in  ten  days  with 
profuse  diarrhoea.    Sometimes  the  disappearance  has  followed  blows. 

Diagnosis. — The  cyst  occupies  the  upper  abdomen,  usually  forming 
a  semicircular  bulging  in  the  median  line,  rarely  to  either  side.  In  16 
cases  Korte  states  that  the  chief  projection  was  below  the  navel.  In  one  case 
operated  upon  by  Halsted  the  tumor  occupied  the  greater  part  of  the  abdo- 
men. The  cyst  is  immobile,  respiration  having  little  or  no  influence  on 
it.  As  already  mentioned,  the  stomach,  as  a  rule,  lies  above  it  and  the  colon 
below. 

In  a  majority  of  the  cases  the  fluid  is  of  a  reddish  or  dark-brown  color, 
and  contains  blood  or  blood  coloring  matter,  cell  detritus,  fat  granules, 
and  sometimes  cholesterin.  The  consistence  of  the  fluid  is  usually  mucoid, 
rarely  thin.  The  reaction  is  alkaline,  the  specific  gravity  from  1.010  to 
1.030.    In  23  cases  Korte  states  that  the  fluid  was  not  haemorrhagic. 

The  existence  of  ferments  is  important.  In  54  cases  they  were  present 
in  the  fluid  or  in  the  material  from  the  fistula.  In  30  cases  only  one  ferment 
was  present,  in  30  cases  two,  and  in  14  cases  all  three  of  the  pancreatic  fer- 
ments were  found.  As  diastatic  and  fat  emulsifying  ferments  occur  widely 
in  various  exudates  the  most  important  and  only  positive  signs  in  the  diag- 
nosis of  the  pancreatic  secretion  is  the  digestion  of  fibrin  and  albumin. 

Results. — Korte  states  of  101  cases  in  which  the  cyst  was  opened  and 
drained  4  deaths  followed  the  operation  directly;  1  resulted  from  infec- 
tion of  the  fistula.  In  14  cases  the  cyst  was  extirpated;  of  these  13  re- 
covered. In  cases  of  Bull  and  of  Kronig  diabetes  followed  the  extirpation 
of  cysts. 

V.    TUMORS    OF    THE    PANCREAS. 

Of  new  growths  in  the  organ  carcinoma  is  the  most  frequent.  Sarcoma, 
adenoma,  and  lymphoma  are  rare. 

Frequency. — At  the  General  Hospital  in  Vienna  in  18,069  autopsies 
there  were  33  cases  of  cancer  of  the  pancreas  (Biach).  In  11,473  post- 
mortems at  Milan,  Segre  found  133  tumors  of  the  pancreas,  137  of  which 
were  carcinomata,  3  sarcomata,  3  cysts,  and  1  syphiloma.  In  6,000  autop- 
sies at  Guy's  Hospital  there  were  only  30  cases  of  primary  malignant  dis- 
ease of  the  organ  (Hale  White).  In  the  first  1,500  autopsies  at  the  Johns 
Hopkins  Hospital  there  were  6  cases  of  adeno-carcinoma,  and  1  doubtful 
case  in  which  the  exact  origin  could  not  be  stated.  There  were  8  cases 
of  secondary  malignant  disease  of  the  pancreas.  The  head  of  the  gland 
is  most  commonly  involved,  but  the  disease  may  be  limited  to  the  body  or 
to  the  tail.    The  majority  of  the  patients  are  in  the  middle  period  of  life. 

Symptoms. — The  diagnosis  is  not  often  possible.  The  following  are 
the  most  important  and  suggestive  features:  (a)  Epigastric  pains,  often 


PANCREATIC  CALCULI.  •         595 

occurring  in  paroxysms.  (6)  Jaundice,  due  to  pressure  of  the  tumor  in 
the  head  of  the  pancreas  on  the  bile-duct.  The  jaundice  is  intense  and 
permanent,  and  associated  with  dilatation  of  the  gall-bladder,  which  may 
reach  a  very  large  size,  (c)  The  presence  of  a  tumor  in  the  epigastrium. 
This  is  very  variable.  In  137  cases  Da  Costa  found  the  tumor  present 
in  only  13.  Palpation  under  aneesthesia  with  the  stomach  empty  would 
probably  give  a  very  much  larger  percentage.  As  the  tumor  rests  directly 
upon  the  aorta  there  is  usually  a  marked  degree  of  pulsation,  sometimes 
with  a  bruit.  There  may  be  pressure  on  the  portal  vein,  causing  throm- 
bosis and  its  usual  sequels,  (d)  Symptoms  due  to  loss  of  function  of  the 
pancreas  are  less  important.  Fatty  diarrhoea  is  not  very  often  present.  In 
consequence  of  the  absence  of  bile  the  stools  are  usually  very  clay-colored 
and  greasy.  Diabetes  also  is  not  common,  (e)  A  very  rapid  wasting  and 
cachexia.  Of  other  symptoms  nausea  and  vomiting  are  common.  In  some 
instances  the  pylorus  is  compressed  and  there  is  great  dilatation  of  the 
stomach.    In  a  few  cases  there  has  been  profuse  salivation. 

The  points  of  greatest  importance  in  the  diagnosis  are  the  intense  and 
permanent  jaundice,  with  dilatation  of  the  gall-bladder,  rapid  emaciation, 
and  the  presence  of  a  tumor  in  the  epigastric  region.  Of  less  importance 
are  features  pointing  to  disturbance  of  the  function  of  the  gland. 

Of  other  new  growths  sarcoma  and  lymphoma  have  been  occasionally 
found.  Miliary  tubercle  is  not  very  uncommon  in  the  gland.  Syphilis 
may  occur  as  rather  a  chronic  interstitial  inflammation,  or  in  the  form  of 
gummous  tumors. 

The  outlook  in  tumors  of  the  pancreas  is,  as  a  rule,  hopeless.  How- 
ever, of  10  cases  operated  upon  of  late  years,  6  recovered  (Korte). 


VI.    PANCREATIC    CALCULI. 

Pancreatic  lithiasis  is  comparatively  rare.  In  1883  George  W.  John- 
ston collected  35  cases  in  the  literature.  In  1,500  autopsies  at  the  Johns 
Hopkins  Hospital  there  were  2  cases. 

The  stones  are  usually  numerous,  either  round  in  shape  or  rough, 
spinous  and  coral-like.  The  color  is  opaque  white.  They  are  composed 
chiefly  of  carbonate  of  lime.  The  effects  of  the  stones  are:  (1)  A  chronic 
interstitial  inflammation  of  the  gland  substance  with  dilatation  of  the  duct; 
sometimes  there  is  cystic  dilatation  of  the  gland;  (2)  acute  inflammation 
with  suppuration;  (3)  the  irritation  of  the  stones,  as  in  the  gall-bladder, 
may  lead  to  carcinoma. 

Symptoms. — Pepper  in  1882  made  a  diagnosis  of  calculus  of  the  pan- 
creas, of  which,  however,  there  was  no  confirmation  either  by  the  passage 
of  the  stone  or  by  autopsy.  Minnich  has  reported  a  case  in  which,  after  an 
attack  of  colic,  calculi  composed  of  calcic  carbonate  and  phosphate  were 
passed  in  the  stools.  Lichtheim,  in  a  case  with  severe  colic,  diabetes,  and 
fatty  diarrhoea,  made  the  diagnosis  of  pancreatic  calculi,  which  was  after- 
ward confirmed  by  autopsy. 


596  *  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

X.    DISEASES   OF  TKE  PEEITO^^UM. 
I.   ACUTE   GENERAL   PERITONITIS. 

Definition. — Acute  inflammation  of  the  peritongeum. 
Etiology. — The  condition  may  be  primary  or  secondary. 

(a)  Primary,  Idiopathic  Peritonitis. — Considering  how  frequently  the 
pleura  and  pericardium  are  primarily  inflamed  the  rarity  of  idiopathic  in- 
flammation of  the  peritongeum  is  somewhat  remarkable.  It  may  foljow 
cold  or  exposure  and  is  then  known  as  rheumatic  peritonitis.  No  instance 
of  the  kind  has  come  under  my  notice.  In  Bright's  disease,  gout,  and 
arterio-sclerosis  acute  peritonitis  may  develop  as  a  terminal  event.  Of  102 
cases  of  peritonitis  which  came  to  autopsy  at  the  Johns  Hopkins  Hospital, 
13  were  of  this  form.  In  these  there  was  some  pre-existing  chronic  disease 
(Flexner). 

(b)  Secondary  peritonitis  is  due  to  extension  of  inflammation  from,  or 
perforation  of  one  of  the  organs  covered  by  the  peritongeum.  Peritonitis 
from  extension  may  follow  inflammation  of  the  stomach  or  intestines,  ex- 
tensive ulceration  in  these  parts,  cancer,  acute  suppurative  inflammations 
of  the  spleen,  liver,  pancreas,  retroperitoneal  tissues,  and  the  pelvic  vis- 
cera. 

Perforative  peritonitis  is  the  most  common,  following  external  wounds, 
perforation  of  ulcer  of  the  stomach  or  bowels,  perforation  of  the  gall- 
bladder, abscesS'  of  the  liver,  spleen,  or  kidneys.  Two  important  causes  are 
appendicitis  and  suppurating  inflammation  about  the  Fallopian  tubes  and 
ovaries.  There  are  instances  in  which  peritonitis  has  followed  rupture  of 
an  apparently  normal  Graafian  follicle. 

Of  the  above  102  cases,  56  originated  in  an  extension  from  some  dis- 
eased abdominal  viscus.  The  remaining  34  followed  surgical  operations 
upon  the  peritongeum  or  the  contained  organs. 

The  peritonitis  of  septicsemia  and  pygemia  is  almost-  invariably  the  re- 
sult of  a  local  process.  An  exceedingly  acute  form  of  peritonitis  may  be 
caused  by  the  development  of  tubercles  on  the  membrane. 

Morbid  Anatomy. — In  recent  cases,  on  opening  the  abdomen  the 
intestinal  coils  are  distended  and  glued  together  by  lymph,  and  the  peri- 
tonaeum presents  a  patchy,  sometimes  a  uniform  injection.  The  exuda- 
tion may  be:  (a)  Fibrinous,  with  little  or  no  fluid,  except  a  few  pockets 
of  clear  serum  between  the  coils,  (b)  Sero-fibrinous.  The  coils  are  cov- 
ered with  lymph,  and  there  is  in  addition  a  large  amount  of  a  yellowish, 
sero-fibrinous  fluid.  In  instances  in  which  the  stomach  or  intestine  is 
perforated  this  may  be  mixed  with  food  or  faeces,  (c)  Purulent,  in  which 
the  exudate  is  either  thin  and  greenish  yellow  in  color,  or  opaque  white 
and  creamy,  (d)  Putrid.  Occasionally  in  puerperal  and  perforative  peri- 
tonitis, particularly  when  the  latter  has  been  caused  by  cancer,  the  exudate 
is  thin,  grayish  green  in  color,  and  has  a  gangrenous  odor,  (e)  Hgemor- 
rhagic.  This  is  sometimes  found  as  an  admixture  in  cases  of  acute  peri- 
tonitis following  wounds,  and  occurs  in  the  cancerous  and  tuberculous 


ACUTE  GENERAL   PERITONITIS.  597 

forms.  (/)  A  rare  form  occurs  in  which  the  injection  is  present,  but  almost 
all  signs  of  exudation  are  wanting.  Close  inspection  may  be  necessary  to 
detect  a  slight  dulling  of  the  serous  surfaces.  The  bacteriological  exami- 
nation reveals  large  numbers  of  bacteria. 

The  amount  of  the  effusion  varies  from  half  a  litre  to  20  or  30  litres. 
There  are  probably  essential  differences  between  the  various  kinds  of  peri- 
tonitis. 

Bacteriology  of  Acute  Peritonitis. — Much  work  has  been  done  lately 
upon  the  subject.  Flexner  has  analyzed  103  cases  of  peritonitis,  in  which 
bacteriological  studies  were  made,  which  came  to  autopsy  in  the  Johns 
Hopkins  Hospital.  He  makes  three  classes.  The  first  class  embraces  the 
primary  or  idiopathic  form,  of  which  12  cases  were  found.  These  Avere 
with  one  exception  mono-infections.  The  prevailing  micro-organism  was 
the  streptococcus  pyogenes  (five  times),  the  remaining  ones  being  the  staphy- 
lococcus aureus,  micrococcus  lanceolatus,  bacillus  proteus,  pyocyaneus,  and 
coli  communis.  The  second  class  followed  operations  upon  the  peritonaeum, 
excepting  operations  upon  the  intestine.  The  majority  of  these  cases  were 
examples  of  wound  infection.  They  were  33  in  number.  In  25  of  these 
mono-infections,  in  8  mixed  infections  existed.  The  prevailing  micro- 
organism M^as  the  staphylococcus  aureus,  which  was  present  alone  in  12 
and  combined  in  2  cases.  The  streptococcus  occurred  5  times  uncom- 
bined  and  4  times  combined.  The  bacillus  coli  was  found  5  times  in  all, 
being  unassociated  in  3  cases.  Other  organisms  found  were  the  micro- 
coccus lanceolatus,  staphylococcus  albus,  bacillus  pyocyaneus,  and  ^rogenes 
capsulatus.  The  remaining  56  cases,  forming  the  third  class,  were  instances 
of  intestinal  infection.  These  comprised  23  mono-  and  33  polyinfections. 
The  predominating  micro-organism  was  the  bacillus  coli  communis  which 
occurred  in  43  cases,  8  times  alone  and  35  in  association.  The  strepto- 
coccus was  present  in  37  cases,  being  alone  in  7.  The  staphylococci,  pneu- 
mococcus,  bacillus  proteus,  pyocyaneus,  typhosus,  and  aerogenes  capsulatus 
occurred  in  a  smaller  number  of  instances. 

Among  the  micro-organisms  thus  far  found  rarely  in  peritonitis,  may 
be  mentioned  the  gonococcus,  the  anthrax  bacillus,  the  proteus  bacillus, 
and  the  typhoid  bacillus.  As  illustrating  the  importance  of  the  gonococ- 
cus, I  may  state  that  as  I  write  there  are  two  young  girls  both  of  whom 
were  admitted  to  my  wards  with  diffuse  peritonitis  arising  from  fresh 
gonorrhoeal  salpingitis.  Both  were  operated  upon  by  Gushing  success- 
fully. Welch  has  found  the  bacillus  coli  communis  in  peritonitis  due  to 
ulceration  of  the  intestines  without  perforation. 

Symptoms. — In.  the  perforative  and  septic  cases  the  onset  is  marked 
by  chilly  feelings  or  an  actual  rigor  with  intense  pain  in  the  abdomen.  In 
typhoid  fever,  when  the  sensorium  is  benumbed,  the  onset  may  not  be 
noticed.  The  pain  is  general,  and  is  usually  intense  and  aggravated  by 
movements  and  pressure.  A  position  is  taken  which  relieves  the  tension 
of  the  abdominal  muscles,  so  that  the  patient  lies  on  the  back  with  the 
thighs  drawn  up  and  the  shoulders  elevated.  The  greatest  paints  usually 
below  the  umbilicus,  but  in  peritonitis  from  perforation  of  the  stomach 
pain  may  be  referred  to  the  back,  the  chest,  or  the  shoulder.    The  respira- 


598  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tion  is  superficial — costal  in  type — as  it  is  painful  to  use  the  diaphragm. 
For  the  same  reason  the  action  of  coughing  is  restrained,  and  even  the 
movements  necessary  for  talking  are  limited.  In  this  early  stage  the  sensi- 
tiveness may  be  great  and  the  abdominal  muscles  are  often  rigidly  con- 
tracted. If  the  patient  is  at  perfect  rest  the  pain  may  be  very  slight,  and 
there  ~are  instances  in  which  it  is  not  at  all  marked,  and  may,  indeed,  be 
absent. 

The  abdomen  gradually  becomes  distended  and  tense  and  is  tympanitic 
on  percussion.  The  pulse  is  rapid,  small,  and  hard,  and  often  has  a  peculiar 
wiry  quality.  It  ranges  from  110  to  150.  The  temperature  may  rise  rapid- 
ly after  the  chill  and  reach  104°  or  105°,  but  the  subsequent  elevation  is 
moderate.  In  some  very  severe  cases  there  may  be  no  fever  throughout. 
The  tongue  at  first  is  white  and  moist,  but  subsequently  becomes  dry  and 
often  red  and  fissured.  Vomiting  is  an  early  and  prominent  feature  and 
causes  great  pain.  The  contents  of  the  stomach  are  first  ejected,  then  a 
yellowish  and  bile-stained  fluid,  and  finally  a  greenish  and,  in  rare  in- 
stances, a  brownish-black  liquid  with  slight  faecal  odor.  The  bowels  may 
be  loose  at  the  onset  and  then  constipation  may  follow.  Frequent  micturi- 
tion may  be  present,  less  often  retention.  The  urine  is  usually  scanty  and 
high-colored,  and  contains  a  large  quantity  of  indican. 

The  appearance  of  the  patient  when  these  symptoms  have  fully  devel- 
oped is  very  characteristic.  The  face  is  pinched,  the  eyes  are  sunken,  and 
the  expression  is  very  anxious.  The  constant  vomiting  of  fluids  causes  a 
wasted  appearance,  and  the  hands  sometimes  present  the  washer-woman's 
skin.  Except  in  cholera,  we  see  the  Hippocratic  facies  more  frequently 
in  this  than  in  any  other  disease — "  a  sharp  nose,  hollow  eyes,  collapsed 
temples;  the  ears  cold,  contracted,  and  their  lohes  turned  out;  the  shin  about 
the  forehead  being  rough,  distended,  and  parched;  the  color  of  the  whole  face 
being  brown,  blacTc,  livid,  or  lead-colored."  There  are  one  or  two  additional 
points  about  the  abdomen.  The  tympany  is  usually  excessive,  owing  to  the 
great  relaxation  of  the  walls  of  the  intestines  by  inflammation  and  exuda- 
tion. The  splenic  dulness  may  be  obliterated,  the  diaphragm  pushed  up, 
and  the  apex  beat  of  the  heart  dislocated  to  the  fourth  interspace.  Th^ 
liver  dulness  may  be  greatly  reduced,  or  may,  in  the  mammary  line,  be 
obliterated.  It  has  been  claimed  that  this  is  a  distinctive  feature  of  per- 
forative peritonitis,  but  on  several  occasions  I  have  been  able  to  demon- 
strate that  the  liver  dulness  in  the  middle  and  mammary  line  was  obliter- 
ated by  tympanites  alone.  In  the  axillary  line,  on  the  other  hand,  the 
liver  dulness,  though  diminished,  may  persist.  Pneumo-peritonasum  fol- 
lowing perforation  more  certainly  obliterates  the  hepatic  dulness.  In  such 
cases  the  fluid  effused  produces  a  dulness  in  the  lateral  region;  but  with 
gas  in  the  peritonaeum,  if  the  patient  is  turned  on  the  left  side,  a  clear 
note  is  heard  beneath  the  seventh  and  eighth  ribs.  Acute  peritonitis  may 
present  a  flat,  rigid  abdomen  throughout  its  course. 

Effusion  of  fluid — ascites — is  usually  present  except  in  some  acute 
rapidly  fatal  cases.  The  flanks  are  dull  on  percussion.  The  dulness  may 
be  movable,  though  this  depends  altogether  upon  the  degree  of  adhesions. 
There  may  be  considerable  effusion  without  either  movable  dulness  or 


ACUTE   GENERAL   PERITONITIS.  599 

fluctuation.  A  friction-rub  may  be  present,  as  first  pointed  out  by  Bright, 
but  it  is  not  nearly  so  common  in  acute  as  in  chronic  peritonitis. 

Course. — The  acute  diffuse  peritonitis  usually  terminates  in  death. 
The  most  intense  forms  may  kill  within  thirty-six  to  forty-eight  hours; 
more  commonly  death  results  in  four  or  five  days,  or  the  attack  may  be 
prolonged  to  eight  or  ten  days.  The  pulse  becomes  irregular,  the  heart- 
sounds  weak,  the  breathing  shallow;  there  are  lividity  with  pallor,  a  cold 
skin  with  high  rectal  temperature — a  group  of  symptoms  indicating  pro- 
found failure  of  the  vital  functions  for  which  Gee  has  revived  the  old  term 
Upothymia.  Occasionally  death  occurs  with  great  suddenness,  owing,  pos- 
sibly, to  paralysis  of  the  heart. 

Diagnosis. — In  typical  cases  the  severe  pain  at  onset,  the  distention 
of  the  abdomen,  the  tenderness,  the  fever,  the  gradual  development  of 
effusion,  collapse  symptoms,  and  the  vomiting  give  a  characteristic  picture. 
Careful  inquiries  should  at  once  be  made  concerning  the  previous  condi- 
tion, from  which  a  clew  can  often  be  had  as  to  the  starting-point  of  the 
trouble.  In  young  adults  a  considerable  proportion  of  all  cases  depends 
upon  perforating  appendicitis,  and  there  may  be  an  account  of  previous 
attacks  of  pain  in  the  iliac  region,  or  of  constipation  alternating  with  diar- 
rhoea. In  women  the  most  frequent  causes  are  suppurative  processes  in 
the  pelvic  viscera,  associated  with  salpingitis,  abscesses  in  the  broad  liga- 
ments, or  acute  puerperal  infection.  Perforation  of  gastric  ulcer  is  a  more 
common  factor  in  women  than  in  men.  It  is  not  always  easy  to  determine 
the  cause.  Many  cases  come  under  observation  for  the  first  time  with  the 
abdomen  distended  and  tender,  and  it  is  impossible  to  make  a  satisfactory 
examination.  In  such  instances  the  pelvic  organs  should  be  examined 
with  the  greatest  care.  In  typhoid  fever,  if  the  patient  is  conscious,  the 
sudden  onset  of  pain,  the  development  of  great  meteorism,  and  the  aggra- 
vation of  the  general  symptoms  indicate  clearly  what  has  happened.  When 
the  patient  is  in  deep  coma,  on  the  other  hand,  the  perforation  may  be 
overlooked.  The  following  conditions  are  most  apt  to  be  mistaken  for 
acute  peritonitis: 

(a)  Acute  Entero-colitis. — Here  the  pain  and  distention  and  the  sen- 
sitiveness on  pressure  may  be  marked.  The  pain  is  more  colicky  in  char- 
acter, the  diarrhoea  is  more  frequent,  and  the  collapse  is  more  extreme. 

(b)  The  So-called  Hysterical  Peritonitis. — This  has  deceived  the  very 
elect,  as  almost  every  feature  of  genuine  peritonitis,  even  the  collapse,  may 
be  simulated.  The  onset  may  be  sudden,  with  severe  pain  in  the  abdomen, 
tenderness,  vomiting,  diarrhoea,  difficulty  in  micturition,  and  the  charac- 
teristic decubitus.  Even  the  temperature  may  be  elevated.  There  may  be 
recurrence  of  the  attack.  A  case  has  been  reported  by  Bristowe  in  which 
four  attacks  occurred  within  a  year,  and  it  was  not  until  special  hysterical 
symptoms  developed  that  the  true  nature  of  the  trouble  was  suspected. 

(c)  Obstruction  of  the  hoivel,  as  already  mentioned,  may  simulate  peri- 
tonitis, both  having  pain,  vomiting,  tympanites,  and  constipation  in  com- 
mon. It  may  for  a  couple  of  days  really  be  impossible  to  make  a  diagnosis 
in  the  absence  of  a  satisfactory  history. 

(d)  Rupture  of  an  abdominal  aneurism  or  embolism  of  the  superior 


600  DISEASES  OF  THE  DIGESTIVE  SYSTEM.      ^ 

mesenteric  artery  may  cause  symptoms  which  simulate  peritonitis.  In  the 
latter,  sudden  onset  with  severe  pain,  the  collapse  symptoms,  frequent 
vomiting,  and  great  distention  of  the  abdomen  may  be  present. 

(e)  I  have  already  referred  to  the  fact  that  acute  hsemorrhagic  pan- 
creatitis may  be  mistaken  for  peritonitis.  Lastly,  a  ruptured  tubal  preg- 
nancy may  resemble  acute  peritonitis. 


II.    PERITONITIS    IN    INFANTS. 

Peritonitis  may  occur  in  the  foetus  as  a  consequence  of  syphilis,  and 
may  lead  to  constriction  of  the  bowel  by  fibrous  adhesions. 

In  the  new-born  a  septic  peritonitis  may  extend  from  an  inflamed  cord. 
Distention  of  the  abdomen,  slight  swelling  and  redness  about  the  cord,  and 
not  infrequently  jaundice  are  present.  It  is  an  uncommon  event,  and 
existed  in  only  4  of  51  infants  dying  with  inflammation  of  the  cord  and 
septicaemia  (Eunge). 

During  childhood  peritonitis  develops  from  causes  similar  to  those  af- 
fecting the  adult.  Perforative  appendicitis  is  common.  Peritonitis  fol- 
lowing blows  or  kicks  on  the  abdomen  occurs  more  frequently  at  this 
period.  In  boys  injury  while  playing  foot-ball  may  be  followed  by  diffuse 
peritonitis.  A  rare  cause  in  children  is  extension  through  the  diaphragm 
from  an  empyema.  There  are  on  record  instances  of  peritonitis  occurring 
in  several  children  at  the  same  school,  and  it  has  been  attributed  to  sewer- 
gas  poisoning.  It  was  in  investigating  an  epidemic  of  this  kind  at  the 
Wandsworth  school,  in  London,  that  Anstie  received  the  post-mortem 
wound  of  which  he  died. 


III.    LOCALIZED    PERITONITIS. 

1.  Subphrenic  Peritonitis. — The  general  peritoneum  covering  the  right 
and  left  lobes  of  the  liver  may  be  involved  in  an  extension  from  the  pleura 
of  suppurative,  tuberculous,  or  cancerous  processes.  In  various  affections 
of  the  liver — cancer,  abscess,  hydatid  disease,  and  in  affections  of  the 
gall-bladder — the  inflammation  may  be  localized  to  the  peritonasum  cover- 
ing the  upper  surface  of  the  organ.  These  forms  of  localized  subphrenic 
peritonitis  in  the  greater  sac  are  not  so  important  in  reality  as  those  which 
occur  in  the  lesser  peritongeum.  The  anatomical  relations  of  this  struc- 
ture are  as  follows:  It  lies  behind  and  below  the  stomach,  the  gastro- 
hepatic  omentum,  and  the  anterior  layer  of  the  great  omentum.  Its 
lower  limit  forms  the  upper  layer  of  the  transverse  meso-colon.  On  either 
side  it  reaches  from  the  hepatic  to  the  splenic  flexure  of  the  colon,  and 
from  the  foramen  of  "Winslow  to  the  hilus  of  the  spleen.  Behind  it  cov- 
ers and  is  tightly  adherent  to  the  front  of  the  pancreas.  Its  upper  limit 
is  formed  by  the  transverse  fissure  of  the  liver,  and  by  that  portion  of  the 
diaphragm  which  is  covered  by  the  lower  layer  of  the  right  lateral  liga- 
ment of  the  liver;  the  lobus  Spigelii  lies  bare  in  the  cavity.    The  foramen 


LOCALIZED  PERITONITIS.  601 

of  Winslow,  through  which  the  lesser  communicates  with  the  greater  peri- 
toneum, is  readily  closed  by  inflammation. 

Inflammatory  processes,  exudates,  and  hemorrhages  may  be  confined 
entirely  to  the  lesser  peritoneum.  The  exudate  of  tuberculous  peritonitis 
may  be  confined  to  it.  Perforations  of  certain  parts  of  the  stomach,  of 
the  duodenum,  and  of  the  colon  may  excite  inflammation  in  it  alone;  and 
in  various  affections  of  the  pancreas,  particularly  trauma  and  hemorrhage, 
the  effusion  into  the  sac  has  often  been  confounded  with  cyst  of  this  organ. 
"  Pathological  distention  of  the  lesser  peritoneum  gives  rise  to  a  tumor 
in  the  left  hypochondriac,  epigastric,  and  umbilical  regions  of  a  somewhat 
characteristic  shape,  but  which  appears  to  vary  from  time  to  time  in  form 
and  size,  according  to  the  conditions  of  the  overlying  stomach;  for  when 
the  viscus  is  full  of  liquid  contents  it  increases  the  area  of  the  tumor's 
dulness,  while  it  makes  its  outlines  less  definable  by  palpation,  and  if  the 
stomach  is  distended  with  gas  the  dull  area  becomes  resonant  and  apparent- 
ly the  tumor  may  disappear  altogether.  The  colon  always  lies  below  the 
tumor  and  never  in  front  of  or  above  it,  as  is  the  case  in  kidngy  enlarge- 
ment "  (Jordan  Lloyd). 

Special  mention  must  be  made  of  the  remarkable  form  of  subphrenic 
abscess  containing  air,  which  may  simulate  closely  pneumothorax,  and 
hence  was  called  by  Leyden  Pyo-pneumotliorax  sub-phrenicus.  The  affection 
has  been  thoroughly  studied  of  late  years  by  Scheurlen,  Mason,  Meltzer, 
and  Lee  Dickinson.  In  142  out  of  170  recorded  cases  the  cause  was  known. 
In  a  few  instances,  as  in  one  reported  by  Meltzer,  the  subphrenic  abscess 
seemed  to  have  followed  pneumonia.  Pyothorax  is  an  occasional  cause. 
By  far  the  most  frequent  condition  is  gastric  ulcer,  which  occurred  in  80 
of  the  cases.  Duodenal  ulcer  was  the  cause  in  6  per  cent.  In  about  10 
per  cent  of  the  cases  the  appendix  was  the  starting-point  of  the  abscess. 
Cancer  of  the  stomach  is  an  occasional  cause.  Other  rare  causes  are  trauma, 
which  was  present  in  one  of  my  cases,  perforation  of  an  hepatic  or  a  renal 
abscess,  lesions  of  the  spleen,  abscess,  and  cysts  of  the  pancreas. 

In  a  majority  of  all  the  cases  in  which  the  stomach  or  duodenum  is  per- 
forated— sometimes,  indeed,  in  the  cases  following  trauma,  as  in  Case  3 
of  my  series — the  abscess  contains  air. 

The  symptoms  of  subphrenic  abscess  vary  very  considerably,  depending 
a  good  deal  upon  the  primary  cause.  The  onset,  as  a  rule,  is  abrupt,  par- 
ticularly when  due  to  perforation  of  a  gastric  ulcer.  There  are  severe 
pain,  vomiting,  often  of  bilious  or  of  bloody  material;  respiration  is  em- 
barrassed, owing  to  the  involvement  of  the  diaphragm;  then  the  constitu- 
tional symptoms  develop  associated  with  suppuration,  chills,  irregular 
fever,  and  emaciation.  Subsequently  perforation  may  take  place  into  the 
pleura  or  into  the  lung,  with  severe  cough  and  abundant  purulent  ex- 
pectoration. 

The  conditions  are  so  obscure  that  the  diagnosis  of  subphrenic  abscess 
is  not  often  made.  The  perihepatic  abscess  beneath  the  arch  of  the  dia- 
phragm, whether  to  the  right  or  left  of  the  suspensory  ligament,  when  it 
does  not  contain  air,  is  almost  invariably  mistaken  for  empyema.  "When  a 
pus  collection  of  any  size  is  in  the  lesser  peritoneum,  the  tumor  is  formed 


602  DISEASES  OF  THE  DiaSSTIVE  SYSTEM. 

which  has  the  characters  already  mentioned  in  a  quotation  from  Mr.  Jor- 
dan Lloyd. 

The  most  remarkable  features  are  those  which  are  superadded  when 
the  abscess  cavity  contains  air.  Here,  on  the  right  side,  when  the  abscess 
is  in  the  greater  peritoneum,  above  the  right  lobe  of  the  liver,  the  dia- 
phragm may  be  pushed  up  to  the  level  of  the  second  or  third  rib,  and  the 
physical  signs  on  percussion  and  auscultation  are  those  of  pneumothorax, 
particularly  the  tympanitic  resonance  and  the  movable  dulness.  The  liver 
is  usually  greatly  depressed  and  there  is  bulging  on  the  right  side.  Still 
more  obscure  are  the  cases  of  air-containing  abscesses  due  to  perforation 
of  the  stomach  or  duodenum,  in  which  the  gas  is  contained  in  the  lesser 
peritonajum.  Here  the  diaphragm  is  pushed  up  and  there  are  signs  of 
pneumothorax  on  the  left  side.  In  a  large  majority  of  all  the  cases 
which  follow  perforation  of  a  gastric  ulcer  the  effusion  lies  between  the 
diaphragm  above,  and  the  spleen,  stomach,  and  the  left  lobe  of  the  liver 
below. 

The  prognosis  in  subphrenic  abscess  is  not  very  hopeful.     Of  the  cases ' 
on  record  about  20  per  cent  only  have  recovered.     Of  the  five  cases  which 
have  come  under  my  observation,  three  recovered  after  operation. 

2.  Appendicular. — The  most  frequent  cause  in  the  male  of  localized 
peritonitis  is  inflammation  of  the  appendix  vermiformis.  The  situation 
varies  with  the  position  of  this  extremely  variable  organ.  The  adhesion, 
perforation,  and  intraperitoneal  abscess  cavity  may  be  within  the  pelvis, 
or  to  the  left  of  the  median  line  in  the  iliac  region,  in  the  lower  right 
quadrant  of  the  umbilical  region — a  not  uncommon  situation — or,  of  course, 
most  frequently  in  the  right  iliac  fossa.  In  the  most  common  situation 
the  locahzed  abscess  lies  upon  the  psoas  muscle,  bounded  by  the  csecum 
on  the  right  and  the  terminal  portion  of  the  ileum  and  its  mesentery  in 
front  and  to  the  left.  In  many  of  these  eases  the  limitation  is  perfect, 
and  post-mortem  records  show  that  complete  healing  may  take  place  with 
the  obliteration  of  the  appendix  in  a  mass  of  firm  scar  tissue. 

3.  Pelvic  Peritonitis. — The  most  frequent  cause  is  inflammation  about 
the  uterus  and  Fallopian  tubes.  Puerperal  septicemia,  gonorrhoea,  and 
tuberculosis  are  the  usual  causes.  The  tubes  are  the  starting-point  in  a 
majority  of  the  cases.  The  fimbrise  become  adherent  and  closely  matted 
to  the  ovary,  and  there  is  gradually  produced  a  condition  of  thickening  of 
the  parts,  in  which  the  individual  organs  are  scarcely  recognizable.  The 
tubes  are  dilated  and  filled  with  cheesy  matter  or  pus,  and  there  may  be 
small  abscess  cavities  in  the  broad  ligaments.  Eupture  of  one  of  these  may 
cause  general  peritonitis,  or  the  membrane  may  be  involved  by  extension, 
as  in  tuberculosis  of  these  parts. 


IV.    CHRONIC    PERITONITIS. 

The  following  varieties  may  be  recognized:  (a)  Local  adhesive  perito- 
nitis, a  very  common  condition,  which  occurs  particularly  about  the  spleen, 
forming  adhesions  between  the  capsule  and  the  diaphragm,  about  the  liver, 


CHRONIC  PERITONITIS.  603 

less  frequently  about  the  intestines  and  mesentery.  Points  of  thickening 
or  puckering  on  the'  peritoneum  occur  sometimes  with  union  of  tlie  coils 
or  with  fibrous  bands.  In  a  majority  of  such  cases  the  condition  is  met 
accidentally  post  mortem.  Two  sets  of  symptoms  may,  however,  be  caused 
by  these  adhesions.  When  a  fibrous  band  is  attached  in  such  a  way  as 
to  form  a  loop  or  snare,  a  coil  of  intestine  may  pass  through  it.  Tlius, 
of  the  295  cases  of  intestinal  obstruction  analyzed  by  Fitz,  63  were  due  to 
this  cause.  The  second  group  is  less  serious  and  comprises  cases  with  per- 
sistent abdominal  pain  of  a  colicky  character,  sometimes  rendering  life  mis- 
erable. Instances  of  this  kind  have  been  successfully  operated  upon  by 
Homans  and  H.  A.  Kelly. 

(b)  Diffuse  Adhesive  Peritonitis. — This  is  a  consequence  of  an  acute  in- 
flammation, either  simple  or  tuberculous.  The  peritongeum  is  obliterated. 
On  cutting  through  the  abdominal  wall,  the  coils  of  intestines  are  uni- 
formly matted  together  and  can  neither  be  separated  from  each  other  nor 
can  the  visceral  and  parietal  layers  be  distinguished.  There  may  be  thick- 
ening of  the  layers,  and  the  liver  and  spleen  are  usually  involved  in  the 
adhesions. 

(c)  Proliferative  Peritonitis.— Apart  from  cancer  and  tubercle,  which 
produce  typical  lesions  of  chronic  peritonitis,  the  most  characteristic  form 
is  that  which  may  be  described  under  this  heading.  The  essential  ana- 
tomical feature  is  great  thickening  of  the  peritoneal  layers,  usually  without 
much  adhesion.  The  cases  are  sometimes  seen  with  sclerosis  of  the  stom- 
ach. In  one  instance  I  found  it  in  connection  with  a  sclerotic  condition 
of  the  caecum  and  the  first  part  of  the  colon.  In  the  inspection  of  a  case 
of  this  kind  there  is  usually  moderate  effusion,  more  rarely  extensive  ascites. 
The  peritonaeum  is  opaque-white  in  color,  and  everywhere  thickened,  often 
in  patches.  The  omentum  is  usually  rolled  and  forms  a  thickened  mass 
transversely  placed  between  the  stomach  and  the  colon.  The  peritonasum 
over  the  stomach,  intestines,  and  mesentery  is  sometimes  greatly  thickened. 
The  liver  and  spleen  may  simply  be  adherent,  or  there  is  a  condition  of 
chronic  perihepatitis  or  perisplenitis,  so  that  a  layer  of  firm,  almost  gristly 
connective  tissue  of  from  one  fourth  to  half  an  inch  in  thickness  encircles 
these  organs.  Usually  the  volume  of  the  liver  is  in  consequence  greatly 
reduced.  The  gastro-hepatic  omentum  may  be  constricted  by  this  new 
growth  and  the  calibre  of  the  portal  vein  much  narrowed.  A  serous  effu- 
sion may  be  present.  On  account  of  the  adhesions  which  form,  the  peri- 
tonaeum may  be  divided  into  three  or  four  different  sacs,  as  is  more  fully 
described  under  the  tuberculous  peritonitis.  In  these  cases  the  intestines 
are  usually  free,  though  the  mesentery  is  greatly  shortened.  There  are  in- 
stances of  chronic  peritonitis  in  which  the  mesentery  is  so  shortened  by 
this  proliferative  change  that  the  intestines  form  a  ball  not  larger  than  a 
cocoa-nut  situated  in  the  middle  line,  and  after  the  removal  of  the  exuda- 
tion can  be  felt  as  a  solid  tumor.  The  intestinal  wall  is  greatly  thickened 
and  the  mucous  membrane  of  the  ileum  is  thrown  into  folds  like  the  valvulaa 
conniventes.  This  proliferative  peritonitis  is  found  frequently  in  the  sub- 
jects of  chronic  alcoholism.  In  cases  of  long-continued  ascites  the  serous 
surfaces  generally  become  thickened  and  present  an  opaque,  dead-white 


eOi  DISEASES   OF   THE   DIGESTIVE   SYSTEM, 

color.  This  condition  is  observed  especially  in  hepatic  cirrhosis,  but  attends 
tumors,  chronic  passive  congestions,  etc. 

In  all  forms  of  chronic  peritonitis  a  friction  may  be  felt  usually  in  the 
upper  zone  of  the  abdomen.  Polyorrhomenitis,  polyserositis,  general 
chronic  inflammation  of  the  serous  membranes,  Concato's  disease  (as  the 
Italians  call  it),  may  occur  ^>vith  this  form  as  well  as  in  the  tuberculous 
variety.    The  pericardium  and  both  pleurge  may  be  involved. 

In  some  instances  of  chronic  peritonitis  the  membrane  presents  numer- 
ous nodular  thickenings,  which  may  be  mistaken  for  tubercles.  J.  F. 
Payne  has  described  a  case  of  this  sort  associated  with  disseminated 
growths  throughout  the  liver  which  were  not  cancerous.  It  has  been 
suggested  that  some  of  the  cases  of  tuberculous  peritonitis  cured  by  oper- 
ation have  been  of  this  nature,  but  histological  examination  would,  as 
a  rule,  readily  determine  between  the  conditions.  Miura,  in  Japan,  has 
reported  a  case  in  which  these  nodules  contained  the  ova  of  a  parasite.  One 
case  has  been  reported  in  which  the  exciting  cause  was  regarded  as  choles- 
terin  plates,  which  were  contained  within  the  granulomatous  nodules. 

(d)  Cliroilic  Hsemorrliagic  Peritonitis. — Blood-stained  effusions  in  the 
peritonaeum  occur  particularly  in  cancerous  and  tuberculous  disease.  There 
is  a  form  of  chronic  inflammation  analogous  to  the  hgemorrhagic  pachymen- 
ingitis of  the  brain.  It  was  described  first  by  Virchow,  and  is  localized 
most  commonly  in  the  pelvis.  Layers  of  new  connective  tissue  form  on 
the  surface  of  the  peritongeum  with  large  wide  vessels  from  which  haemor- 
rhage occurs.  This  is  repeated  from  time  to  time  with  the  formation  of 
regular  layers  of  haemorrhagie  effusion.  It  is  rarely  diffuse,  more  com- 
monly circumscribed. 


V.    NEW   GROWTHS    IN   THE    PERITONAEUM. 

(a)  Tuberculous  Peritonitis. — This  has  already  been  considered. 

(&)  Cancer  of  the  Peritonseum. — Although,  as  a  rule,  secondary  to  disease 
of  the  stomach,  liver,  or  pelvic  organs,  cases  of  primary  cancer  have  been 
described.  It  is  probable  that  the  so-called  primary  cancers  of  the  serous 
membranes  are  endotheliomata  and  not  carcinomata.  Secondary  malig- 
nant peritonitis  occurs  in  connection  with  all  forms  of  cancer.  It  is  usually 
characterized  by  a  number  of  round  tumors  scattered  over  the  entire  peri- 
tonaeum, sometimes  small  and  miliary,  at  other  times  large  and  nodular, 
with  puckered  centres.  The  disease  most  commonly  starts  from  the  stom- 
ach or  the  ovaries.  The  omentum  is  indurated,  and,  as  in  tuberculous 
peritonitis,  forms  a  mass  which  lies  transversely  across  the  upper  portion 
of  the  abdomen.  lirimary  malignant  disease  of  the  peritonaeum  is  extremely 
rare.  Colloid  is  said  to  have  occurred,  forming  enormous  masses,  which  in 
one  case  weighed  over  100  pounds.  Cancer  of  this  membrane  spreads, 
either  by  the  detachment  of  small  particles  which  are  carried  in  the  lymph 
currents  and  by  the  movements  to  distant  parts,  or  by  contact  of  opposing 
surfaces.  It  occurs  more  frequently  in  women  than  in  men,  and  more  com- 
monly at  the  later  period  of  life. 

The  diagnosis  of  cancer  of  the  peritonaeum  is  easy  with  a  history  of  a 


ASCITES.  (305 

local  malignant  disease;  as  when  it  occurs  witli  ovarian  tumor  or  with 
cancer  of  the  pylorus.  In  cases  in  which  there  is  no  evidence  of  a  primary 
lesion  the  diagnosis  may  be  doubtful.  The  clinical  picture  is  usually  that 
of  chronic  ascites  with  progressive  emaciation.  There  may  be  no  fever. 
If  there  is  much  effusion  nothing  definite  can  be  felt  on  examination.  After 
tapping,  irregular  nodules  or  the  curled  omentum  may  be  felt  lying  trans- 
versely across  the  upper  portion  of  the  abdomen.  Unfortunately,  this  tumor 
upon  which  so  much  stress  is  laid  occurs  as  frequently  in  tuberculous  peri- 
tonitis and  may  be  present  in  a  typical  manner  in  the  chronic  proliferative 
form,  so  that  in  itself  it  has  no  special  diagnostic  value.  Multiple  nodules, 
if  large,  indicate  cancer,  particularly  in  persons  above  middle  life.  Nodu- 
lar tuberculous  peritonitis  is  most  frequent  in  children.  The  presence 
about  the  navel  of  secondary  nodules  and  indurated  masses_is  more  com- 
mon in  cancer.  Inflammation,  suppuration,  and  the  discharge  of  pus  from 
the  navel  rarely  occurs  except  in  tuberculous  disease.  Considerable  en- 
largement of  the  inguinal  glands  may  be  present  in  cancer.  The  nature 
of  the  fluid  in  cancer  and  in  tubercle  may  be  much  alike.  It  may  be  hemor- 
rhagic in  both;  more  often  in  the  latter.  The  histological  examination  in 
cancer  may  show  large  multinuclear  cells  or  groups  of  cells — the  sprouting 
cell-groups  of  Foulis — which  are  extremely  suggestive.  The  colloid  cancer 
may  produce  a  totally  different  picture;  instead  of  ascitic  fluid,  the  abdo- 
men is  occupied  by  the  semi-solid  gelatinous  substance,  and  is  firm,  not 
fluctuating. 

And,  lastly,  there  are  instances  of  echinococci  in  the  peritonaeum  which 
may  simulate  cancer  very  closely.  I  have  reported  a  case  of  this  kind,  in 
which  the  enlarged  liver  and  the  innumerable  nodular  masses  in  the  peri- 
tongeum  naturally  led  to  this  diagnosis. 


VI.    ASCITES  {Hydro-peritonceum). 

Definition.  — The  accumulation  of  serous  fluid  in  the  peritoneal  cavity. 

Etiology.— (1)  Local  Causes. — (a)  Chronic  inflammation  of  the  peri- 
tonaeum, either  simple,  cancerous,  or  tuberculous,  (b)  Portal  obstruction  in 
the  terminal  branches  within  the  liver,  as  in  cirrhosis  and  chronic  passive 
congestion,  or  by  compression  of  the  vein  in  the  gastro-hepatic  omentum, 
either  by  proliferative  peritonitis,  by  new  growths,  or  by  aneurism,  (c) 
Tumors  of  the  abdomen.  The  solid  growths  of  the  ovaries  may  cause  con- 
siderable ascites,  which  may  completely  mask  the  true  condition.  The  en- 
larged spleen  in  leukasmia,  less  commonly  in  malaria,  may  be  associated 
with  recurring  ascites. 

(2)  General  Causes. — The  ascites  is  part  of  a  general  dropsy,  the  result 
of  mechanical  effects,  as  in  heart-disease,  chronic  emphysema,  and  sclerosis 
of  the  lung.  In  cardiac  lesions  the  effusion  is  sometimes  confined  to  the 
peritona3um,  in  which  case  it  is  due  to  secondary  changes  in  the  liver,  or  it 
has  been  suggested  to  be  connected  with  a  failure  of  the  suction  action  of 
this  organ,  by  which  the  peritonaeum  is  kept  dry.  Ascites  occurs  also  in 
the  dropsy  of  Brighfs  disease,  and  in  hydra^mic  states  of  the  blood. 


606  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

Symptoms. — A  gradual  uniform  enlargement  of  the  alDdomen  is  the 
characteristic  symptom  of  ascites.  The  physical  signs  are  usually  distinctive, 
(a)  Inspection. — According  to  the  amount  of  fluid  the  abdomen  is  pro- 
tuberant and  flattened  at  the  sides.  With  large  effusions,  the  skin  is  tense 
and  may  present  the  linear  albicantes.  Frequently  the  navel  itself  and  the 
parts  about  it  are  very  prominent.  In  many  cases  the  superficial  veins  are 
enlarged  and  a  plexus  joining  the  mammary  vessels  can  be  seen.  Sometimes 
it  can  be  determined  by  pressure  on  these  veins  that  the  current  is  from 
below  upward.  In  some  instances,  as  in  thrombosis  or  obliteration  of  the 
portal  vein,  these  superficial  abdominal  vessels  may  be  extensively  varicose. 
About  the  navel  in  cases  of  cirrhosis  there  is  occasionall}'  a  large  bunch  of 
distended  veins,  the  so-called  caput  Medusas. 

(h)  Palpation. — Fluctuation  is  obtained  by  placing  the  fingers  of  one 
hand  upon  one  side  of  the  abdomen  and  by  giving  a  sharp  tap  on  the  op- 
posite side  with  the  other  hand,  when  a  wave  is  felt  to  strike  as  a  definite 
shock  against  the  applied  fingers.  Even  comparatively  small  quantities  of 
fluid  may  give  this  fluctuation  shock.  When  the  abdominal  walls  are 
thick  or  very  fat,  an  assistant  may  place  the  edge  of  the  hand  or  a  piece 
of  cardboard  in  the  front  of  the  abdomen.  A  different  procedure  is 
adopted  in  palpating  for  the  solid  organs  in  case  of  ascites.  Instead  of  plac- 
ing the  hand  flat  upon  the  abdomen,  as  in  the  ordinary  method,  the  pads 
of  the  fingers  only  are  placed  lightly  upon  the  skin,  and  then  by  a  sudden 
depression  of  the  fingers  the  fiuid  is  displaced  and  the  solid  organ  or  tumor 
may  be  felt.  By  this  method  of  "  dipping  "  or  displacement,  as  it  is  called, 
the  liver  may  be  felt  below  the  costal  margin,  or  the  spleen,  or  sometimes 
solid  tumors  of  the  omentum  or  intestine. 

(c)  Percussion. — In  the  dorsal  position  with  a  moderate  quantity  of 
fluid  in  the  peritonseum  the  flanks  are  dull,  while  the  umbilical  and  epi- 
gastric regions,  into  which  the  intestines  float,  are  tympanitic.  This  area 
of  clear  resonance  may  have  an  oval  outline.  Having  obtained  the  lateral 
limit  of  the  dulness  on  one  side,  if  the  patient  turns  on  the  opposite  side, 
the  fluid  gravitates  to  the  dependent  part  and  the  uppermost  flank  is 
now  tympanitic.  In  moderate  effusions  this  movable  dulness  changes  great- 
ly in  the  different  postures.  Small  amounts  of  fluid,  probably  under  a 
litre,  would  scarcely  give  movable  dulness,  as  the  pelvis  and  the  renal  re- 
gions hold  a  considerable  quantity.  In  such  cases  it  is  best  to  place  the 
patient  in  the  knee-elbow  position,  when  a  dull  note  will  be  determined  at 
the  most  dependent  portion.  By  careful  attention  to  these  details  mis- 
takes are  usually  avoided. 

The  following  are  among  the  conditions  which  may  be  mistaken  for 
dropsy:  Ovarian  tumor,  in  Avhich  the  sac  develops,  as  a  rule,  unilaterally, 
though  when  large  it  is  centrally  placed.  The  dulness  is  anterior  and  the 
resonance  is  in  the  flanks,  into  which  the  intestines  are  pushed  by  the  cyst. 
Examination  per  vaginam  may  give  important  indications.  In  those  rare 
instances  in  which  gas  develops  in  the  cyst  the  diagnosis  may  be  very  diffi- 
cult. Succussion  has  been  obtained  in  such  cases.  A  distended  bladder 
may  reach  above  the  umbilicus.  In  such  instances  some  urine  dribbles 
away,  and  suspicion  of  ascites  or  a  cyst  is  occasionally  entertained.    I  once 


ASCITES.  607 

saw  a  trochar  thrust  into  a  distended  bladder,  which  was  supposed  to  be 
an  ovarian  cyst,  and  it  is  stated  that  John  Hunter  tapped  a  bladder,  sup- 
posing it  to  be  ascites.  Such  a  mistake  should  be  avoided  by  careful 
catheterization  prior  to  any  operative  procedures.  And  lastly,  there  are 
large  pancreatic  or  hydatid  cysts  in  the  abdomen  which  may  simulate  ascites. 

Nature  of  the  Ascitic  Fluid. — Usually  this  is  a  clear  serum,  light  yel- 
low in  the  ascites  of  anaemia  and  Bright's  disease,  often  darker  in  color  in 
cirrhosis  of  the  liver.  The  specific  gravity  is  low,  seldom  more  than  1.010 
or  1.015,  whereas  in  the  fluid  of  ovarian  cysts  the  specific  gravity  is  high, 
1,020  or  over.  It  is  albuminous  and  sometimes  coagulates  spontaneously. 
Dock  has  called  attention  to  the  importance  of  the  study  of  the  cells  in 
the  exudate.  In  cancer  very  characteristic  forms,  with  nuclear  figures,  may 
be  found.  Hgemorrhagic  effusion  usually  occurs  in  cancer  and  tubercu- 
losis, and  occasionally  in  cirrhosis.  I  have  already  referred  to  the  in- 
stances of  hemorrhagic  effusion  in  connection  with  ruptured  tubal  preg- 
nancy. A  chylous,  milky  exudate  is  occasionally  found.  Busey  has  col- 
lected 33  cases  from  the  literature.  There  are,  as  Quincke  has  pointed  out, 
two  distinct  varieties,  a  fatty  and  a  chylous,  which  may  be  distinguished 
by  the  microscope,  as  in  the  former  there  are  distinct  fat-globules.  These 
cases  have  been  sometimes  connected  with  peritoneal  or  mesenteric  cancer. 
In  the  true  chylous  ascites  the  fluid  is  turbid  and  milky.  In  some  of  the 
cases,  as  in  Whitla's,  a  perforation  of  the  thoracic  duct  has  been  found. 
The  condition  does  not  necessarily  follow  obliteration  of  the  thoracic  duct. 
Mild  grades  of  chylous  ascites,  which  are  occasionally  found  clinically,  may 
be  due  to  the  fact  that  the  patient  upon  a  milk  diet  has  a  permanent 
lipsemia,  such  as  is  present  in  young  animals  and  in  diabetics,  in  whom  the 
liquor  sanguinis  is  always  fatty.  Under  such  circumstances  an  exudate 
may  contain  enough  of  the  molecular  base  of  the  chyle  to  produce  turbid- 
ity of  the  fluid.  Some  of  the  cases  have  been  associated  with  filariasis. 
In  a  recent  case  in  my  clinic  IST.  McL.  Harris  isolated  the  bacillus  diph- 
therias from  the  chylous  fluid. 

Treatment  of  the  Previous  Conditions. — {a)  Acute  Peri- 
tonitis.— Eest  is  enjoined  upon  the  patient  by  the  severe  pain  which  fol- 
lows the  slightest  movement,  and  he  should  be  propped  in  the  position 
which  gives  him  greatest  relief.  For  the  pain  morphia  should  be  injected 
hypodermically  in  full  doses.  In  an  adult  it  is  better  to  give  a  third  or 
half  a  grain  at  once,  and  subsequently  at  intervals  repeat  it  in  smaller 
doses,  when  necessary.  The  action  of  the  drug  should  be  carefully 
watched  and  the  patient  should  not  be  allowed  to  pass  into  such  a  degree 
of  unconsciousness  that  he  cannot  be  aroused.  The  respiration  and  the 
condition  of  the  pupils  also  give  valuable  information.  The  amount  of 
opium  which  has  been  given  in  certain  instances  is  remarkable,  and  indi- 
cates a  tolerance  of  the  drug.  The  doses  given  by  the  late  Alonzo  Clark, 
of  New  York,  may  be  truly  termed  heroic.  Austin  Flint  notes  that  a  pa- 
tient under  the  care  of  this  physician  took  "  in  the  first  twenty-four  hours, 
of  opium  and  the  sulphate  of  morphia,  a  quantity  equivalent  to  106  grains 
of  opium;  in  the  second  twenty-four  hours  she  took  472  grains:  on  the 
third  day,  236  grains;  on  the  fourth  day,  120  grains;  on  the  fifth  day, 
38 


g08  DISEASES   OP  THE  DIGESTIVE  SYSTEM. 

54  grains;  on  the  sixth  day,  22  grains;  on  the  seventh  day,  18  grains;  after 
which  the  treatment  was  suspended."  It  is  unnecessary  to  use  these  enor- 
mous doses,  as,  even  when  the  pain  is  most  intense,  from  a  third  to  a  half 
grain  of  morphia  every  few  hours  will  usually  keep  the  patient  thoroughly 
under  the  influence  of  the  drug.  In  a  rohust,  strong  patient,  seen  at  the 
outset,  twenty  leeches  applied  over  the  abdomen  will  give  great  relief. 

Local  applications — either  hot  turpentine  stupes  or  cloths  wrung  out 
of  ice-water — may  be  laid  upon  the  abdomen.  The  patients  sometimes 
declare  that  they  are  greatly  relieved  by  the  latter. 

The  question  of  the  use  of  purgatives  in  peritonitis  has  of  late  been 
warmly  discussed.  Lawson  Tait  and  other  gynsecologists  have  used  the 
saline  purges  with  the  greatest  benefit  in  post-operation  peritonitis.  Theo- 
retically it  appears  correct  to  give  salines  in  concentrated  form,  which 
cause  a  rapid  and  profuse  exosmosis  of  serum  from  the  intestinal  vessels, 
relieving  the  congestion  and  reducing  the  oedema,  which  is  one  important 
factor  in  causing  the  meteorism.  It  is  also  urged  that  the  increased  peri- 
stalsis prevents  the  formation  of  adhesions.  In  reading  the  reports  of  these 
successful  cases,  one  is  not  always  convinced,  however,  that  peritonitis 
actually  existed.  Still,  in  cases  of  acute  peritonitis  due  to  extension  or 
following  operation  or  in  septic  conditions  the  judgment  of  many  careful 
men  is  decidedly  in  favor  of  the  use  of  salines.  I  cannot  speak  from  per- 
sonal experience  on  this  question.  The  majority  of  cases  of  peritonitis 
which  come  under  the  care  of  the  physician  follow  lesions  of  the  abdominal 
viscera  or  are  due  to  perforation  of  ulcer  of  the  stomach,  the  ileum,  or  the 
appendix.  In  such  cases,  particularly  in  the  large  group  of  appendix  cases, 
to  give  saline  purgatives  is,  to  say  the  least,  most  injudicious  treatment. 
The  safety  of  the  patient  lies  in  the  restriction  of  the  peristalsis  and  the 
localization  of  the  inflammation,  for  which  purpose  opium  alone  is  of 
service.  In  these  instances  rectal  injections  should  be  employed  to  relieve 
the  large  bowel.  No  symptom  in  acute  peritonitis  is  more  serious  than 
the  tympanites,  and  none  is  more  difficult  to  meet.  The  use  of  the  long 
tube  and  injections  containing  turpentine  may  be  tried.  Drugs  by  the 
mouth  cannot  be  retained. 

For  the  vomiting,  ice  and  small  quantities  of  soda  water  may  be  em- 
ployed. The  patient  should  be  fed  on  milk,  but  if  the  vomiting  is  dis- 
tressing it  is  best  not  to  attempt  to  give  food  by  the  mouth,  but  to  use 
small  nutrient  enemata.  In  all  cases  of  peritonitis  it  is  best  to  have  a  sur- 
geon in  consultation  early  in  the  disease,  as  the  question  of  operation  may 
come  up  at  any  moment.  I  have  already  mentioned  the  conditions  under 
which  laparotomy  is  indicated  in  perforative  appendicitis.  The  acute 
purulent  cases,  particularly  those  in  which  the  streptococci  occur,  usually 
die;  but  the  results  of  operative  interference  even  in  this  form  are  steadily 
improving.  In  the  acute  forms  of  tuberculous  peritonitis  operative  meas- 
ures appear  to  be  more  hopeful,  but  they  are  not  always  successful. 

(b)  Chronic  Peritonitis. — For  the  cases  of  chronic  proliferative  peri- 
tonitis very  little  can  be  done.  The  treatment  is  practically  that  of  ascites. 
In  all  these  forms,  when  the  distention  becomes  extreme,  tapping  is  indi- 
cated.    The  treatment  of  tuberculous  peritonitis  has  fallen  largely  into 


ASCITES.  609 

the  hands  of  the  surgeons,  and  the  results  in  many  cases  are  very  good. 
According  to  the  statistics  of  Maurange,*  of  71  cases,  28  survived  the  opera- 
tion for  more  than  a  year.  Of  26  additional  cases  which  I  have  collected,! 
14  were  dead  at  the  time  of  the  report.  Within  two  years  and  three  months 
there  were  6  operations  performed  at  the  Johns  Hopkins  Hospital  in  tuber- 
culous peritonitis,  with  4  recoveries.  Maurice  Eichardson,  in  a  child  aged 
five,  with  a  suspected  appendicitis  (tumor,  etc.),  found  the  symptoms  to 
be  due  to  enlarged,  tuberculous  mesenteric  glands,  which  were  removed, 
and  the  boy  remained  well  five  years  after  the  operation  (Phila.  Med.  Jr., 
1890,  ii). 

(c)  Ascites. — The  treatment  depends  somewhat  on  the  nature  of  the 
case.  In  cirrhosis  early  and  repeated  tapping  may  give  time  for  the  estab- 
lishment of  the  collateral  circulation,  and  temporary  cures  have  followed 
this  preeedure.  Permanent  drainage  with  Southey's  tube,  incision,  and 
washing  out  the  peritonaeum  have  also  been  practised.  In  the  ascites 
of  cardiac  and  renal  disease  the  cathartics  are  most  satisfactory,  particularly 
the  bitartrate  of  potash,  given  alone  or  with  jalap,  and  the  large  doses  of 
salts  given  an  hour  before  breakfast  with  as  little  water  as  possible.  These 
sometimes  cause  rapid  disappearance  of  the  effusion,  but  they  are  not  so 
successful  in  ascites  as  in  pleurisy  with  effusion.  The  stronger  cathartics 
may  sometimes  be  necessary.  The  ascites  forming  part  of  the  general 
anasarca  of  Bright's  disease  will  receive  consideration  under  another  sec- 
tion. 


*  Paris  Thesis,  1889. 

t  On  Tuberculous  Peritonitis,  Johns  Hopkins  Hospital  Reports,  1890. 


SECTION  VL 
DISEASES   OF   THE   EESPIEATOEY   SYSTEM 


I.    DISEASES   OF  THE  I^OSE. 
1.   ACUTE   CORYZA. 

Acute  catarrhal  inflammation  of  the  upper  air-passages,  popularly 
known  as  a  "  catarrh  "  or  a  "  cold/'  is  usually  an  independent  affection, 
but  may  precede  the  development  of  another  disease. 

Etiology. — It  prevails  most  extensively  in  the  changeable  weather  of 
the  spring  and  early  winter,  and  may  occur  in  epidemic  form,  many  cases 
developing  in  a  community  within  a  few  weeks.  These  outbreaks  are 
very  like,  though  less  intense  than  the  epidemic  influenza,  cases  of  which 
may  begin  with  symptoms  of  ordinary  coryza.  The  disease  probably  de- 
pends upon  a  micro-organism.  Irritating  fumes,  such  as  those  of  iodine  or 
ammonia,  also  may  cause  an  acute  catarrh  of  the  nose. 

Symptoms. — The  patient  feels  indisposed,  perhaps  chilly,  has  slight 
headache,  and  sneezes  frequently.  In  severe  cases  there  are  pains  in  the 
back  and  limbs.  There  is  usually  slight  fever,  the  temperature  rising  to 
101°.  The  pulse  is  quick,  the  skin  is  dry,  and  there  are  all  the  features  of 
a  feverish  attack.  At  first  the  mucous  membrane  of  the  nose  is  swollen, 
"  stuffed  up,"  and  the  patient  has  to  breathe  through  the  mouth.  A  thin, 
clear,  irritating  secretion  flows,  and  makes  the  edges  of  the  nostrils  sore. 
The  mucous  membrane  of  the  tear-ducts  is  swollen,  so  that  the  eyes  weep 
and  the  conjunctivae  are  injected.  The  sense  of  smell  and,  in  part,  the 
sense  of  taste  is  lost.  With  the  nasal  catarrh  there  is  slight  soreness  of 
the  throat  and  stiffness  of  the  neck;  the  pharynx  looks  red  and  swollen, 
and  sometimes  the  act  of  swallowing  is  painful.  The  larynx  also  may  be 
involved,  and  the  voice  becomes  husky  or  is  even  lost.  If  the  inflamma- 
tion extends  to  the  Eustachian  tubes  there  may  be  impairment  of  the 
hearing.  In  more  severe  cases  there  are  bronchial  irritation  and  cough. 
Occasionally  there  is  an  outbreak  of  labial  or  nasal  herpes.  Usually  within 
thirty-six  hours  the  nasal  secretion  becomes  turbid  and  more  profuse,  the 
swelling  of  the  mucosa  subsides,  the  patient  gradually  becomes  able  to 
breathe  through  the  nostrils,  and  within  four  or  five  days  the  symptoms 
disappear,  with  the  exception  of  the  increased  discharge  from  the  nose 
610 


CHRONIC  NASAL   CATARRH.  611 

and  upper  pharynx.  There  are  rarely  any  bad  effects  from  a  simple  coryza." 
When  the  attacks  are  frequently  repeated  the  disease  may  become  chronic. 

The  diagnosis  is  always  easy^  but  caution  must  be  exercised  lest  the 
initial  catarrh  of  measles  or  severe  influenza  should  be  mistaken  for  the 
Bimple  coryza. 

Treatment. — Many  cases  are%o  mild  that  the  patients  are  able  to  be 
about  and  to  attend  to  their  work.  If  there  are  fever  and  constitutional 
disturbance^  the  patient  should  be  kept  in  bed  and  should  take  a  simple 
fever  mixture,  and  at  night  a  drink  of  hot  lemonade  and  a  full  dose  of 
Dover's  powder.  Many  persons  find  great  benefit  from  the  Turkish  bath. 
For  the  distressing  sense  of  tightness  and  pain  over  the  frontal  sinuses, 
cocaine  is  very  useful  and  sometimes  gives  immediate  relief.  The  4-per- 
eent  solution  may  be  injected  into  the  nostrils,  or  cotton-wool  soaked  in 
it  may  be  inserted  into  them.  Later,  the  snuff  recommended  by  Ferrier 
is  advantageous,  composed,  as  it  is,  of  morphia  (gr.  ij),  bismuth  (3  iv), 
acacia  powder  (oij).  This  may  occasionally  be  blown  or  snuffed  into  the 
nostrils.  The  fluid  extract  of  hamamelis,  "  snuffed  "  from  the  hand  every 
two  or  three  hours,  is  much  better. 


II.  CHRONIC  NASAL  CATARRH. 

(Rhinitis  ;  Rhinitis  hypertrophica  ;  Rhinitis  atrophica). 

In  simple  chronic  catarrh  there  is  increased  irritability  of  the  mucous 
membrane,  particularly  of  the  erectile  tissue  on  the  septum  and  turbinated 
bones.  There  is  a  tendency  to  frequent  stoppage  of  one  or  both  nostrils 
and  the  patient  very  easily  catches  cold.  The  secretion  is  at  first  clear 
and  afterward  thick  and  tenacious.  The  sense  of  smell  is  not  specially 
disturbed  at  this  stage.  With  the  mirror  the  mucous  membrane  looks 
congested  and  swollen  and  the  veins  may  be  distended. 

In  hypertrophic  rhinitis,  which  is  usually  a  sequel  of  the  former  con- 
dition, the  nasal  passages  are  obstructed,  chiefly  by  enlargement  of  the 
lower  turbinated  bodies  and  swelling  of  the  mucous  membrane  of  the  sep- 
tum. Very  often  there  is  hypertrophy  of  the  adenoid  tissue  in  the  vault 
of  the  pharynx  and  of  the  mucous  membrane  about  the  orifices  of  the 
Eustachian  tubes.  The  two  conditions  frequently  go  together  as  expressed 
in  the  designation,  chronic  naso-pharyngeal  catarrh.  The  symptoms  of 
this  hypertrophic  rhinitis  may  be  local  or  general. 

The  most  important  local  symptom  is  the  obstruction  of  the  passage  of 
air  through  the  nostrils,  so  that  the  patients  become  mouth-breathers. 
During  the  day  this  may  not  be  very  distressing,  but  at  night  the  mouth 
and  throat  get  extremely  dry  and  the  sleep  is  disturbed.  The  voice  be- 
comes nasal  in  quality  and  in  advanced  cases,  when  the  Eustachian  tubes 
are  obstructed,  there  may  be  deafness.  It  should  ever  be  borne  in  mind  by 
the  practitioner  that  a  very  large  proportion  of  all  cases  of  deafness  origi- 
nate in  chronic  naso-pharyngeal  catarrh.  The  general  symptoms  have 
been  considered  more  fully  under  chronic  pharyngeal  catarrh  and  mouth- 
breathing. 


612  DISEASES  OF  THE  EESPIRATORY  SYSTEM. 

Atrophic  rhinitis,  which  is  also  known  under  the  names  coryza  fetida 
and  ozsena^  may  be  a  sequence  of  the  hypertrophic  form.  Oz^na  is  only  a 
symptom,  and  is  met  with  in  many  ulcerative  conditions  of  the  nostrils, 
particularly  as  a  result  of  syphilis,  foreign  bodies,  caries  and  necrosis  of 
the  bones,  and  glanders.  Fortunately,  the  atrophic  form  by  no  means 
necessarily  follows  the  hypertrophic  st*e.  The  cases  are  much  more  fre- 
quent in  women  than  in  men,  and  usually  occur  early  in  life.  The  mucous 
membrane  is  thin  and  covered  with  grayish  crusts  which,  when  removed, 
show  a  slightly  excoriated  surface,  but  true  ulcers  are  rarely  seen.  The 
erectile  tissue  is  completely  atrophied  by  a  process  of  slow  connective-tissue 
growth,  or,  as  J.  N.  Mackenzie  calls  it,  a  cirrhosis.  The  mucous  mem- 
brane of  the  pharynx  is  usually  dry  and  glazed. 

The  symptoms  are  most  distinctive,  owing  to  the  horrible  odor  which 
comes  from  the  nose,  and  of  which,  fortunately,  the  patient  is  himself 
unconscious,  because  the  sense  of  smell  is  lost.  The  secretion,  which  is 
puriform,  dries  and  forms  large  crusts,  which  are  dislodged  by  picking  or 
which  gradually  fall  off.  The  cause  of  the  offensive  odor  has  been  much 
discussed — whether  it  is  due  to  a  special  organism  or  to  specially  favorable 
conditions  for  the  growth  and  development  of  the  germs  of  putrefaction. 
Probably  the  latter  view  is  correct. 

The  treatment  of  hypertrophic  rhinitis  consists  in  the  thorough  cleans- 
ing of  the  nasal  passages,  the  removal  of  the  pharyngeal  growths,  and  the 
reduction  of  the  hypertrophied  nasal  mucosa.  It  is  best  to  use  a  simple 
douche,  in  order  to  keep  the  membrane  absolutely  clean.  The  Birming- 
ham nasal  douche  is  the  most  simple  and  satisfactory,  and  may  be  filled 
with  alkaline  and  antiseptic  or  deodorizing  solutions.  One  of  the  most 
satisfactory  is  the  bicarbonate  of  soda  (1^  drachm),  listerine  (6  drachms), 
and  water  (1  ounce).  Operative  procedures  are  necessary  in  a  majority 
of  the  cases,  and  the  practitioner  should  early  call  to  his  assistance  the 
specialist.  It  is  sad  to  think  of  the  misery  which  has  been  entailed  upon 
thousands  of  people  owing  to  neglect  of  naso-pharyngeal  catarrh  by  parents 
and  physicians. 

The  treatment  of  atrophic  rhinitis  comes  more  properly  under  the 
special  monographs. 


III.    AUTUMNAL    CATARRH  {Hay  Fever). 

An  affection  of  the  upper  air-passages,  often  associated  with  asthmatic 
attacks,  due  to  the  action  of  certain  stimuli  upon  a  hypersensitive  mucous 
membrane. 

This  affection  was  first  described  in  1819  by  Bostock,  who  called  it 
catarrhus  wstivus.  Morrill  "Wyman,  of  Cambridge,  Mass.,  wrote  a  mono- 
graph on  the  subject,  and  described  two  forms,  the  "  June  cold,"  or  "  rose 
cold,"  which  comes  on  in  the  spring,  and  the  autumnal  form  which,  in 
this  country,  does  not  develop  until  August  and  September,  and  never 
persists  after  a  severe  frost.  Blakely  studied  its  connection  with  the  pol- 
len of  various  grasses  and  flowers.     The  late  George  M.  Beard  made  many 


AUTUMNAL  CATARRH.  613 

careful  observations  on  the  disease.  Until  recently  this  form  of  catarrh 
was  believed  to  result  exclusively  from  the  action  of  certain  irritants  on 
the  mucous  membrane  of  the  nose,  particularly  the  pollen  of  plants, 
which,  as  the  experiments  of  Blakeley  showed,  play  an  important  role  in 
the  disease.  Other  emanations  also  may  induce  an  attack,  as  in  the  case 
of  the  late  Austin  Flint,  who  was  liable  to  coryza,  or  even  asthma,  if  he 
slept  on  a  certain  sort  of  feather  pillow.  This,  however,  is  only  one  factor 
in  the  disease.  A  second,  most  important  one,  was  discovered  in  the  con- 
dition of  the  nasal  mucous  membrane  in  these  cases.  Yoltolini,  of  Breslau, 
in  1871,  observed  the  cure  of  a  case  of  asthma  by  the  removal  of  a  nasal 
polypus.  Since  that  date  the  observations  of  Hack,  in  Germany,  and  par- 
ticularly of  Daly,  of  Pittsburg,  Eoe,  of  Rochester,  John  N.  Mackenzie,  of 
Baltimore,  and  Harrison  Allen,  of  Philadelphia,  have  demonstrated  the 
association  of  asthmatic  attacks  with  nasal  disease.  Daly  discovered  that 
in  a  large  proportion  of  the  cases  of  hay  asthma  there  was  local  disease  of 
the  mucous  membrane  of  the  nose,  the  cure  of  which  rendered  the  pa- 
tient insusceptible  to  conditions  previously  exciting  the  attacks.  This  has 
been  abundantly  confirmed.  Still  identical  lesions  exist  in  many  people 
who  never  suffer  with  the  disease,  so  that  there  must  be  a  third  factor,  a 
neurotic  constitution.  In  the  etiology  of  hay  fever,  then,  these  three  ele- 
ments prevail — a  nervous  constitution,  an  irritable  nasal  mucosa,  and  the 
stimulus. 

The  disease  affects  certain  families,  particularly,  it  is  said,  those  with  a 
neurotic  taint.  The  peculiarity  may  occur  through  several  generations. 
It  is  certainly  more  common  in  the  United  States  than  in  Europe,  and 
much  more  common  in  the  United  States  than  in  Canada.  The  United 
States  Hay  Fever  Association  now  numbers  thousands  of  members. 

Dwellers  in  cities  are  more  subject  than  residents  in  the  country.  The 
structural  peculiarities  of  the  nasal  mucous  membrane  are  those  of  hyper- 
trophic rhinitis.  Harrison  Allen  states  that  the  inferior  turbinated  bones 
lie  well  above  the  floor  of  the  nostrils,  which  renders  the  mucous  mem- 
brane more  liable  to  irritation  from  inhaled  substances.  Deflection  of  the 
septum,  hypertrophy  of  the  soft  parts,  and  excessive  hypergesthesia,  so  that 
the  mere  touch  with  a  probe  may  be  sufficient  to  induce  an  attack,  are 
common  conditions. 

Symptoms. — These  are,  in  a  majority  of  the  cases,  very  like  those  of 
ordinary  coryza.  There  may,  however,  be  much  more  headache  and  dis- 
tress, and  some  patients  become  very  low-spirited.  Cough  is  a  common 
symptom  and  may  be  very  distressing.  Paroxysms  of  asthma  may  develop, 
so  like  as  to  be  indistinguishable  from  the  ordinary  bronchial  form.  The 
two  conditions  may  indeed  alternate,  the  patient  having  at  one  time  an 
attack  of  common  hay  fever  and  at  another,  under  similar  circumstances, 
an  attack  of  bronchial  asthma.  Of  the  immediate  exciting  causes  of  the 
attack,  unquestionably  in  a  majority  of  the  cases  coming  on  in  the  autumn 
there  is  an  association  with  the  presence  of  pollen  in  the  atmosphere,  but 
this  is  only  one  of  a  host  of  exciting  causes.  In  certain  persons  the  parox- 
ysms may  develop  at  any  season  from  sudden  changes  in  the  temperature. 
An  attack  may  even  come  on  through  association  of  ideas.      The  well- 


614  DISEASES  OP   THE  EESPIEATORY  SYSTEM. 

known  experiment  of  J,  N.  Mackenzie,  of  inducing  an  attack  in  a  sus- 
ceptible person  by  offering  her  an  artificial  rose  to  smell,  strikingly  illus- 
trates the  neurotic  element  in  the  disease. 

Treatment. — This  may  be  comprised  under  three  heads:  First,  since 
the  disease  appears  in  many  instances  to  be  a  form  of  chronic  neurosis, 
remedies  which  improve  the  stability  of  the  nervous  system  may  be  em- 
ployed— such  as  arsenic,  phosphorus,  and  strychnia.  Second,  climatic. 
Dwellers  in  the  cities  of  the  Atlantic  seaboard  and  of  the  Central  States 
enjoy  complete  immunity  in  the  Adirondacks  and  "White  Mountains.  As 
a  rule  the  disease  is  aggravated  by  residence  in  agricultural  districts.  The 
dry  mountain  air  is  unquestionably  the  best;  there  are  cases,  however,  which 
do  well  at  the  seaside.  Third,  the  thorough  local  treatment  of  the  nose, 
particularly  the  destruction  of  the  vessels  and  sinuses  over  the  sensitive 
areas. 

IV.    EPISTAXIS. 

Etiology. — Bleeding  from  the  nose  may  result  from  local  or  consti- 
tutional conditions.  Among  local  causes  may  be  mentioned  traumatism, 
small  ulcers,  picking  or  scratching  the  nose,  new  growths,  and  the  presence 
of  foreign  bodies.  In  chronic  nasal  catarrh  bleeding  is  not  infrequent. 
The  blood  may  come  from  one  or  both  nostrils.  The  flow  may  be  profuse 
after  an  injury. 

Among  general  conditions  with  which  nose-bleeding  is  associated,  the 
following  are  the  most  important:  It  occurs  in  growing  children,  particu- 
larly about  the  age  of  puberty;  more  frequently  in  the  delicate  and  in  the 
rheumatic  than  in  the  strong  and  vigorous.  I  have  reported  three  cases 
of  chronic  recurring  epistaxis  in  adults  associated  with  remarkable  telan- 
giectases of  the  skin  and  visible  mucous  membranes. 

Epistaxis  is  a  very  common  event  in  persons  of  so-called  plethoric 
habit.  It  is  stated  sometimes  to  precede,  or  to  indicate  a  liability  to,  apo- 
plexy.   There  may  be  an  hereditary  tendency  to  it. 

In  venous  engorgement  epistaxis  is  not  common  and  there  may  be  a 
most  extreme  grade  of  cyanosis  without  its  occurrence.  It  is  frequent  in 
cirrhosis  hepatis.  In  balloon  and  mountain  ascensions,  in  the  very  rarefied 
atmosphere,  haemorrhage  from  the  nose  is  a  common  event.  In  haemo- 
philia the  nose  ranks  first  of  the  mucous  membranes  from  which  bleeding 
arises.  It  occurs  in  all  forms  of  chronic  anaemias.  It  precedes  the  onset 
of  certain  fevers,  more  particularly  typhoid,  with  which  it  seems  associated 
in  a  special  manner.  Vicarious  epistaxis  has  been  described  in  cases  of 
suppression  of  the  menses.  Lastly,  it  is  said  to  be  brought  on  by  certain 
psychical  impressions,  but  the  observations  on  this  point  are  not  trust- 
worthy. The  blood  in  epistaxis  results  from  capillary  oozing  or  diapedesis. 
The  mucous  membrane  is  deeply  congested  and  there  are  often  capillary 
angiomata  situated  usually  in  the  respiratory  portion  of  the  nostril  and 
upon  the  cartilaginous  septum. 

Symptoms. — Slight  haemorrhage  is  not  associated  with  any  special 
features.     When  the  bleeding  is  protracted  the  patients  have  the  more 


ACUTE   CATARRHAL  LARYNGITIS.  615 

serious  manifestations  of  loss  of  blood.  In  the  slow  dripping  which  takes 
place  in  some  instances  of  haemophilia,  there  may  be  formed  a  remarkable 
blood  tumor  projecting  from  one  nostril  and  extending  even  below  the 
mouth. 

Death  from  ordinary  epistaxis  is  very  rare.  The  more  blood  is  lost, 
the  greater  is  the  tendency  to  clotting  with  spontaneous  cessation  of  the 
bleeding. 

The  diagnosis  is  usually  easy.  One  point  only  need  be  mentioned; 
namely,  that  bleeding  from  the  posterior  nares  occasionally  occurs  during 
sleep  and  the  blood  trickles  into  the  pharynx  and  may  be  swallowed.  If 
vomited,  it  may  be  confounded  with  hsematemesis;  or,  if  coughed  up,  with 
hsemoptysis. 

Treatment. — In  a  majority  of  the  cases  the  bleeding  ceases  of  itself. 
Various  simple  measures  may  be  employed,  such  as  holding  the  arms 
above  the  head,  the  application  of  ice  to  the  nose,  or  the  injection  of  cold 
or  hot  water  into  the  nostrils.  Astringents,  such  as  zinc,  alum,  or  tannin, 
may  be  used;  and  the  tincture  of  the  perchloride  of  iron,  diluted  with  ice- 
water,  may  be  introduced  into  the  nostrils.  If  the  bleeding  comes  from 
an  ulcerated  surface,  an  attempt  should  be  made  to  apply  chromic  acid  or 
to  cauterize.  If  the  bleeding  is  at  all  severe  and  obstinate,  the  posterior 
nares  should  be  plugged.  Ergot  may  be  given  internally  or  hypodermically. 
The  inhalation  of  carbonic-acid  gas  may  be  tried  or  a  solution  of  gelatine 
or  of  adrenalin  injected  into  the  nostril. 


II.   DISEASES   OF  THE   LARTISTX. 
I.    ACUTE    CATARRHAL    LARYNGITIS. 

This  may  come  on  as  an  independent  affection  or  in  association  with 
general  catarrh  of  the  upper  respiratory  passages. 

Etiology. — Many  cases  are  due  to  catching  cold  or  to  overuse  of  the 
voice;  others  develop  in  consequence  of  the  inhalation  of  irritating  gases. 
It  may  occur  in  the  general  catarrh  associated  with  influenza  and  measles. 
Very  severe  laryngitis  is  excited  by  traumatism,  either  injuries  from  with- 
out or  the  lodgment  of  foreign  bodies.  It  may  be  caused  by  the  action  of 
very  hot  liquids  or  corrosive  poisons. 

Symptoms. — There  is  a  sense  of  tickling  referred  to  the  larynx;  the 
cold  air  irritates  and,  owing  to  the  increased  sensibility  of  the  mucous  mem- 
brane, the  act  of  inspiration  may  be  painful.  There  is  a  dry  cough,  and 
the  voice  is  altered.  At  first  it  is  simply  husky,  but  soon  phonation  be- 
comes painful,  and  finally  the  voice  may  be  completely  lost.  In  adults  the 
respirations  are  not  increased  in  frequency,  but  in  children  dyspnoea  is  not 
uncommon  and  may  occur  in  spasmodic  attacks.  If  much  oedema  accom- 
panies the  inflammatory  swelling,  there  may  be  urgent  dyspnoea. 

The  laryngoscope  shows  a  swollen  and  tumefied  mucous  membrane  of 
the  larynx,  particularly  the  ary-epiglottidean  folds.     The  vocal  cords  have 


QIQ  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

lost  their  smooth  and  shining  appearance  and  are  reddened  and  swollen. 
Their  mobility  also  is  greatly  impaired,  owing  to  the  infiltration  of  the 
adjoining  mucous  membrane  and  of  the  muscles.  A  slight  mucoid  exuda- 
tion covers  the  parts.  The  constitutional  symptoms  are  not  severe.  There 
is  rarely  much  fever,  and  in  many  cases  the  patient  is  not  seriously  ill.  Occa- 
sionally cases  come  on  with  greater  intensity,  the  cough  is  very  distressing, 
deglutition  is  painful,  and  there  may  be  urgent  dyspnoea. 

Diagnosis. — There  is  rarely  any  difficulty  in  determining  the  nature 
of  a  case  if  a  satisfactory  laryngoscopic  examination  can  be  made.  The 
severer  forms  may  simulate  oedema  of  the  glottis.  When  the  loss  of  voice 
is  marked,  the  case  may  be  mistaken  for  one  of  nervous  aphonia,  but  the 
laryngoscope  would  decide  the  question  at  once.  Much  more  difficult  is 
the  diagnosis  of  acute  laryngitis  in  children,  particularly  in  the  very  young, 
in  whom  it  is  so  hard  to  make  a  proper  examination.  From  ordinary  laryn- 
gismus it  is  to  be  distinguished  by  the  presence  of  fever,  the  mode  of  onset, 
and  particularly  the  coryza  and  the  previous  symptoms  of  hoarseness  or  loss 
of  voice.  Membranous  laryngitis  may  at  first  be  quite  impossible  to  differ- 
entiate, but  in  a  majority  of  cases  of  this  affection  there  are  patches  on  the 
pharynx  and  early  swelling  of  the  cervical  glands.  The  symptoms,  too,  are 
much  more  severe. 

Treatment. — Eest  of  the  larynx  should  be  enjoined,  so  far  as  phona- 
tion  is  concerned.  In  cases  of  any  severity  the  patient  should  be  kept 
in  bed.  The  room  should  be  at  an  even  temperature  and  the  air  saturated 
with  moisture.  Early  in  the  disease,  if  there  is  much  fever,  aconite  and 
citrate  of  potash  may  be  given,  and  for  the  irritating  painful  cough  a  full 
dose  of  Dover's  powder  at  night.  An  ice-bag  externally  often  gives  great 
relief. 

II.    CHRONIC    LARYNGITIS. 

Etiology. — The  cases  usually  follow  repeated  acute  attacks.  The  most 
common  causes  are  overuse  of  the  voice,  particularly  in  persons  whose  occu- 
pation necessitates  shouting  in  the  open  air.  The  constant  inhalation  of 
irritating  substances,  as  tobacco-smoke,  may  also  cause  it. 

Symptoms. — The  voice  is  usually  hoarse  and  rough  and  in  severe 
cases  may  be  almost  lost.  There  is  usually  very  little  pain;  only  the  un- 
pleasant sense  of  tickling  in  the  larynx,  which  causes  a  frequent  desire  to 
cough.  With  the  laryngoscope  the  mucous  membrane  looks  swollen,  but 
much  less  red  than  in  the  acute  condition.  In  association  with  the  granu- 
lar pharyngitis,  the  mucous  glands  of  the  epiglottis  and  of  the  ventricles 
may  be  involved. 

Treatment. — The  nostrils  should  be  carefully  examined,  since  in  some 
instances  chronic  laryngitis  is  associated  with  and  even  dependent  upon 
obstruction  to  the  free  passage  of  air  through  the  nose.  Local  application 
must  be  made  directly  to  the  larynx,  either  with  a  brush  or  by  means  of  a 
spray.  Among  the  remedies  most  recommended  are  the  solutions  of  nitrate 
of  silver,  chlorate  of  potash,  perchloride  of  zinc,  and  tannic  acid.  Insuflfla- 
tions  of  bismuth  are  sometimes  useful. 


.  SPASMODIC  LARYNGITIS.  6I7 

Among  directions  to  be  given  are  the  avoidance  of  heated  rooms  and 
loud  speaking,  and  abstinence  from  tobacco  and  alcohol.  The  throat  should 
not  be  too  much  muffled,  and  morning  and  evening  the  neck  should  be 
sponged  with  cold  water. 


III.    CEDEMATOUS    LARYNGITIS. 

Etiology. — (Edema  of  the  glottis,  or,  more  correctly,  of  the  structures 
which  form  the  glottis,  is  a  very  serious  affection  which  is  met  with  (a)  As 
a  rare  sequence  of  ordinary  acute  laryngitis.  (&)  In  chronic  diseases  of  the 
larynx,  as  syphilis  or  tubercle,  (c)  In  severe  inflammatory  diseases  like 
diphtheria,  in  erysipelas  of  the  neck,  and  in  various  forms  of  cellulitis,  (d) 
Occasionally  in  the  acute  infectious  diseases — scarlet  fever,  typhus,  or 
typhoid.  In  Bright's  disease,  either  acute  or  chronic,  there  may  be  a  rap- 
idly developing  cedema.     (e)  In  angio-neurotic  oedema. 

Symptoms. — There  is  dyspnoea,  increasing  in  intensity,  so  that  with- 
in an  hour  or  two  the  condition  becomes  very  serious.  There  is  sometimes 
marked  stridor  in  respiration.  The  voice  becomes  husky  and  disappears. 
The  laryngoscope  shows  enormous  swelling  of  the  epiglottis,  which  can 
sometimes  be  felt  with  the  finger  or  even  seen  when  the  tongue  is  strongly 
depressed  with  a  spatula.  The  ary-epiglottidean  folds  are  the  seat  of  the 
chief  swelling  and  may  almost  meet  in  the  middle  line.  Occasionally  the 
oedema  is  below  the  true  cords. 

The  diagnosis  is  rarely  difficult,  inasmuch  as  even  without  the  laryn- 
goscope the  swollen  epiglottis  can  be  seen  or  felt  with  the  finger.  The 
disease  is  very  fatal. 

Treatm.ent.^ — An  ice-bag  should  be  placed  on  the  larynx,  and  the  pa- 
tient given  ice  to  suck.  If  the  symptoms  are  urgent,  the  throat  should  be 
sprayed  with  a  strong  solution  of  cocaine,  and  the  swollen  epiglottis  scari- 
fied. If  relief  does  not  follow,  tracheotomy  should  immediately  be  per- 
formed. The  high  rate  of  mortality  is  due  to  the  fact  that  this  operation 
is  as  a  rule  too  long  delayed. 


IV.    SPASMODIC    LARYNGITIS  (Laryngismus  stridulus). 

Spasm  of  the  glottis  is  met  with  in  many  affections  of  the  larynx,  but 
there  is  a  special  disease  in  children  which  has  received  the  above-mentioned 
and  other  names. 

Etiology. — A  purely  nervous  affection,  without  any  inflammatory  con- 
dition of  the  larynx,  it  occurs  in  children  between  the  ages  of  six  months 
and  three  years,  and  is  most  commonly  seen  in  connection  with  rickets. 
As  Escherich  has  shown,  the  disease  has  close  relations  with  tetany  and 
may  display  many  of  the  accessory  phenomena  of  this  disease.  Often  the 
attack  comes  on  when  the  child  has  been  crossed  or  scolded.  Mothers 
sometimes  call  the  attacks  "  passion  fits "  or  attacks  of  "  holding  the 
breath.^'    It  was  supposed  at  one  time  that  they  were  associated  with  en- 


Qlg  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

largement  of  the  thymus,  and  the  condition  therefore  received  the  name 
of  thymic  asthma. 

The  actual  state  of  the  larynx  during  a  paroxysm  is  a  spasm  of  the 
adductors,  hut  the  precise  nature  of  the  influences  causing  it  is  not  yet 
known,  whether  centric  or  reflex  from  peripheral  irritation.  The  disease 
is  not  so  common  in  America  as  in  England. 

Symptoms,  ^ — The  attacks  may  come  on  either  in  the  night  or  in  the 
day;  often  just  as  the  child  awakes.  There  is  no  cough,  no  hoarseness, 
but  the  respiration  is  arrested  and  the  child  struggles  for  breath,  the  face 
gets  congested,  and  then,  with  a  sudden  relaxation  of  the  spasm,  the  air 
is  drawn  into  the  lungs  with  a  high-pitched  crowing  sound,  which  has 
given  to  the  affection  the  name  of  "  child-crowing."  Convulsions  may 
occur  during  an  attack  or  there  may  be  carpo-pedal  spasms.  Death  may, 
but  rarely  does,  occur  during  the  attack.  With  the  cyanosis  the  spasm  re- 
laxes and  respiration  begins.  The  attacks  may  recur  with  great  frequency 
throughout  the  day. 

Treatm.ent. — The  gums  should  be  carefully  examined  and,  if  swol- 
len and  hot,  freely  lanced.  The  bowels  should  be  carefully  regulated,  and 
as  these  children  are  usually  delicate  or  rickety,  nourishing  diet  and  cod- 
liver  oil  should  be  given.  By  far  the  most  satisfactory  method  of  treat- 
ment is  the  cold  sponging.  In  severe  cases,  two  or  three  times  a  day  the 
child  should  be  placed  in  a  warm  bath  and  the  back  and  chest  thoroughly 
sponged  for  a  minute  or  two  with  cold  water.  Since  learning  this  practice 
from  Einger,  at  the  University  Hospital,  I  have  seen  many  cases  in  which 
it  proved  successful.  It  may  be  employed  when  the  child  is  in  a  paroxysm, 
though  if  the  attack  is  severe  and  the  lividity  is  great  it  is  much  better  to 
dash  cold  water  into  the  face.  Sometimes  the  introduction  of  the  finger 
far  back  into  the  throat  will  relieve  the  spasm. 

Spasmodic  croup,  believed  to  be  a  functional  spasm  of  the  muscles  of 
the  larynx,  is  an  affection  seen  most  commonly  between  the  ages  of  two  and 
five  years.  According  to  Trousseau's  description,  the  child  goes  to  bed  well, 
and  about  midnight  or  in  the  early  morning  hours  awakes  with  oppressed 
breathing,  harsh,  croupy  cough,  and  perhaps  some  huskiness  of  voice.  The 
oppression  and  distress  for  a  time  are  very  serious,  the  face  is  congested,  and 
there  are  signs  of  approaching  cyanosis.  The  attack  passes  off  abruptly, 
the  child  falls  asleep  and  awakes  the  next  morning  feeling  perfectly  well. 
These  attacks  may  be  repeated  for  several  nights  in  succession,  and  usually 
cause  great  alarm  to  the  parents.  Whether  this  is  entirely  a  functional 
spasm  is,  I  think,  doubtful.  There  are  instances  in  which  the  child  is 
somewhat  hoarse  throughout  the  day,  and  has  slight  catarrhal  symptoms 
and  a  brazen,  croupy  cough.  There  is  probably  slight  catarrhal  laryngitis 
with  it.  These  cases  are  not  infrequently  mistaken  for  true  croup,  and 
parents  are  sometimes  unnecessarily  disturbed  by  the  serious  view  which 
the  physician  takes  of  the  case.  Too  often  the  poor  child,  deluged  with 
drugs,  is  longer  in  recovering  from  the  treatment  than  he  would  be  from 
the  disease.  To  allay  the  spasm  a  whiff  of  chloroform  may  be  administered, 
which  will  in  a  few  moments  give  relief,  or  the  child  may  be  placed  in  a 
hot  bath.     A  prompt  emetic,  such  as  zinc  or  wine  of  ipecac,  will  usually 


TUBERCULOUS  LARYNGITIS.  619 

relieve  the  spasm,  and  is  specially  indicated  if  the  child  has  overloaded  the 
stomach  through  the  day. 


V.    TUBERCULOUS    LARYNGITIS. 

Etiology.' — Tuhercles  may  develop  primarily  in  the  laryngeal  mucosa, 
but  in  the  great  majority  of  cases  the  affection  is  secondary  to  pulmonary 
tuberculosis,  in  which  it  is  met  with  in  a  variable  proportion  of  from  18 
to  30  per  cent.  Laryngitis  may  occur  very  early  in  pulmonary  tubercu- 
losis. There  may  be  well-marked  involvement  of  the  larynx  with  signs  of 
very  limited  trouble  at  one  apex.  These  are  cases  which,  in  my  experience, 
run  a  very  unfavorable  course. 

Morbid  Anatomy. — The  mucosa  is  at  first  swollen  and  presents  scat- 
tered tubercles,  which  seem  to  begin  in  the  neighborhood  of  the  blood-ves- 
sels. By  their  fusion  small  tuberculous  masses  arise,  which  caseate  and 
finally  ulcerate,  leaving  shallow  irregular  losses  of  substance.  The  ulcers 
are  usually  covered  with  a  grayish  exudation,  and  there  is  a  general  thick- 
ening of  the  mucosa  about  them,  which  is  particularly  marked  upon  the 
arytenoids.  The  ulcers  may  erode  the  true  cords  and  finally  destroy  them, 
and  passing  deeply  may  cause  perichondritis  with  necrosis  and  occasionally 
exfoliation  of  the  cartilages.  The  disease  may  extend  laterally  and  involve 
the  pharynx,  and  downward  over  the  mucous  membrane,  covering  the  cri- 
coid cartilage  toward  the  oesophagus.  Above,  it  may  reach  the  posterior 
wall  of  the  pharynx,  and  in  rare  cases  extend  to  the  fauces  and  tonsils. 
The  epiglottis  may  be  entirely  destroyed.  There  are  rare  instances  in 
which  cicatricial  changes  go  on  to  such  a  degree  that  stenosis  of  the  larynx 
is  induced. 

Symptoms.' — The  first  indication  is  slight  huskiness  of  the  voice, 
which  finally  deepens  to  hoarseness,  and  in  advanced  stages  there  may  be 
complete  loss  of  voice.  There  is  something  very  suggestive  in  the  early 
hoarseness  of  tuberculous  laryngitis.  My  attention  has  frequently  been 
directed  to  the  lungs  simply  by  the  quality  of  the  voice. 

The  cough  is  in  part  due  to  involvement  of  the  larynx.  Early  in  the 
disease  it  is  not  very  troublesome,  but  when  the  ulceration  is  extensive  it 
becomes  husky  and  ineffectual.  Of  the  s3'mptoms  of  laryngeal  tuberculo- 
sis, none  is  more  aggravating  than  the  dysphagia,  which  is  met  with  par- 
ticularly when  the  epiglottis  is  involved,  and  when  the  ulceration  has  ex- 
tended to  the  pharynx.  There  is  no  more  distressing  or  painful  compli- 
cation in  phthisis.  In  instances  in  which  the  epiglottis  is  in  great  part 
destroyed,  with  each  attempt  to  take  food  there  are  distressing  paroxysms 
of  cough,  and  even  of  suffocation. 

With  the  laryngoscope  there  is  seen  early  in  the  disease  a  pallor  of  the 
mucous  membrane,  which  also  looks  thickened  and  infiltrated,  particularly 
that  covering  the  arytenoid  cartilages.  The  tuberculous  ulcers  are  very 
characteristic.  They  are  broad  and  shallow,  with  gray  bases  and  ill-defined 
outlines.  The  vocal  cords  are  infiltrated  and  thickened,  and  ulceration  is 
very  common. 


620  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

The  diagnosis  of  tuberculous  laryngitis  is  rarely  difficulty,  as  it  is  usually 
associated  with  well-marked  pulmonary  disease.  In  case  of  doubt  some  of 
the  secretion  from  the  base  of  an  ulcer  should  be  removed  and  examined  for 
bacilli. 

Treatment. — Physicians  pay  scarcely  sufficient  attention  to  the  laryn- 
geal complications  of  consumption.  The  ulcers  should  be  sprayed  and  kept 
thoroughly  cleansed.  Solutions  of  tannic  acid,  nitrate  of  silver,  or  sulphide 
of  zinc  may  be  employed.  The  insufflation,  two  or  three  times  a  day,  of  a 
powder  of  iodoform,  with  morphia,  after  thoroughly  cleansing  the  ulcers 
with  a  spray,  relieves  the  pain  in  a  majority  of  the  cases.  Cocaine  (4-per- 
eent  solution)  applied  with  the  atomizer  will  often  enable  the  patient  to 
swallow  his  food  comfortably.  There  are,  however,  distressing  cases  of  ex- 
tensive larj^ngeal  and  pharyngeal  ulceration  in  which  even  cocaine  loses  its 
good  effects.  When  the  epiglottis  is  lost  the  difficulty  in  swallowing  be- 
comes very  great.  Wolfenden  states  that  this  may  be  obviated  if  the  pa- 
tient hangs  his  head  over  the  side  of  the  bed  and  sucks  milk  through  a  rub- 
ber tubing  from  a  mug  placed  on  the  floor. 


VI.    SYPHILITIC    LARYNGITIS. 

Syphilis  attacks  the  larynx  with  great  frequency.  It  may  result  from 
the  inherited  disease  or  be  a  secondary  or  tertiary  manifestation  of  the  ac- 
quired form. 

Symptoms.— In  secondary  syphilis  there  is  occasionally  erythema  of 
the  larynx,  which  may  go  on  to  definite  catarrh,  but  has  nothing  charac- 
teristic. The  process  may  proceed  to  the  formation  of  superficial  whitish 
ulcers,  usually  symmetrically  placed  on  the  cords  or  ventricular  bands. 
Mucous  patches  and  condylomata  are  rarely  seen.  The  symptoms  are  prac- 
tically those  of  slight  loss  of  voice  with  laryngeal  irritation,  as  in  the  simple 
catarrhal  form. 

The  tertiary  laryngeal  lesions  are  numerous  and  very  serious.  True 
gummata,  varying  in  size  from  the  head  of  a  pin  to  a  small  nut,  develop 
in  the  submucous  tissue,  most  commonly  at  the  base  of  the  epiglottis.  They 
go  through  the  changes  characteristic  of  these  structures  and  may  either 
break  down,  producing  extensive  and  deep  ulceration,  or — and  this  is  more 
characteristic  of  syphilitic  laryngitis — in  their  healing  form  a  fibrous  tissue 
which  shrinks  and  produces  stenosis.  The  ulceration  is  apt  to  extend 
deeply  and  involve  the  cartilage,  inducing  necrosis  and  exfoliation,  and 
even  haemorrhage  from  erosion  of  the  arteries.  CEdema  may  suddenly  prove 
fatal.  The  cicatrices  which  follow  the  sclerosis  of  the  gummata  or  the 
healing  of  the  ulcers  produce  great  deformity.  The  epiglottis,  for  instance, 
may  be  tied  down  to  the  pharyngeal  wall  or  to  the  epiglottic  folds,  or  even 
to  the  tongue;  and  eventually  a  stenosis  results,  which  may  necessitate 
tracheotomy. 

The  laryngeal  symptoms  of  inherited  syphilis  have  the  usual  course  of 
these  lesions  and  appear  either  early,  within  the  first  five  or  six  months,  or 
after  puberty;  most  commonly  in  the  former  period.     Of  76  cases,  J.  N. 


ACUTE  BRONCHITIS,  621 

Mackenzie  found  that  63  occurred  within  tlie  first  year.  The  gummatous 
infiltration  leads  to  ulceration,  most  commonly  of  the  epiglottis  and  in  the 
ventricles,  and  the  process  may  extend  deeply  and  involve  the  cartilage. 
Cicatricial  contraction  may  also  occur. 

The  diagnosis  of  syphilis  of  the  larynx  is  rarely  difficult,  since  it  occurs 
most  commonly  in  connection  with  other  symptoms  of  the  disease. 

Treatment. — The  administration  of  constitutional  remedies  is  the 
most  important,  and  under  mercury  and  iodide  of  potassium  the  local  symp- 
toms may  rapidly  he  relieved.  The  tertiary  laryngeal  manifestations  are 
always  serious  and  difficult  to  treat.  The  deep  ulceration  is  specially  hard 
to  combat,  and  the  cicatrization  may  necessitate  tracheotomy,  or  the  gradual 
dilatation,  as  practised  by  Schroetter. 


III.   DISEASES   OF  THE  BRONCHI. 
I.    ACUTE    BRONCHITIS. 

Acute  catarrhal  inflammation  of  the  bronchial  mucous  membrane  is  a 
very  common  disease,  rarely  serious  in  healthy  adults,  but  very  fatal  in  the 
old  and  in  the  young,  owing  to  associated  pulmonary  complications.  It  is 
bilateral  and  affects  either  the  larger  and  medium  sized  tubes  or  the  smaller 
bronchi,  in  which  case  it  is  known  as  capillary  bronchitis. 

We  shall  speak  only  of  the  former,  as  the  latter  is  part  and  parcel  of 
broncho-pneumonia. 

Etiology. — Acute  bronchitis  is  a  common  sequel  of  catching  cold, 
and  is  often  nothing  more  than  the  extension  downward  of  an  ordinary 
coryza.  It  occurs  most  frequently  in  the  changeable  weather  of  early  spring 
and  late  autumn.  Its  association  with  cold  is  well  indicated  by  the  popu- 
lar expression  "  cold  on  the  chest."  It  may  prevail  as  an  epidemic  apart 
from  influenza,  of  which  it  is  an  important  feature. 

Acute  bronchitis  is  associated  with  many  other  affections,  notably 
measles.  It  is  by  no  means  rare  at  the  onset  of  typhoid  fever  and  malaria. 
It  is  present  also  in  asthma  and  whooping-cough.  The  subjects  of  spinal 
curvature  are  specially  liable  to  the  disease.  The  bronchitis  of  Bright's 
disease,  gout,  and  heart-disease  is  usually  a  chronic  form.  It  attacks  per- 
sons of  all  ages,  but  most  frequently  the  young  and  the  old.  There  are  in- 
dividuals who  have  a  special  disposition  to  bronchial  catarrh,  and  the 
slightest  exposure  is  apt  to  bring  on  an  attack.  Persons  who  live  an  out- 
of-door  life  are  usually  less  subject  to  the  disease  than  those  who  follow 
sedentary  occupations. 

The  affection  is  probably  microbic,  though  we  have  as  yet  no  definite 
evidence  upon  this  point. 

Morbid  Anatomy. — The  mucous  membrane  of  the  trachea  and 
bronchi  is  reddened,  congested,  and  covered  with  mucus  and  muco-pus, 
which  may  be  seen  oozing  from  the  smaller  bronchi,  some  of  which  are 
dilated.     The  finer  changes  in  the  mucosa  consist  in  desquamation  of  the 


622  DISEASES  OF  THE  RESPffiATORY  SYSTEM. 

ciliated  epithelium,  swelling  and  oedema  of  the  submucosa,  and  infiltration 
of  the  tissue  with  leucocytes.    The  mucous  glands  are  much  swollen. 

Symptoms. — The  symptoms  of  an  ordinary  "  cold  "  accompany  the 
onset  of  an  acute  bronchitis.  The  coryza  extends  to  the  tubes,  and  may 
also  affect  the  larynx,  producing  hoarseness,  which  in  many  cases  is  marked. 
A  chill  is  rare,  but  there  is  invariably  a  sense  of  oppression,  with  heavi- 
ness and  languor  and  pains  in  the  bones  and  back.  In  mild  cases  there  is 
scarcely  any  fever,  but  in  severer  forms  the  range  is  from  101°  to  103°. 
The  bronchial  symptoms  set  in  with  a  feeling  of  tightness  and  rawness 
beneath  the  sternum  and  a  sensation  of  oppression  in  the  chest.  The 
cough  is  rough  at  first,  and  often  of  a  ringing  character.  It  comes  on  in 
paroxysms  which  rack  and  distress  the  patient  extremely.  During  the 
severe  spells  the  pain  may  be  very  intense  beneath  the  sternum  and  along 
the  attachments  of  the  diaphragm.  At  first  the  cough  is  dry  and  the  ex- 
pectoration scanty  and  viscid,  but  in  a  few  days  the  secretion  becomes 
muco-purulent  and  abundant,  and  finally  purulent.  With  the  loosening 
of  the  cough  great  relief  is  experienced.  The  sputum  is  made  up  largely 
of  pus-cells,  with  a  variable  number  of  the  large  round  alveolar  cells,  many 
of  which  contain  carbon  grains,  while  others  have  undergone  the  myelin 
degeneration. 

Physical  Signs. — The  respiratory  movements  are  not  greatly  increased 
in  frequency  unless  the  fever  is  high.  There  are  instances,  however,  in 
which  the  breathing  is  rapid  and  when  the  smaller  tubes  are  involved 
there  is  dyspnoea.  On  palpation  the  bronchial  fremitus  may  often  be  felt. 
On  auscultation  in  the  early  stage,  piping  sibilant  rales  are  everywhere  to 
be  heard.  They  are  very  changeable,  and  appear  and  disappear  with  cough- 
ing. With  the  relaxation  of  the  bronchial  membranes  and  the  greater 
labundance  of  the  secretion,  the  rales  change  and  become  mucous  and  bub- 
bling in  quality.  The  bases  of  the  lungs  should  be  carefully  examined 
each  day,  particularly  in  children  and  the  aged. 

The  course  of  the  disease  depends  on  the  conditions  under  which  it 
develops.  In  healthy  adults,  by  the  end  of  a  week  the  fever  subsides  and 
the  cough  loosens.  In  another  week  or  ten  days  convalescence  is  fully 
established.  In  young  children  the  chief  risk  is  in  the  extension  of  the 
process  downward.  In  measles  and  whooping-cough,  the  ordinary  bron- 
chial catarrh  is  very  apt  to  descend  to  the  finer  tubes,  which  become  dilated 
and  plugged  with  muco-pus,  inducing  areas  of  collapse,  and  finally  broncho- 
pneumonia. This  extension  is  indicated  by  changes  in  the  ph5^Gical  signs. 
Usually  at  the  base  the  rales  are  subcrepitant  and  numerous  and  there 
may  be  areas  of  defective  resonance  and  of  feeble  or  distant  tubular  breath- 
ing. In  the  aged  and  debilitated  there  are  similar  dangers  if  the  process 
extends  from  the  larger  to  the  smaller  tubes.  In  old  age  the  bronchial 
mucosa  is  less  capable  of  expelling  the  mucus,  which  is  more  apt  to  sag  to 
the  dependent  parts  and  induce  dilatation  of  the  tubes  with  extension  of 
the  inflammation  to  the  contiguous  air-cells. 

The  diagnosis  of  acute  bronchitis  is  rarely  difficult.  Although  the 
mode  of  onset  may  be  brusque  and  perhaps  simulate  pneumonia,  yet  the 
absence  of  dulness  and  blowing  breathing,  and  the  general  character  of 


CHRONIC  BRONCHITIS.  623 

the  bronchial  inflammation,  render  the  diagnosis  simple.  About  once  a 
year  I  see  a  case  of  typhoid  fever,  in  which  the  diagnosis  at  first  has  been 
acute  bronchitis.  The  complication  of  broncho-pneumonia  is  indicated  by 
the  greater  severity  of  the  symptoms,  particularly  the  dyspnoea,  the  changed 
color,  and  the  physical  signs. 

Treatment. — In  mild  cases,  household  measures  suffice.  The  hot 
foot-bath,  or  the  warm  bath,  a  drink  of  hot  lemonade,  and  a  mustard  plaster 
on  the  chest  will  often  give  relief.  For  the  dry,  racking  cough,  the  symp- 
tom most  complained  of  by  the  patient,  Dover's  powder  is  the  best  remedy. 
It  is  a  ]3opular  belief  that  quinine,  in  full  doses,  will  check  an  oncoming 
cold  on  the  chest,  but  this  is  doubtful.  It  is  a  common  custom  when  per- 
sons feel  the  approach  of  a  cold  to  take  a  Turkish  bath,  and  though  the 
tightness  and  oppression  may  be  relieved  by  it,  there  is  in  a  majority  of  the 
cases  great  risk.  Some  of  the  severest  cases  of  bronchitis  which  I  have 
seen  have  followed  this  initial  Turkish  bath.  No  doubt,  if  the  person 
could  go  to  bed  directly  from  the  bath,  its  action  would  be  beneficial,  but 
there  is  great  risk  of  catching  additional  "  cold  "  in  going  home  from  the 
bath.  Eelief  is  obtained  from  the  unpleasant  sense  of  rawness  by  keep- 
ing the  air  of  the  room  saturated  with  moisture,  and  in  this  dry  stage 
the  old-fashioned  mixture  of  the  wines  of  antimony  and  ipecacuanha  with 
liquor  ammonii  acetatis  and  nitrous  ether  is  useful.  If  the  pulse  is  very 
rapid,  tincture  of  aconite  may  be  given,  particularly  in  the  case  of  chil- 
dren. For  the  cough,  when  dry  and  irritating,  opium  should  be  freely 
used  in  the  form  of  Dover's  powder.  Of  course,  in  the  very  young  and 
the  aged  care  must  be  exercised  in  the  use  of  opium,  particularly  if  the 
secretions  are  free;  but  for  the  distressing,  irritative  cough,  which  keeps 
the  patient  awake,  no  remedy  can  take  its  place.  As  the  cough  loosens 
ahd  the  expectoration  is  more  abundant,  the  patient  becomes  more  com- 
fortable. In  this  stage  it  is  customary  to  ply  him  with  expectorants  of 
various  sorts.  Though  useful  occasionally,  they  should  not  be  given  as  a 
matter  of  routine.  A  mixture  of  squills,  amn^oijia,  and  senega  is  a  favorite 
one  with  many  practitioners  at  this  stage. 

In  the  acute  bronchitis  of  children,  if  the  amount  of  secretion  is  large 
and  difficult  to  expectorate,  or  if  there  is  dyspnoea  and  the  color  begins 
to  get  dusky,  an  emetic  (a  tablespoonful  of  ipecac  wine)  should  be  given 
at  once  and  repeated  if  necessary. 


II.    CHRONIC    BRONCHITIS. 

Etiology. — This  affection  may  follow  repeated  attacks  of  acute  bron- 
chitis, but  it  is  most  commonly  met  with  in  chronic  lung  affections,  heart- 
disease,  aneurism  of  the  aorta,  gout,  and  renal  disease.  It  is  frequent  in 
the  aged;  the  young  rarely  are  affected.  Climate  and  season  have  an  im- 
portant influence.  It  is  the  winter  cough  of  the  old  man,  which  recurs 
with  regularity  as  the  weather  gets  cold  and  changeable. 

Morbid  Anatomy. — The  bronchial  mucosa  presents  a  great  variety 
of  changes,  depending  somewhat  upon  the  disease  with  which  chronic 
39 


^24  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

broncliitis  is  associated.  In  some  cases  the  mucous  membrane  is  very 
thin,  so  that  the  longitudinal  bands  of  elastic  tissue  stand  out  prominently. 
The  tubes  are  dilated,  the  muscular  and  glandular  tissues  are  atrophied, 
and  the  epithelium  is  in  great  part  shed. 

In  other  instances  the  mucosa  is  thickened,  granular,  and  infiltrated. 
There  may  be  ulceration,  particularly  of  the  mucous  follicles.  Bronchial 
dilatations  are  not  uncommon  and  emphysema  is  a  constant  accompani- 
ment. 

Symptoms. — In  the  form  met  with  in  old  men,  associated  with  em- 
physema, gout,  or  heart-disease,  the  chief  symptoms  are  as  follows:  Short- 
ness of  breath,  which  may  not  be  noticeable  except  on  exertion.  The 
patients  "  puff  and  blow  "  on  going  up  hill  or  up  a  flight  of  stairs.  This  is 
due  not  so  much  to  the  chronic  bronchitis  itself  as  to  associated  emphysema 
or  even  to  cardiac  weakness.  They  complain  of  no  pain.  The  cough  is 
variable,  changing  with  the  weather  and  with  the  season.  During  the 
summer  they  may  remain  free,  but  each  succeeding  winter  the  cough  comes 
on  with  severity  and  persists.  There  may  be  only  a  spell  in  the  morning, 
or  the  chief  distress  is  at  night.  The  sputum  in  chronic  bronchitis  is  very 
variable.  In  cases  of  the  so-called  dry  catarrh  there  is  no  expectoration. 
Usually,  however,  it  is  abundant,  muco-purulent,  or  distinctly  purulent  in 
character.  There  are  instances  in  which  the  patient  coughs  up  for  years 
a  thin  fluid  sputum.  There  is  rarely  fever.  The  general  health  may  be 
good  and  the  disease  may  present  no  serious  features  apart  from  the  lia- 
bility to  induce  emphysema  and  bronchiectasy.  In  many  cases  it  is  an 
incurable  affection.  Patients  improve  and  the  cough  disappears  in  the 
summer  time  only  to  return  during  the  winter  months. 

Physical  Signs. — The  chest  is  usually  distended,  the  movements  arc 
limited,  and  the  condition  is  often  that  which  we  see  in  emphysema.  The 
percussion  note  is  clear  or  hyperresonant.  On  auscultation,  expiration  is 
prolonged  and  wheezy  and  rhonchi  of  various  sorts  are  heard — some  high- 
pitched  and  piping,  others  deep-toned  and  snoring.  Crepitation  is  com- 
mon at  the  bases. 

Clinical  Varieties. — The  description  just  given  is  of  the  ordinary 
chronic  bronchitis  which  occurs  in  connection  with  emphysema  and  heart- 
disease  and  in  many  elderly  men.  There  are  certain  forms  which  merit 
special  description:  (a)  On  several  occasions  I  have  met  with  a  form  of 
cJironic  ironcJiitis,  particularly  in  women,  which  comes  on  between  the  ages 
of  twenty  and  thirty  and  may  continue  indefinitely  without  serious  impair- 
ment of  the  health. 

(b)  BroncJiorrlicea. — ^Excessive  bronchial  secretion  is  met  with  under 
several  conditions.  It  must  not  be  mistaken  for  the  profuse  expectoration 
of  bronchiectasy.  The  secretion  may  be  very  liquid  and  watery — hronchor- 
rhcea  serosa,  and  in  extraordinary  amount.  More  commonly,  it  is  purulent 
though  thin,  and  with  greenish  or  yellow-green  masses.  It  may  be  thick 
and  uniform.  This  profuse  bronchial  secretion  is  usually  a  manifestation 
of  chronic  bronchitis  and  may  lead  to  dilatation  of  the  tubes  and  ultimately 
to  fetid  bronchitis.  In  the  young  the  condition  may  persist  for  years  with- 
out impairment  of  health  and  without  apparently  damaging  the  lungs. 


CHRONIC  BRONCHITIS.  625 

(c)  Putrid  BroncTiiiis. — Fetid  expectoration  is  met  with  in  connection 
with  hronchiectasis,  gangrene,  abscess,  or  with  decomposition  of  secretions 
within  phthisical  cavities  and  in  an  empyema  which  has  perforated  the 
lung.  There  are  instances  in  which,  apart  from  any  of  these  states,  the 
expectoration  has  a  fetid  character.  The  §puta  are  abundant,  usually 
thin,  grayish-white  in  color,  and  they  separate  into  an  upper  fluid  layer 
capped  with  frothy  mucus  and  a  thick  sediment  in  which  may  sometimes 
be  found  dirty  yellow  masses  the  size  of  peas  or  beans — the  so-called  Dit- 
trich's  plugs.  The  affection  is  very  rare  apart  from  the  above-mentioned 
conditions.  In  severe  cases  it  leads  to  changes  in  the  bronchial  walls, 
pneumonia,  and  often  to  abscess  or  gangrene.  Metastatic  brain  abscess  has 
followed  putrid  bronchitis  in  a  certain  number  of  cases. 

(d)  Dry  Catarrh. — The  catarrhe  sec  of  Laennec,  a  not  uncommon  form, 
is  characterized  by  paroxysms  of  coughing  of  great  intensity,  with  little  or 
no  expectoration.  It  is  usually  met  with  in  elderly  persons  with  emphy- 
sema, and  is  one  of  the  most  obstinate  of  all  varieties  of  bronchitis. 

In  England  the  damp  cold  of  the  unwarmed  houses  is  responsible  in 
great  part  for  the  prevalence  of  chronic  bronchitis  among  the  aged  and 
weak.  An  equable,  warm  temperature  is  of  the  first  importance  to  all 
persons  prone  to  the  disease. 

Treatment. — By  far  the  most  satisfactory  method  of  treating  the 
recurring  winter  bronchitis  is  change  of  climate.  Eemoval  to  a  southern 
latitude  may  prevent  the  onset.  Southern  France,  southern  California, 
and  Florida  furnish  winter  climates  in  which  the  subjects  of  chronic  bron- 
chitis live  with  the  greatest  comfort.  All  cases  of  prolonged  bronchial 
irritation  are  benefited  by  change  of  air. 

The  first  endeavor  in  treating  a  case  of  chronic  bronchitis  is  to  ascer- 
tain, if  possible,  whether  there  are  constitutional  or  local  affections  with 
which  it  is  associated.  In  many  instances  the  urine  is  found  to  be  highly 
acid,  perhaps  slightly  albuminous,  and  the  arteries  are  stiff.  In  the  form 
associated  with  this  condition,  sometimes  called  gouty  bronchitis,  the  at- 
tacks seem  related  to  the  defective  renal  elimination,  and  to  this  condition 
the  treatment  should  be  first  directed.  In  other  instances  there  are  heart- 
disease  and  emphysema.  In  the  form  occurring  in  old  men  much  may  be 
done  in  the  way  of  prophylaxis.  Septuagenarians  should  read  Oliver  Wen- 
dell Holmes's  *  "  De  Senectute  "  with  reference  to  the  care  of  the  health. 
There  is  no  doubt  that  with  prudence  even  in  our  changeable  winter 
weather  much  may  be  done  to  prevent  the  onset  of  chronic  bronel litis. 
Woollen  undergarments  should  be  used  and  especial  care  should  be  taken 
in  the  spring  months  not  to  change  them  for  lighter-  ones  before  the  warm 
weather  is  established. 

Cure  is  seldom  effected  by  medicinal  remedies.  There  are  instances 
in  which  iodide  of  potassium  acts  with  remarkable  benefit,  and  it  should 
always  be  given  a  trial  in  cases  of  paroxysmal  bronchitis  of  obscure  origin. 
For  the  morning  cough,  bicarbonate  of  sodium  (gr.  xv),  chloride  of  sodium 
(gr.  v),  spirits  of  chloroform  (ttiv)  in  anise  water  and  taken  with  an  equal 

*  Over  the  Tea-cups,  Boston,  1890. 


626  DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

amount  of  warm  water  will  be  found  useful  (Fowler).  "When  tliere  is  much 
sense  of  tightness  and  fulness  of  the  chest,  the  portable  Turkish  bath  may 
be  tried.  Wlien  the  secretion  is  excessive  muriate  of  ammonia  and  senega 
are  useful.  Stimulating  expectorants  are  contraindicated.  When  the  heart 
is  feeble,  the  combination  of  digitalis  and  strychnia  is  very  beneficial.  Tur- 
pentine, the  old-fashioned  remedy  so  warmly  recommended  by  the  Dublin 
physicians,  has  in  many  quarters  fallen  undeservedly  into  disuse.  Prepara- 
tions of  tar,  creasote,  and  terebene  are  sometimes  useful.  Of  other  balsamic 
remedies,  sandal-wood,  the  compound  tincture  of  benzoin,  copaiba,  balsam 
of  Peru  or  tolu  may  be  used.  Inhalations  of  eucalyptus  and  of  the  spray 
of  ipecacuanha  wine  are  often  very  useful.  If  fetor  be  present,  carbolic 
acid  in  the  form  of  spray  (10  to  20  per  cent  solution)  will  lessen  the  odor, 
or  thymol  (1  to  1,000).  For  urgent  dyspnoea  with  cyanosis,  bleeding  from 
the  arm  gives  most  relief. 


III.    BRONCHIECTASIS. 

Etiology. — Dilatation  of  the  bronchi  occurs  under  the  following  con- 
ditions: (1)  As  a  congenital  defect  or  anomaly.  Such  cases  are  extremely 
rare,  commonly  unilateral.  Grawitz  has  described  the  condition  as  hron- 
cJiiedasis  universalis.  Welch  has  met  an  instance  in  a  young  girl.  (2)  In 
connection  with  inflammation  of  the  bronchi,  particularly  when  this  leads 
to  weakness  of  the  walls  with  the  accumulation  of  secretion.  I  have  seen 
an  instance  after  influenza.  Under  this  category  comes  the  dilatation  met 
with  in  chronic  bronchitis  and  emphysema,  the  dilated  bronchi  in  chronic 
phthisis,  in  the  catarrhal  pneumonias  of  children,  and  particularly  the  dila- 
tation which  results  from  the  presence  of  foreign  bodies  in  the  air-tubes 
or  from  pressure,  as  of  an  aneurism  on  one  bronchus.  (3)  In  extreme 
contraction  of  the  lung  tissue,  whether  due  to  interstitial  pneumonia  or  to 
compression  by  pleural  adhesions,  bronchial  dilatation  is  a  common  though 
not  a  constant  accompaniment. 

Unquestionably  the  weakening  of  the  bronchial  wall  is  the  most  impor- 
tant, probably  the  essential,  factor  in  inducing  bronchiectasy,  since  the  wall 
is  then  not  able  to  resist  the  pressure  of  air  in  severe  spells  of  coughing 
and  in  straining.  In  some  instances  the  mere  weight  of  the  accumulated 
secretion  may  be  sufiicient  to  distend  the  terminal  tubules,  as  is  seen  in 
compression  of  a  bronchus  by  aneurism. 

Morbid  Anatomy. — Two  chief  forms  are  recognized — the  cylin- 
drical and  the  saccular — which  may  exist  together  in  the  same  lung.  The 
condition  may  be  general  or  partial.  Universal  bronchiectasis  is  always 
unilateral.  It  occurs  in  rare  congenital  cases  and  is  occasionally  seen  as  a 
sequence  of  interstitial  pneumonia.  The  entire  bronchial  tree  is  repre- 
sented by  a  series  of  sacculi  opening  one  into  the  other.  The  walls  are 
smooth  and  possibly  without  ulceration  or  erosion  except  in  the  dependent 
parts.  The  lining  membrane  of  the  sacculi  is  usually  smooth  and  glisten- 
ing. The  dilatations  may  form  large  cysts  immediately  beneath  the  pleura. 
Intervening  between  the  sacculi  is  a  dense  cirrhotic  lung  tissue.      The 


BRONCHIECTASIS.  G27 

partial  dilatations — the  saccular  and  cylindrical — are  common  in  chronic 
phthisis,  particularly  at  the  apex,  in  chronic  pleurisy  at  the  base,  and  in 
emphysema.  Here  the  dilatation  is  more  commonly  cylindrical,  some- 
times fusiform.  The  bronchial  mucous  membrane  is  much  involved  and 
sometimes  there  is  a  narrowing  of  the  lumen.  Occasionally  one  meets 
with  a  single  saccular  bronchiectasy  in  connection  with  chronic  bronchitis 
or  emphysema.  Some  of  these  look  like  simple  cysts,  with  smooth  walls, 
without  fluid  contents.  A  form  of  acute  bronchiectasis  in  children  has 
been  described  by  Sharkey,  Carr,  and  others.  A  good  account  of  it  is  given 
in  Fowler  and  Godlee's  work  on  the  lungs. 

Histologically  the  bronchi  which  are  the  seat  of  dilatation  show  im- 
portant changes.  In  the  large,  smooth  dilatations  the  cylindrical  is  re- 
placed by  a  pavement  epithelium.  The  muscular  layer  is  stretched,  atro- 
phied, and  the  fibres  separated;  the  elastic  tissue  is  also  much  stretched 
and  separated.  In  the  large  saccular  bronchiectases  and  in  some  of  the 
cylindrical  forms,  due  to  retained  secretions,  the  lining  membrane  is  ulcer- 
ated. The  contents  of  some  of  the  larger  bronchiectatic  cavities  are  hor- 
ribly fetid. 

Symptoms. — In  the  limited  dilatations  of  phthisis,  emphysema,  and 
chronic  bronchitis,  the  symptoms  are  in  great  part  those  of  the  original 
disease,  and  the  condition  often  is  not  suspected  during  life. 

In  extensive  saccular  bronchiectasy  the  characters  of  the  cough  and 
expectoration  are  distinctive.  The  patient  will  pass  the  greater  part  of 
the  day  without  any  cough  and  then  in  a  severe  paroxysm  will  bring  up 
a  large  quantity  of  sputum.  Sometimes  change  of  the  position  will  bring 
on  a  violent  attack,  probably  due  to  the  fact  that  some  of  the  secretion 
flows  from  the  dilatation  to  a  normal  tube.  The  daily  spell  of  coughing 
is  usually  in  the  morning.  The  expectoration  is  in  many  instances  very 
characteristic.  It  is  grayish  or  grayish  brown  in  color,  fluid,  purulent, 
with  a  peculiar  acid,  sometimes  fetid,  odor.  Placed  in  a  conical  glass,  it 
separates  into  a  thick  granular  layer  below  and  a  thin  mucoid  intervening 
layer  above,  which  is  capped  by  a  brownish  froth.  Microscopically  it 
consists  of  pus-corpuscles,  often  large  crystals  of  fatty  acids,  which  are 
sometimes  in  enormous  numbers  over  the  field  and  arranged  in  bunches. 
Hsematoidin  crystals  are  sometimes  present.  Elastic  fibres  are  seldom 
found  except  when  there  is  ulceration  of  the  bronchial  walls.  Tubercle 
bacilli  are  not  present.  In  some  cases  the  expectoration  is  very  fetid 
and  has  all  the  characters  of  that  described  under  fetid  bronchitis.  Num- 
mular expectoration,  such  as  comes  from  phthisical  cavities,  is  not  com- 
mon. Haemorrhage  occurred  in  14  out  of  35  cases  analyzed  by  Fowler. 
Abscess  of  the  brain  has  in  a  few  instances  followed  the  bronchiectasis. 
Eheumatoid  affections  may  develop,  and  it  is  one  of  the  conditions  with 
which  the  pulmonary  osteo-arthropathy  is  commonly  associated. 

The  diagnosis  is  not  possible  in  a  large  number  of  the  cases.  In  the 
extensive  sacculated  forms,  unilateral  and  associated  with  interstitial  pneu- 
monia or  chronic  pleurisy,  the  diagnosis  is  easy.  There  is  contraction  of 
the  side,  which  in  some  instances  is  not  at  all  extreme.  The  cavernous 
signs  may  be  chiefly  at  the  base  and  may  vary  according  to  the  condi- 


628  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

tion  of  the  cavity,  whether  full  or  empty.  There  may  be  the  most  ex- 
quisite amphoric  phenomena  and  loud  resonant  rales.  The  condition 
persists  for  years  and  is  not  inconsistent  with  a  tolerably  active  life.  The 
patients  frequently  show  signs  of  marked  embarrassment  of  the  pul- 
monary circulation.  There  is  cyanosis  on  exertion,  the  finger-tips  are 
clubbed,  and  the  nails  incurved.  A  condition  very  difl&cult  to  distin- 
guish from  bronchiectasy  is  a  limited  pleural  cavity  communicating  with  a 
bronchus. 

Treatment. — Medical  treatment  is  not  satisfactory,  since  it  is  impos- 
sible to  heal  the  cavity.  I  have  practised  the  injection  of  antiseptic  fluids 
in  some  instances  with  benefit.  Intratracheal  injections  have  been  very 
warmly  recommended  of  late.  With  a  suitable  syringe  a  drachm  may  be 
injected  twice  a  day  of  the  following  solution:  Menthol  10  parts,  guaia- 
col  3  parts,  olive  oil  88  parts.  The  creasote  vapor  bath  may  be  given  in  a 
small  room.  The  patient's  eyes  must  be  protected  with  well-fitting  goggles, 
and  the  nostrils  stuffed  with  cotton-wool.  A  drachm  of  creasote  is  poured 
upon  water  in  a  saucer  and  vaporized  by  placing  the  saucer  over  a  spirit 
lamp.  At  first  the  vapor  is  very  irritating  and  disagreeable,  but  the  pa- 
tient gets  used  to  it.  The  bath  should  be  taken  at  first  every  other  day 
for  fifteen  minutes,  then  gradually  increased  to  an  hour  daily.  The  treat- 
ment should  be  continued  for  three  months.  I  can  recommend  it  as  a 
most  satisfactory  method  of  treatment.  In  suitable  cases  drainage  of  the 
cavities  may  be  attempted,  particularly  if  the  patieiit  is  in  fairly  good  con- 
dition. For  the  fetid  secretion  turpentine  may  be  given,  or  terebene,  and 
inhalations  used  of  carbolic  acid  or  thymol. 


IV.    BRONCHIAL  ASTHMA. 

Asthma  is  a  term  which  has  been  applied  to  various  conditions  associ- 
ated with  dyspnoea — Whence  the  names  cardiac  and  renal  asthma — ^but  its 
use  should  be  limited  to  the  affection  known  as  bronchial  or  spasmodic 
asthma. 

Etiology.— All  writers  agree  that  there  is  in  a  majority  of  cases  of 
bronchial  asthma  a  strong  neurotic  element.  Many  regard  it  as  a  neu- 
rosis in  which,  according  to  one  view,  spasm  of  the  bronchial  muscles,  ac- 
cording to  the  other  turgescence  of  the  mucosa,  results  from  disturbed  in- 
nervation, pneumogastric  or  vaso-motor.  Of  the  numerous  theories  the 
following  are  the  most  important: 

(1)  That  it  is  due  to  spasm  of  the  bronchial  muscles,  a  theory  which 
has  perhaps  the  largest  number  of  adherents.  The  original  experiments 
of  C.  J.  B.  Williams,  upon  which  it  is  largely  based,  have  not,  however, 
been  confirmed  of  late  years. 

(2)  That  the  attack  is  due  to  swelling  of  the  bronchial  mucous  mem- 
brane— fluctionary  hypergemia  (Traube),  vaso-motor  turgescence  (Weber), 
diffuse  hypersemic  swelling  (Clark). 

(3)  That  in  many  cases  it  is  a  special  form  of  inflammation  of  the 
smaller  bronchioles — bronchiolitis  exudativa   (Curschmann).     Other  theo- 


BRONCHIAL  ASTHMA.  •  629 

ries  which  may  be  mentioned  are  that  the  attack  depends  on  spasm  of  the 
diaphragm  or  on  reflex  spasm  of  all  the  inspiratory  muscles. 

As  already  mentioned,  the  so-called  hay  fever  is  an  affection  which  has 
many  resemblances  to  bronchial  asthma,  with  which  the  attacks  may  alter- 
nate. In  the  suddenness  of  onset  and  in  many  of  their  features  these  dis- 
eases have  the  same  origin  and  differ  only  in  site,  as  suggested  by  Sir 
Andrew  Clark  and  now  generally  acknowledged  by  specialists.  Making 
due  allowance  for  anatomical  differences,  if  the  structural  changes  occur- 
ring in  the  nasal  mucous  membrane  during  an  attack  of  hay  fever  were  to 
occur  also  in  various  parts  of  the  bronchial  mucosa,  their  presence  there 
would  afford  a  complete  and  adequate  explanation  of  the  facts  observed 
during  a  paroxysm  of  bronchial  asthma  (Clark).  With  this  statement  I 
fully  agree,  but  the  observations  of  Curschmann  have  directed  attention 
to  a  feature  in  asthma  which  has  been  neglected;  namely,  that  in  a  ma- 
jority of  the  cases  it  is  associated  with  an  exudation,  such  as  might  be 
supposed  to  come  from  a  turgescent  mucosa  and  which  is  of  a  very  charac- 
teristic and  peculiar  character.  The  hyperemia  and  swelling  of  the  mu- 
cosa and  the  extremely  viscid,  tenacious  mucus  explain  well  the  hindrance 
to  inspiration  and  expiration  and  also  the  quality  of  the  rales.  An  oedema 
of  the  angio-neurotic  type  has  been  described  in  the  hands  and  arms  in 
asthma  (J.  S.  Billings,  Jr.). 

Some  general  facts  .with  reference  to  etiology  may  be  mentioned.  The 
affection  sometimes  runs  in  families,  particularly  those  with  irritable  and 
unstable  nervous  systems.  The  attack  may  be  associated  with  neuralgia 
or,  as  Salter  mentions,  even  alternate  with  epilepsy.  Men  are  more  fre- 
quently affected  than  women.  The  disease  often  begins  in  childhood  and 
sometimes  lasts  until  old  age.  It  may  follow  an  attack  of  whooping-cough. 
Oiie  of  its  most  striking  peculiarities  is  the  hizarre  and  extraordinary  variety 
of  circumstances  which  at  times  induce  a  paroxysm.  Among  these  local 
conditions  climate  or  atmosphere  are  most  important.  A  person  may  be 
free  in  the  city  and  invariably  suffer  from  an  attack  when  he  goes  into  the 
country,  or  into  one  special  part  of  the  country.  Such  cases  are  by  no 
means  uncommon.  Breathing  the  air  of  a  particular  room  or  a  dusty  at- 
mosphere may  bring  on  an  attack.  Odors,  particularly  of  flowers  and  of 
hay,  or  emanations  from  animals,  as  the  horse,  dog,  or  cat,  may  at  once  cause 
an  outbreak.  Fright  or  violent  emotion  of  any  sort  may  bring  on  a  parox- 
ysm. Uterine  and  ovarian  troubles  were  formerly  thought  to  induce  at- 
tacks and  may  do  so  in  rare  instances.  Diet,  too,  has  an  important  influ- 
ence, and  in  persons  subject  to  the  disease  severe  paroxysms  may  be  induced 
by  overloading  the  stomach,  or  by  taking  certain  articles  of  food.  Chronic 
cases,  in  which  the  attacks  recur  year  after  year,  gradually  become  asso- 
ciated with  emphysema,  and  every  fresh  "  cold  "  induces  a  paroxysm.  And 
lastly,  many  cases  of  bronchial  asthma  are  associated  with  affections  of  the 
nose,  particularly  with  hypertropliic  rhinitis  and  nasal  polypi.  According 
to  some  specialists  of  large  experience,  all  cases  of  bronchial  asthma  have 
some  affection  of  the  upper  air-passages,  but  I  am  convinced  from  personal 
observation  that  this  is  erroneous.  Still  physicians  must  acknowledge  the 
debt  which  we  owe  to  Voltolini,  Hack,  Daly,  Eoe,  and  others  who  have 


630  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

shown  the  close  connection  which  exists  between  affections  of  the  naso- 
pharynx and  many  cases  of  bronchial  asthma. 

Briefly  stated  then,  bronchial  asthma  is  a  neurotic  affection,  character- 
ized by  hyperemia  and  turgescence  of  the  mucosa  of  the  smaller  bronchial 
tubes  and  a  peculiar  exudate  of  mucin.  The  attacks  may  be  due  to  direct 
irritation  of  the  bronchial  mucosa  or  may  be  induced  reflexly,  by  irritation 
of  the  nasal  mucosa,  and  indirectly,  too,  by  reflex  influences,  from  stomach, 
intestines,  or  genital  organs. 

Symptoms. — Premonitory  sensations  precede  some  attacks,  such  as 
chilly  feelings,  a  sense  of  tightness  in  the  chest,  flatulence,  the  passage  of  a 
large  quantity  of  urine,  or  great  depression  of  spirits.  Nocturnal  attacks 
are  common.  After  a  few  hours'  sleep,  the  patient  is  aroused  with  a  dis- 
tressing sense  of  want  of  breath  and  a  feeling  of  great  oppression  in  the 
chest.  Soon  the  respiratory  efforts  become  violent,  all  the  accessory  mus- 
cles are  brought  into  play,  and  in  a  few  minutes  the  patient  is  in  a  paroxysm 
of  the  most  intense  dyspnoea.  The  face  is  pale,  the  expression  anxious, 
speech  is  impossible,  and  in  spite  of  the  most  strenuous  inspiratory  efforts 
very  little  air  enters  the  lungs.  Expiration  is  prolonged  and  also  wheezy. 
The  number  of  respirations,  however,  is  not  much  increased.  The  asth- 
matic fit  may  last -from  a  few  minutes  to  several  hours.  When  severe,  the 
signs  of  defective  aeration  soon  appear,  the  face  becomes  bedewed  with 
sweat,  the  pulse  is  small  and  quick,  the  extremities  get  cold,  and  just  as 
the  patient  seems  to  be  at  his  worst,  the  breathing  begins  to  get  easier,  and 
often  with  a  paroxysm  of  coughing  relief  is  obtained  and  he  sinks  ex- 
hausted to  sleep.  The  relief  may  be  but  temporary  and  a  second  attack 
may  soon  come  on.  In  a  majority  of  the  cases  even  in  the  intervals  be- 
tween the  asthmatic  fits  the  respiration  is  somewhat  embarrassed.  The 
cough  is  at  first  very  tight  and  dry  and  the  expectoration  is  tenacious.  Em- 
physema of  the  neck  may  occur  during  the  violent  coughing  spells. 

The  physical  signs  during  an  attack  are  very  characteristic.  On  in- 
spection the  thorax  looks  enlarged,  barrel-shaped,  and  is  fixed,  the  amount 
of  expansion  being  altogether  disproportionate  to  the  intensity  of  the  in- 
spiratory movements.  The  diaphragm  is  lowered  and  moves  but  slightly. 
Inspiration  is  short  and  quick,  expiration  prolonged.  Percussion  may  not 
reveal  any  special  difference,  but  there  is  sometimes  marked  hyperreso- 
nance,  particularly  in  cases  which  have  had  repeated  attacks. 

On  auscultation,  with  inspiration  and  expiration,  there  are  innumer- 
able sibilant  and  sonorous  rales  of  all  varieties,  piping  and  high-pitched, 
low-pitched  and  grave.    Later  in  the  attack  there  are  moist  rales. 

The  sputum  in  bronchial  asthma  is  quite  distinctive,  unlike  that  which 
occurs  in  any  other  affection.  Early  in  the  attack  it  is  brought  up  with 
great  difficulty  and  is  in  the  form  of  rounded  gelatinous  masses,  the  so- 
called  "  perles  "  of  Laennec.  Though  ball-like,  they  can  be  unfolded  and 
really  represent  moulds  in  mucus  of  the  smaller  tubes.  The  entire  expec- 
toration may  be  made  up  of  these  somewhat  translucent-looking  pellets, 
floating  in  a  small  quantity  of  thin  mucus.  Some  of  them  are  opaque. 
Often  with  a  naked  eye  a  twisted  spiral  character  can  be  seen,  particularly 
if  the  sputum  is  spread  on  a  glass  with  a  black  background.     Microscopic- 


BRONCHIAL  ASTHMA.  631 

ally,  many  of  these  pellets  have  a  spiral  structure,  which  renders  them 
among  the  most  remarkable  bodies  met  with  in  sputum.  It  is  not  a  little 
curious  that  they  should  have  been  practically  overlooked  until  described  a 
few  years  ago  by  Curschmann.  Under  the  microscope  the  spirals  are  of 
two  forms.  In  one  there  is  simply  a  twisted,  spirally  arranged  mucin,  in 
which  are  entangled  leucocytes,  the  majority  of  which  are  eosinophiles. 
The  twist  may  be  loose  or  tight.  The  second  form  is  much  more  peculiar. 
In  the  centre  of  a  tightly  coiled  skein  of  mucin  fibrils  with  a  few  scattered 
cells  is  a  filament  of  extraordinary  clearness  and  translucency,  probably 
composed  of  transformed  mucin.  As  Curschmann  suggests,  these  spirals 
are  doubtless  formed  in  the  finer  bronchioles  and  constitute  the  product 
of  an  acute  bronchiolitis.  It  is  difficult  to  explain  their  spiral  nature.  I 
do  not  know  of  any  observations  upon  the  course  of  the  currents  produced 
by  the  ciliated  epithelium  in  the  bronchi,  but  it  is  quite  possible  that  their 
action  may  be  rotatory,  in  which  case,  particularly  when  combined  with 
spasm  of  the  bronchial  muscles,  it  is  possible  to  conceive  that  the  mucus 
formed  in  the  tube  might  be  compelled  to  assume  a  spiral  form.  Within 
two  or  three  days  the  sputum  changes  entirely  in  character;  it  becomes 
muco-purulent  and  Curschmann's  spirals  are  no  longer  to  be  found.  They 
occur  in  all  instances  of  true  bronchial  asthma  in  the  early  period  of  the 
attack.  I  have  never  seen  the  true  spirals  either  in  bronchitis  or  pneu- 
monia. There  are,  in  addition,  in  many  cases,  the  pointed,  octahedral  crys- 
tals described  by  Leyden  and  sometimes  called  asthma  crystals.  They  are 
identical  with  the  crystals  found  in  the  semen  and  in  the  blood  in  leu- 
kaemia. At  one  time  they  were  supposed,  by  their  irritating  character,  to 
induce  the  paroxysms.  Eosinophiles  in  the  blood  are  enormously  increased 
in  asthma — to  25  or  35  per  cent  of  the  leucocytes,  or  even  to  53.6  per  cent 
in  one  case  (J.  S.  Billings,  Jr.). 

The  course  of  the  disease  is  very  variable.  In  severe  attacks  the  par- 
oxysms recur  for  three  or  four  nights  or  even  more,  and  in  the  intervals 
and  during  the  day  there  may  be  wheezing  and  cough.  Early  in  the  disease 
the  patient  may  be  free  in  the  morning,  without  cough  or  much  distress, 
and  the  attacks  may  appear  at  first  to  be  of  a  purely  nervous  character.  In 
the  long-standing  cases  emphysema  almost  invariably  develops,  and  while 
the  pure  asthmatic  fits  diminish  in  frequency  the  chronic  bronchitis  and 
shortness  of  breath  become  aggravated. 

We  have  no  knowledge  of  the  morbid  anatomy  of  true  asthma.  Death 
during  the  attack  is  unknown.  In  long-standing  cases  the  lesions  are  those 
of  chronic  bronchitis  and  emphysema. 

Treatment. — The  asthmatic  attack  usually  demands  immediate  and 
prompt  treatment,  and  remedies  should  be  administered  which  experience 
has  shown  are  capable  of  relieving  the  condition  of  the  bronchial  mucosa. 
A  few  whiffs  of  chloroform  will  produce  prompt  though  temporary  relaxa- 
tion. In  a  child  with  very  severe  attacks,  resisting  all  the  usual  remedies, 
the  treatment  by  chloroform  gave  immediate  and  finally  permanent  relief. 
Hypodermic  injections  of  pilocarpin  (gr.  i)  will  sometimes  relax  the  mu- 
cosa in  the  j)rofuse  sweating.  Perles  of  nitrite  of  amyl  may  be  broken 
on  the  handkerchief  or  from  two  to  five  drops  of  the  solution  may  be  placed 


032  DISEASES  OF  THE  RESPIRATORY   SYSTEM. 

upon  cotton-wool  and  inhaled.  Strong  stimulants  given  hot  or  a  dose  of 
spirits  of  chloroform  in  hot  whisky  will  sometimes  induce  relaxation.  More 
permanent  relief  is  given  by  the  hypodermic  injection  of  morphia  or  of 
morphia  and  cocaine  combined.  In  obstinate  and  repeatedly  recurring 
attacks  this  has  proved  a  very  satisfactory  plan.  The  sedative  antispas- 
modics, such  as  belladonna,  henbane,  stramonium,  and  lobelia,  may  be 
given  in  solution  or  used  in  the  form  of  cigarettes.  Nearly  all  the  popular 
remedies  either  in  this  form  or  in  pastilles  contain  some  plant  of  the  order 
solaiiacece,  with  nitrate  or  chlorate  of  potash.  Excellent  cigarettes  are  now 
manufactured  and  asthmatics  try  various  sorts,  since  one  form  benefits  one 
patient,  another  form  another  patient.  Nitre  paper  made  with  a  strong 
solution  of  nitrate  of  potash  is  very  serviceable.  Filling  the  room  with  the 
fumes  of  this  paper  prior  to  retiring  will  sometimes  ward  off  a  nocturnal 
attack.  I  have  known  several  patients  to  whom  tobacco  smoke  inhaled  was 
quite  as  potent  as  the  prepared  cigarettes. 

The  use  of  compressed  air  in  the  pneumatic  cabinet  is  very  beneficial; 
oxygen  inhalations  may  also  be  tried.  In  preventing  the  recurrence  of 
the  attacks  there  is  no  remedy  so  useful  as  iodide  of  potassium,  which  some- 
times acts  like  a  specific.  From  10  to  20  grains  three  times  a  day  is  usu- 
ally sufiicient. 

Particular  attention  should  be  paid  to  the  diet  of  asthmatic  patients. 
A  rule  which  experience  generally  compels  them  to  make  is  to  take  the 
heavy  meals  in  the  early  part  of  the  day  and  not  retire  to  bed  before  gas- 
tric digestion  is  completed.  As  the  attacks  are  often  induced,  by  flatu- 
lency, the  carbohydrates  should  be  restricted.  Coffee  is  a  more  suitable 
drink  than  tea.  In  respect  to  climate  it  is  very  difficult  to  lay  down  rules 
for  asthmatics.  The  patients  are  often  much  better  in  the  city  than  in 
the  country.  The  high  and  dry  altitudes  are  certainly  more  beneficial  than 
the  sea-shore;  but  in  protracted  cases,  with  emphysema  as  a  secondary  com- 
plication, the  rarefied  air  of  high  altitudes  is  not  advantageous.  In  young 
persons  I  have  known  a  residence  for  six  months  in  Florida  or  southern 
California  to  be  followed  by  prolonged  freedom  from  attacks. 


V.    FIBRINOUS    BRONCHITIS. 

Definition. — An  acute  or  chronic  affection,  characterized  by  the  for- 
mation in  certain  of  the  bronchial  tubes  of  fibrinous  casts,  which  are  ex- 
pelled in  paroxysms  of  dyspnoea  and  cough. 

In  several  diseases  fibrinous  moulds  of  the  bronchi  are  formed,  as  in 
diphtheria  (with  extension  into  the  trachea  and  bronchi),  in  pneumonia, 
and  occasionally  in  phthisis — conditions  which,  however,  have  nothing  to 
do  with  true  filDrinous  bronchitis.  These  casts  are  not  to  be  confounded 
with  the  blood-casts  which  occur  occasionally  in  hgemoptysis. 

Clinical  Description. — Bettman,  in  reporting  a  case  which  occurred 
in  Prof.  Whitridge  Williams's  obstetrical  clinic  at  the  Johns  Hopkins  Hos- 
pital, has  analyzed  all  the  cases  from  the  literature  since  1869,  grouping 
them  into  different  classes.     The  first  and  most  important  is  chronic  idi- 


FIBRINOUS  BRONCHITIS.  633 

opathic  fibrmous  hronchitis.  It  is  a  rare  affection.  I  have  met  with  only 
3  cases.  Of  27  cases,  15  were  in  males.  It  is  most  common  at  the  middle 
period  of  life.  The  attacks  may  occur  at  definite  intervals  for  months  or 
years.  The  form  and  size  of  the  casts  may  be  identical  at  each  attack  as 
though  each  time  precisely  the  same  bronchial  area  was  involved.  The 
expectoration  of  the  casts  is  associated  with  paroxysms  of  dyspnoea  and 
coughing,  which  occur  at  longer  or  shorter  intervals.  Fever  and  hgemop- 
tysis  may  be  present  during  the  attack.  Physical  signs  usually  indicate 
the  portion  of  the  lung  affected,  as  there  are  suppressed  breath  sounds  and 
numerous  rales  on  coughing.  A  very  dry  rale,  called  the  '^  bruit  de  dra- 
peau,"  has  been  described,  caused  by  the  vibration  of  a  loosened  portion 
of  the  cast. 

In  five  cases  there  were  skin  lesions.  Tuberculosis  is  sometimes  pres- 
ent. Death  occurred  in  only  one  case  of  the  series.  The  casts  are  usually 
rolled  up  and  mixed  with  mucus  and  blood.  When  unrolled  they  are  large 
white  branching  structures.  The  main  stem  may  be  as  thick  as  the  little 
finger.  From  the  consistency  and  appearance  they  have  been  described 
as  fibrinous,  but  they  consist  mainly  of  mucin.  On  cross-section  they  show 
a  concentrically  stratified  structure,  with  leucocytes  and  alveolar  epithe- 
lium. Leyden's  crystals  and  Curschmann's  spirals  are  sometimes  found, 
and  in  Bettman's  case  there  were  protozoan-like  bodies. 

There  is  a  very  remarkable  acute  form,  of  which  Bettman  has  col- 
lected 15  cases.  It  comes  on  most  frequently  during  some  fever,  as  typhoid, 
pneumonia,  or  the  eruptive  fevers.  After  a  preliminary  bronchitis  the 
dyspnoea  increases,  and  then  the  casts  are  coughed  up.  Chills  and  fever 
have  been  present.  Four  of  the  15  cases  proved  fatal,  and  the  casts  were 
found  in  situ.  It  is  much  more  serious  than  the  chronic  form.  There  may 
be  casts  expectorated  which  have  not  the  arborescent  structure  of  the  true 
fibrinous  moulds,  but  which  come  from  a  single  tube  or  its  bifurcation. 
Sometimes  they  are  very  small  and  ''  tail  off "  into  true  Curschmann's 
spirals.  I  had  two  interesting  cases  of  this  sort  during  the  session  of 
1900-'01,  both  in  connection  with  chronic  bronchitis.  Fibrinous  casts 
are  expectorated  in  connection  with  chronic  heart  disease  (10  cases)  and  in 
pulmonary  tuberculosis  (14  cases),  in  the  latter  disease  usually  late  in  the 
course  and  of  unfavorable  omen.  In  the  albuminous  expectoration  follow- 
ing tapping  of  a  pleural  exudate  fibrinous  casts  have  been  coughed  up. 

In  hemoptysis  blood-casts  may  be  expectorated,  and  they  are  not  to  be 
confounded  with  the  casts  of  true  fibrinous  bronchitis  which  may  be 
coughed  up  in  an  attack  of  haemoptysis. 

In  pneumonia  small  fibrinous  plugs  are  not  uncommon  in  the  sputa, 
and  in  a  few  rare  instances  quite  large  moulds  of  the  tubes  may  be 
coughed  up. 

The  mycelium  of  the  aspergillus  fumigatus  may  form  membranous  casts 
in  the  bronchi.  I  reported  an  instance  of  the  kind  in  which  a  small  partial 
mould  of  this  kind  was  expectorated,  and  there  is  on  record  a  case  in  which 
for  long  periods  membranes  composed  of  this  fungus  were  coughed  up  in 
attacks  of  dyspnoea. 

The  pathology  of  the  disease  is  obscure.  The  membrane  is  identical 
with  that  to  which  the  term  croupous  is  applied,  and  the  obscurity  relates 


634  DISEASES  OF   THE  RESPIRATORY   SYSTEM. 

not  so  much,  to  the  mechanism  of  the  production,  which  is  probably  the 
same  as  in  other  mucous  surfaces,  as  to  the  curious  limitation  of  the  affec- 
tion to  certain  bronchial  territories  and  in  the  chronic  form  the  remark- 
able recurrence  at  stated  or  irregular  intervals  throughout  a  period  of  many 
years. 

In  the  fatal  cases  the  bronchial  mucous  membrane  may  be  found  in- 
jected or  pale.  In  Biermer's  case  the  epithelial  lining  was  intact  beneath 
the  cast,  but  in  that  of  Kretschy  the  bronchi  were  denuded  of  their  epi- 
thelium. Emphysema  is  almost  invariably  present.  Evidences  of  recent 
or  antecedent  pleurisy  are  sometimes  found.  Model,  in  an  article  published 
from  Baumler's  clinic,  states  that  tuberculosis  was  present  in  10  out  of 
21  autopsies. 

In  the  acute  cases  the  treatment  should  be  that  of  ordinary  acute  bron- 
chitis. We  know  of  nothing  which  can  prevent  the  recurrence  of  the  at- 
tacks in  the  chronic  form.  In  the  uncomplicated  cases  there  is  rarely  any 
danger  during  the  paroxysm,  even  though  the  symptoms  may  be  most  dis- 
tressing and  the  dyspnoea  and  cough  very  severe.  Inhalations  of  ether, 
steam,  or  atomized  lime-water  aid  in  the  separation  of  the  membranes. 
Waldenberg  employed  the  last  remedy  with  success  in  one  case.  Ewart 
recommends  intratracheal  injections  of  olive  oil.  Pilocarpine  might  be 
useful,  as  in  some  instances  it  increases  the  bronchial  secretion.  The  em- 
ployment of  emetics  may  be  necessary,  and  in  some  cases  they  are  effective 
in  promoting  the  removal  of  the  casts. 


lY.  DISEASES   OF  THE  LUl^GS. 

I.    CIRCULATORY    DISTURBANCES    IN    THE    LUNGS. 

Congestion. — There  are  two  forms  of  congestion  of  the  lungs — active  and 
passive. 

(1)  Active  Congestion  of  the  Lungs. — Much  doubt  and  confusion  still 
exist  on  this  subject.  French  writers,  following  Woillez,  regard  it  as  an 
independent  primary  affection  (maladie  de  Woillez).  and  in  their  diction- 
aries and  text-books  allot  much  space  to  it.  English  and  American  au- 
thors more  correctly  regard  it  as  a  symptomatic  affection.  Active  fluxion 
to  the  lungs  occurs  with  increased  action  of  the  heart,  and  when  very  hot 
air  or  irritating  substances  are  inhaled.  In  diseases  which  interfere  locally 
with  the  circulation  the  capillaries  in  the  adjacent  unaffected  portions  may 
be  greatly  distended.  The  importance,  however,  of  this  collateral  fluxion, 
as  it  is  called,  is  probably  exaggerated.  In  a  whole  series  of  pulmonary  affec- 
tions there  is  this  associated  congestion — in  pneumonia,  bronchitis,  pleu- 
risy, and  tuberculosis. 

The  symptoms  of  active  congestion  of  the  lungs  are  by  no  means  defi- 
nite. The  description  given  by  Woillez  and  by  other  French  writers  is  of 
an  affection  which  is  difficult  to  recognize  from  anomalous  or  larval  forms 
of  pneumonia.  The  chief  symptoms  described  are  initial  chill,  pain  in  the 
side,  dyspnoea,  moderate  cough,  and  temperature  from  101°  to  103°.  The 
physical  signs  are  defective  resonance,  feeble  breathing,  sometimes  bronchial 


CIRCULATORY  DISTURBANCES  IN  THE  LUNGS.  635 

in  character,  and  fine  rales.  A  majority  of  clinical  physicians  would  un- 
doubtedly class  such  cases  under  inflammation  of  the  lung.  In  many  epi- 
demics the  abnormal  and  larval  forms  are  specially  prevalent.  This  is  no 
doubt  the  condition  to  which  Porcher,  of  Charleston,  called  attention  a  short 
time  ago  as  a  "  hitherto  undescribed  affection  of  the  lungs." 

The  occurrence  of  an  intense  and  rapidly  fatal  congestion  of  the  lung, 
following  extreme  heat  or  cold  or  sometimes  violent  exertion,  is  recognized 
by  some  authors.  Eenforth,  the  oarsman,  is  said  to  have  died  from  this 
cause  during  the  race  at  Halifax.  Leuf  has  described  cases  in  which,  in 
association  with  drunkenness,  exposure,  and  cold,  death  occurred  suddenly, 
or  within  twenty-four  hours,  the  only  lesion  found  being  an  extreme,  almost 
hemorrhagic,  congestion  of  the  lungs.  It  is  by  no  means  certain  that  in 
these  cases  death  really  occurs  from  pulmonary  congestion  in  the  absence 
of  specific  statements  with  reference  to  the  coronary  arteries.  Several 
times  in  sudden  death  from  ^disease  of  these  vessels  I  have  seen  great  en- 
gorgement of  the  lungs  though  not  the  extreme  grade  mentioned  by  Leuf. 
I  have  no  personal  knowledge  of  cases  such  as  he  describes. 

(2)  Passive  Congestion. — Two  forms  of  this  may  be  recognized,  the  me- 
chanical and  the  hypostatic. 

(a)  Mechanical  congestion  occurs  whenever  there  is  an  obstacle  to  the 
return  of  the  blood  to  the  heart.  It  is  a  common  event  in  many  affections 
of  the  left  heart.  The  lungs  are  voluminous,  russet  brown  in  color,  cut- 
ting and  tearing  with  great  resistance.  On  section  they  show  at  first  a 
brownish-red  tinge,  and  then  the  cut  surface,  exposed  to  the  air,  becomes 
rapidly  of  a  vivid  red  color  from  oxidation  of  the  abundant  hsemoglobin. 
This  is  the  condition  known  as  hrown  induration  of  the  lung.  Histologic- 
ally it  is  characterized  by  (a)  great  distention  of  the  alveolar  capillaries; 
(/3)  increase  in  the  connective-tissue  elements  of  the  lung;  (y)  the  pres- 
ence in  the  alveolar  walls  of  many  cells  containing '  altered  blood-pigment; 
(8)  in  the  alveoli  numerous  epithelial  cells  containing  blood-pigment  in  all 
stages  of  alteration,  which  are  also  found  in  great  numbers  in  the  sputum. 

It  occasionally  happens  that  this  mechanical  hyper£emia  of  the  lung 
results  from  pressure  by  tumors.  So  long  as  compensation  is  maintained 
the  mechanical  congestion  of  the  lung  in  heart-disease  does  not  produce  any 
symptoms,  but  with  enfeebled  heart  action  the  engorgement  becomes  marked 
and  there  are  dyspncea,  cough,  and  expectoration,  with  tlie  characteristic 
alveolar  cells. 

(i)  Hypostatic  congestion.  In  fevers  and  adynamic  states  generally,  it 
is  very  common  to  find  the  bases  of  the  lungs  deeply  congested,  a  condition 
induced  partly  by  the  effect  of  gravity,  the  patient  lying  recumbent  in  one 
posture  for  a  long  time,  but  chiefly  by  weakened  heart  action.  That  it  is 
not  an  effect  of  gravity  alone  is  shown  by  the  fact  that  a  healthy  person 
may  remain  in  bed  an  indefinite  time  without  its  occurrence.  The  term 
hypostatic  congestion  is  applied  to  it.  The  posterior  parts  of  the  lung  are 
dark  in  color  and  engorged  with  blood  and  serum;  in  some  instances  to 
such  a  degree  that  the  alveoli  no  longer  contain  air  and  portions  of  the  lung 
sink  in  water.  The  term  splenization  and  hypostatic  pneumonia  have  been 
given  to  these  advanced  grade*     It  is  a  common  affection  in  protracted 


636  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

cases  of  typhoid  fever  and  in  long  debilitating  illnesses.  In  ascites,  meteor- 
ism,  and  abdominal  tumors  the  bases  of  the  lungs  may  be  compressed  and 
congested.  In  this  connection  must  be  mentioned  the  form  of  passive  con- 
gestion met  with  in  injury  to,  and  organic  disease  of,  the  brain.  In  cere- 
bral apoplexy  the  bases  of  the  lungs  are  deeply  engorged,  not  quite  airless, 
but  heavy,  and  on  section  drip  with  blood  and  serum.  I  have  twice  seen 
this  condition  in  an  extreme  grade  throughout  the  lungs  in  death  from  mor- 
phia poisoning.  In  some  instances  the  lung  tissue  has  a  blackish,  gelati- 
nous, infiltrated  appearance,  almost  like  difEuse  pulmonary  apoplexy.  Occa- 
sionally this  congestion  is  most  marked  in,  and  even  confined  to,  the 
hemiplegic  side.  In  prolonged  coma  the  hypostatic  congestion  may  be 
associated  with  patches  of  consolidation,  due  to  the  aspiration  of  portions 
of  food  into  the  air-passages. 

The  symptoms  of  hypostatic  congestion  are  not  at  all  characteristic, 
and  the  condition  has  to  be  sought  for  by  careful  examination  of  the  bases 
of  the  lungs,  when  slight  dulness,  feeble,  sometimes  blowing,  breathing  and 
liquid  rales  can  be  detected. 

The  treatment  of  congestion  of  the  lungs  is  usually  that  of  the  condi- 
tion with  which  it  is  associated.  In  the  intense  pulmonary  engorgement, 
which  may  possibly  occur  primarily,  and  which  is  met  with  in  heart-disease 
and  emphysema,  free  bleeding  should  be  practised.  From  20  to  30  ounces 
of  blood  should  be  taken  from  the  arm,  and  if  the  blood  does  not  flow 
freely  and  the  condition  of  the  patient  is  desperate,  aspiration  of  the  right 
auricle  may  be  performed.  " 

(Edema. — In  all  forms  of  intense  congestion  of  the  lungs  there  is  a 
transudation  of  serum  from  the  engorged  capillaries  chiefly  into  the  air- 
cells,  but  also  into  the  alveolar  walls.  Not  only  is  it  very  frequent  in  con- 
gestion, but  also  with  inflammation,  with  new  growths,  infarcts,  and  tuber- 
cles. When  limited  to  the  neighborhood  of  an  affected  part,  the  name 
collateral  oedema  is  sometimes  applied  to  it.  General  oedema  occurs  under 
conditions  very  similar  to  those  met  with  in  congestion.  It  is  very  often, 
no  doubt,  a  terminal  event,  occurring  with  the  death  agony.  It  is  seen  in 
typical  form  in  the  cachexias,  in  death  from  anemia,  also  in  chronic  Bright's 
disease,  disease  of  the  heart,  and  cerebral  afiections. 

The  oedematous  lung  is  heavy,  looks  watery,  pits  on  pressure,  and  from 
the  cut  surface  a  large  quantity  of  clear  and,  in  cases  of  congestion,  bloody 
serum  flows  freely;  the  tissue  may  even  have  a  gelatinous,  infiltrated  ap- 
pearance. The  condition  is  much  more  common  at  the  bases,  but  it  may 
exist  throughout  the  entire  lung.  The  pathology  of  pulmonary  oedema  is 
not  always  clear.  Two  factors  usually  prevail  in  extreme  cases — increased 
tension  within  the  pulmonary  system  and  a  diluted  blood  plasma.  The 
increased  tension  alone  is  not  capable  of  producing  it.  The  experiments 
of  Welch  seem  to  indicate  that  the  essential  factor  lies  in  a  disproportion- 
ate weakness  of  the  left  ventricle,  so  that  the  blood  accumulates  in  the 
lung  capillaries  until  transudation  occurs,  a  view  which  satisfactorily  ex- 
plains certain  cases,  particularly  the  terminal  oedemas. 

The  symptoms  of  oedema  of  the  lungs  are  often  only  an  aggravation  of 
those  already  existing,  and  are  due  to  the  primary  disease,  whether  car- 


CIRCULATORY   DISTURBANCES  IN  THE  LUNGS.  637 

diac,  renal,  or  general.  There  are  usually  increasing  dyspnoea  and  cough, 
and  on  examination  there  may  be  defective  resonance  and  large  liquid  rales 
at  the  bases.  There  are  cases  in  which  the  oedema  comes  on  with  great 
suddenness,  and  in  chronic  Bright's  disease  it  may  prove  rapidly  fatal. 

In  the  cases  of  so-called  inflammatory  oedema  fever  is  always  present, 
and  there  are  often  signs,  more  or  less  marked,  of  pneumonia. 

The  treatment  of  oedema  of  the  lung  is  practically  that  of  the  condi- 
tions with  which  it  is  associated.  In  the  acute  cases  active  catharsis,  and, 
if  there  is  cyanosis,  free  venesection  should  be  resorted  to. 

Pulmonary  Haemorrliage. — This  occurs  in  two  forms — hronclio-pul- 
monary  hwmorrhage,  sometimes  called  bronchorrhagia,  in  which  the  blood 
is  poured  out  into  the  bronchi  and  is  expectorated,  and  pulmonary  apo- 
plexy or  pneumorrhagia,  in  which  the  hemorrhage  takes  place  into  the 
air-cells  and  the  lung  tissue. 

1.  Broncho-pulmonary  Hcemorrhage;  Hcemoptysis. — Spitting  of  blood, 
to  which  the  term  haemoptysis  should  be  restricted,  results  from  a  variety 
of  conditions,  among  which  the  following  are  the  most  important:  (a)  In 
young  healthy  persons  haemoptysis  may  occur  without  warning,  and  after 
continuing  for  a  few  days  disappear  and  leave  no  ill  traces.  There  may 
be  at  the  time  of  the  attack  no  physical  signs  indicating  pulmonary  disease. 
In  such  cases  good  health  may  be  preserved  for  years  and  no  further 
trouble  occur.  These  cases  are  not  very  uncommon.  In  Ware's  impor- 
tant contribution  to  this  subject,*  of  386  cases  of  haemoptysis  noted  in 
private  practice  62  recovered  and  pulmonary  disease  did  not  subsequently 
develop  in  them.  I  know  three  professional  men  who  had  haemoptysis  as 
students,  and  who  now,  at  periods  of  from  fifteen  to  eighteen  years  subse- 
quently, remain  in  perfect  health,  (h)  Haemoptysis  in  pulmonary  tubercu- 
losis, which  is  considered  in  pages  302-304.  (c)  In  connection  with  cer- 
tain diseases  of  the  lung,  as  pneumonia  (in  the  initial  stage)  and  cancer, 
occasionally  in  gangrene,  abscess,  and  bronchiectasis,  haemoptysis  occurs. 
(d)  Haemoptysis  is  met  with  in  many  heart  affections,  particularly  mitral 
lesions.  It  may  be  profuse  and  recur  at  intervals  for  years,  (e)  In  ulcera- 
tive affections  of  the  larynx,  trachea,  or  bronchi.  Sometimes  the  haemor- 
rhage is  profuse  and  rapidly  fatal,  as  when  an  ulcer  erodes  a  large  branch 
of  the  pulmonary  artery,  an  accident  which  I  have  known  to  happen  in 
a  case  of  chronic  bronchitis  with  emphysema,  (f)  Aneurism  is  an  occa- 
sional cause  of  haemoptysis.  It  may  be  sudden  and  rapidly  fatal  when  the 
sac  bursts  into  the  air-passages.  Slight  bleeding  may  continue  for  weeks  or 
even  longer,  due  to  pressure  on  the  mucous  membrane  or  erosion  of  the  lung; 
or  in  some  cases  the  sac  "  weeps  "  through  the  exposed  laminae  of  fibrin. 
(g)  Vicarious  haemorrhage,  which  occurs  in  rare  instances  in  cases  of  inter- 
rupted menstruation.  The  instances  are  well  authenticated.  Flint  men- 
tions a  case  which  he  had  had  under  observation  for  four  years,  and  Hip- 
pocrates refers  to  it  in  the  aphorism,  "  Haemoptysis  in  a  woman  is  removed 
by  an  eruption  of  the  menses."  Periodical  haemoptysis  has  also  been  met 
with  after  the  removal  of  both  ovaries.     Even  fatal  haemorrhage  has  oc- 

*  On  Haemoptysis  as  a  Symptom,  by  John  Ware,  M.  D. 


038  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

curred  from  the  lung  during  menstruation  when  no  lesion  was  found  to 
acount  for  it.  (h)  There  is  a  form  of  recurring  haemoptysis  in  arthritic 
subjects  to  which  Sir  Andrew  Clark  has  called  special  attention  and  which 
also  is  described  by  French  writers.  The  cases  occur  in  persons  over  fifty 
years  of  age  who  usually  present  signs  of  the  arthritic  diathesis.  It  rarely 
leads  to  fatal  issue  and  subsides  without  inducing  pulmonary  changes,  (t) 
Hgemoptysis  recurs  sometimes  in  malignant  fevers  and  in  purpura  hemor- 
rhagica. Lastly,  there  is  endemic  hsemoptysis,  due  to  the  Distomum  ivester- 
manni  in  the  bronchial  tubes,  an  affection  which  is  confined  to  parts  of 
China  and  Japan. 

Symptoms. — Hgemoptysis  sets  in  as  a  rule  suddenly.  Often  with- 
out warning  the  patient  experiences  a  warm,  saltish  taste  as  the  mouth 
fills  with  blood.  Coughing  is  usually  induced.  There  may  be  only  an 
ounce  or  so  brought  up  before  the  haemorrhage  stops,  or  the  bleeding  may 
continue  for  days,  the  patient  bringing  up  small  quantities.  In  other  in- 
stances, particularly  when  a  large  vessel  is  eroded  or  an  aneurism  bursts, 
the  amount  is  large,  and  the  patient  after  a  few  attempts  at  coughing  shows 
signs  of  suffocation  and  death  is  produced  by  inundation  of  the  bronchial 
system.  Fatal  haemorrhage  may  even  occur  into  a  large  cavity  in  a  patient 
debilitated  by  phthisis  without  the  production  of  haemoptysis.  I  dissected 
a  case  of  this  kind  at  the  Philadelphia  Hospital.  The  blood  from  the  lungs 
generally  has  characters  which  render  it  readily  distinguishable  from  the 
blood  which  is  vomited.  It  is  alkaline  in  reaction,  frothy,  and  mixed  with 
mucus,  and  when  coagulation  occurs  air-bubbles  are  present  in  the  clot. 
Blood-moulds  of  the  smaller  bronchi  are  sometimes  seen.  Pati-ents  can 
usually  tell  whether  the  blood  has  been  brought  up  by  coughing  or  by 
vomiting,  and  in  a  majority  of  cases  the  history  gives  important  indica- 
tions. In  paroxysmal  hemoptysis  connected  with  menstrual  disturbances 
the  practitioner  should  see  that  the  blood  is  actually  coughed  up,  since  de- 
ception may  be  practised.  The  spurious  haemoptysis  of  hysteria  is  consid- 
ered with  that  disease.  Naturally,  the  patient  is  at  first  alarmed  at  the 
occurrence  of  bleeding,  but,  unless  very  profuse,  as  when  due  to  rupture 
of  an  aortic  aneurism  in  a  pulmonary  cavity,  the  danger  is  rarely  immedi- 
ate. The  attacks,  however,  are  apt  to  recur  for  a  few  days  and  the  sputa 
may  remain  blood-tinged  for  a  longer  period.  In  the  great  majority  of 
cases  the  haemorrhage  ceases  spontaneously.  It  should  be  remembered 
that  some  of  the  blood  may  be  swallowed  and  produce  vomiting,  and, 
after  a  day  or  two,  the  stools  may  be  dark  in  color.  It  is  not  well  during 
an  attack  of  haemoptysis  to  examine  the  chest.  It  was  formerly  thought 
that  haemorrhage  exercised  a  prejudicial  effect  and  excited  inflammation 
of  the  lungs,  but  this  is  not  often  the  case. 

(2)  Pulmonary  Apoplexy;  Hcemorrhagic  Infarct. — In  this  condition 
the  blood  is  effused  into  the  air-cells  and  interstitial  tissue.  It  is  rarely 
indeed  diffuse,  the  parenchyma  being  broken,  as  is  the  brain  tissue  in 
cerebral  apoplexy.  Sometimes,  in  disease  of  the  brain,  in  septic  condi- 
tions, and  in  the  malignant  forms  of  fevers,  the  lung  tissue  is  uniformly 
infiltrated  with  blood  and  has,  on  section,  a  black,  gelatinous  appearance. 

As  a  rule,  the  haemorrhage  is  limited  and  results  from  the  blocking  of 


CIRCULATORY  DISTURBANCES  IN  THE  LUNGS.  639 

a  branch  of  the  pulmonary  artery  either  by  a  thrombus  or  an  embolus. 
The  condition  is  most  common  in  chronic  heart-disease.  Although  the 
pulmonary  arteries  are  terminal  ones,  blocking  is  not  always  followed  by 
infarction;  partly  because  the  wide  capillaries  furnish  sufficient  anasto- 
mosis, and  partly  because  the  bronchial  vessels  may  keep  up  the  circula- 
tion. The  infarctions  are  chiefly  at  the  periphery  of  the  lung,  usually 
wedge-shaped,  with  the  base  of  the  wedge  toward  the  surface.  When  re- 
cent, they  are  dark  in  color,  hard  and  firm,  and  look  on  section  like  an 
ordinary  blood-clot.  Gradual  changes  go  on,  and  the  color  becomes  a 
reddish  brown.  The  pleura  over  an  infarct  is  usually  inflamed.  A  mi- 
croscopical section  shows  the  air-cells  to  be  distended  with  red  blood-cor- 
puscles, which  may  also  be  in  the  alveolar  walls.  The  infarcts  are  usually 
multiple  and  vary  in  size  from  a  walnut  to  an  orange.  Very  large  ones 
may  involve  the  greater  part  of  a  lobe.  In  the  artery  passing  to  the 
affected  territory  a  thrombus  or  an  embolus  is  found.  The  globular 
thrombi,  formed  in  the  right  auricular  appendix,  play  an  important  part 
in  the  production  of  hgemorrhagic  infarction.  In  many  cases  the  source 
of  the  embolus  cannot  be  discovered,  and  the  infarct  may  have  resulted 
from  thrombosis  in  the  pulmonary  artery,  but,  as  before  mentioned,  it  is 
not  infrequent  to  find  total  obstruction  of  a  large  branch  of  a  pulmonary 
artery  without  .hsemorrhage  into  the  corresponding  lung  area.  The  fur- 
ther history  of  an  infarction  is  variable.  It  is  possible  that  in  some  in- 
stances the  circulation  is  re-established  and  the  blood  removed.  More 
commonly,  if  the  patient  lives,  the  usual  changes  go  on  in  the  extravasated 
blood  and  ultimately  a  pigmented,  puckered,  fibroid  patch  results.  Slough- 
ing may  occur  with  the  formation  of  a  cavity.  Occasionally  gangrene 
results.  In  a  case  at  the  University  Hospital,  Philadelphia,  a  gangrenous 
infarct  ruptured  and  produced  fatal  pneumothorax. 

The  symptoms  of  pulmonary  apoplexy  are  by  no  means  definite.  The 
condition  may  be  suspected  in  chronic  heart-disease  when  haemoptysis 
occurs,  particularly  in  mitral  stenosis,  but  the  bleeding  may  be  due  to  the 
extreme  engorgement.  When  the  infarcts  are  very  large,  and  particularly 
in  the  lower  lobe,  in  which  they  most  commonly  occur,  there  may  be  signs 
of  consolidation  Avith  blowing  breathing. 

Treatment  of  Pulmonary  Haemorrhage. — The  pressure  with- 
in the  pulmonary  artery  is  considerably  less  than  that  in  the  aortic  system. 
The  system  is  under  vaso-motor  control,  but  our  knowledge  of  the  mutual 
relations  of  pressure  in  the  aorta  and  in  the  pulmonary  artery,  under  vary- 
ing conditions,  is  still  very  imperfect  (Bradford).  There  may  be  an  influ- 
ence on  the  systemic  blood-pressure  without  any  on  the  pulmonary,  and  the 
pressure  in  the  one  may  rise  while  it  falls  in  the  other,  or  it  may  rise  and 
fall  in  both  together.  The  researches  of  Brodie  and  Dixon  indicate  that 
drugs  which  raise  the  peripheral  blood-pressure  by  vaso-constriction  in- 
crease the  total  blood  in  the  lung.  In  Andrew's  Harveian  Oration  these 
relations  are  thoroughly  described,  and  a  statement  is  made,  based  on  Brad- 
ford's experiments,  as  to  the  action  on  the  pulmonary  blood-pressure  of 
many  of  the  drugs  employed  in  haemoptysis.  Thus  ergot,  the  remedy 
40 


640  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

perhaps  most  commonly  used,  causes  a  distinct  rise  in  the  pulmonary 
blood-pressurC;,  while  aconite  produces  a  definite  fall. 

The  anatomical  condition  in  hsemoptysis  is  either  hypersemia  of  the 
bronchial  mucosa  (or  of  the  lung  tissue)  or  a  perforated  vessel.  In  the 
latter  case  the  patient  often  passes  rapidly  beyond  treatment,  though  there 
are  instances  of  the  most  profuse  haemorrhage,  which  must  have  come  from 
a  perforated  artery  or  a  ruptured  aneurism,  in  which  recovery  has  occurred. 
Practically,  for  treatment,  we  should  separate  these  cases,  as  the  remedies 
which  would  be  applicable  in  a  case  of  congested  and  bleeding  mucosa 
would  be  as  much  out  of  place  in  a  case  of  hemorrhage  from  ruptured 
aneurism  as  in  a  cut  radial  artery.  When  the  blood  is  brought  up  in  large 
quantities,  it  is  almost  certain  either  that  an  aneurism  has  ruptured  or  a 
vessel  has  been  eroded.  In  the  instances  in  which  the  sputa  are  blood- 
tinged  or  when  the  blood  is  in  smaller  quantities,  bleeding  comes  by 
diapedesis  from  hypersemic  vessels.  In  such  cases  the  haemorrhage  may  be 
beneficial  in  relieving  the  congested  blood-vessels. 

.  The  indications  are  to  reduce  the  frequency  of  the  heart-beats  and  to 
lower  the  blood-pressure.  Eest  of  the  body  and  peace  of  the  mind — "  quies, 
securitas,  silentium"  of  Celsus — should  be  secured.  Turn  the  patient  on 
the  affected  side,  if  known,  as  the  regurgitation  is  less  apt  to  occur  into 
the  bronchi  of  the  sound  lung.  As  Aretseus  remarks,  in. haemoptysis  the 
patient  despairs  from  the  first,  and  needs  to  be  strongly  reassured.  Death 
is  rarely  due  directly  to  haemoptysis;  patients  die  after,  not  of  it  (S.  West), 
In  the  majority  of  cases  of  mild  haemoptysis  this  is  sufficient.  Even 
when  the  patient  insists  upon  going  about,  the  bleeding  may  stop  spon- 
taneously. The  diet  should  be  light  and  unstimulating.  Alcohol  should 
not  be  used.  The  patient  may,  if  he  wishes,  have  ice  to  suck.  Small 
doses  of  aromatic  sulphuric  acid  may  be  given,  but  unless  the  bleeding 
is  protracted  styptic  and  astringent  medicines  are  not  indicated.  For 
cough,  which  is  always  present  and  disturbing,  opium  should  be  freely 
given,  and  is  of  all  medicines  most  serviceable  in  haemoptysis.  Digitalis 
should  not  be  used,  as  it  raises  the  blood-pressure  in  the  pulmonary  artery. 
Aconite,  as  it  lowers  the  pressure,  may  be  used  when  there  is  much  vascu- 
lar excitement.  Ergot,  tannic  acid,  and  lead,  which  are  so  much  em- 
ployed, have  little  or  no  influence  in  hsemoptysis;  ergot  probably  does  harm. 
One  of  the  most  satisfactory  means  of  lowering  the  blood-pressure  is  purga- 
tion, and  when  the  bleeding  is  protracted  salts  may  be  freely  given.  In 
profuse  haemoptysis,  such  as  comes  from  erosion  of  an  artery  or  the  rup- 
ture of  an  aneurism,  a  -fatal  result  is  common,  and  yet  post-mortem  evi- 
dence shows  that  thrombosis  may  occur  with  healing  in  a  rupture  of  con- 
siderable size.  The  fainting  induced  by  the  loss  of  blood  is  probably  the 
most  efficient  means  of  promoting  thrombosis,  and  it  was  on  this  principle 
that  formerly  patients  were  bled  from  the  arm,  or  from  both  arms,  as  in 
the  case  of  Laurence  Sterne.  Ligatures,  or  Esmarch's  bandages,  placed 
around  the  legs  may  serve  temporarily  to  cheek  the  bleeding.  The  ice^ 
bag  on  the  sternum  is  of  doubtful  utility.  In  a  protracted  case  Cayley  in- 
duced pneumothorax,  but  without  effect. 

Briefly,  then,  Ave  may  say  that  cases  of  haemorrhage  from  rupture  of 
aneurism  or  erosion  of  a  blood-vessel  usually  prove  fatal.     The  fainting 


BRONOHO-PNEUMONIA.  641 

induced  by  the  loss  of  blood  is  beneficial,  and,  if  the  patient  can  be  kept 
alive  for  twenty-four  hours,  a  thrombus  of  sufficient  strength  to  prevent 
further  bleeding  may  form.  The  chief  danger  is  the  inundation  of  the 
bronchial  system  with  the  blood,  so  that  while  the  hsemorrhage  is  profuse 
the  cough  should  be  encouraged.  Opium  should  not  then  be  used,  and 
stimulants  should  be  given  with  caution. 

In  the  other  group,  in  which  the  haemorrhage  comes  from  a  congested 
area  and  is  limited,  the  patient  gets  well  if  kept  absolutely  quiet,  and 
fatal  haemorrhage  probably  never  occurs  from  this  source.  Rest,  reduc- 
tion of  the  blood-pressure  by  minimum  diet,  purging,  if  necessary,  and  the 
administration  of  opium  to  allay  the  cough  are  the  main  indications. 


II.    BRONCHO-PNEUMONIA    {Capillary  Bronchitis). 

This  is  essentially  an  inflammation  of  the  terminal  bronchus  and  the 
air-vesicles  which  make  up  a  pulmonary  lobule,  whence  the  term  broncho- 
pneumonia. It  is  also  known  as  lobular,  in  contradistinction  to  lobar  pneu- 
monia. The  term  catarrhal  is  less  applicable.  The  process  begins  usually 
with  an  inflammation  of  the  capillary  bronchi,  which  is  a  condition  rarely, 
if  ever,  found  without  involvement  of  the  lobular  structures,  so  that  it  is 
now  customary  to  consider  the  affections  together.  All  forms  of  broncho- 
pneumonia depend  upon  invasion  of  the  lung  with  microbes,  and  it  would 
have  been  more  consistent  to  place  them  with  lobar  pneumonia  among  the 
infectious  disorders,  but  it  is  well  perhaps  to  defer  this  until  the  bacteri- 
ology of  the  different  varieties  has  been  more  fully  worked  out. 

Etiology. — Broncho-pneumonia  occurs  either  as  a  primary  or  as  a  sec- 
ondary afliection.  The  relative  frequency  in  443  cases  is  thus  given  by 
Holt:  Primar}'-,  without  previous  bronchitis,  154;  secondary  (a)  to  bron- 
chitis of  larger  tubes,  41;  to  measles,  89;  to  whooping-cough,  QQ;  to  diph- 
theria, 47;  to  scarlet  fever,  7;  to  influenza,  6;  to  varicella,  3;  to  erysipelas, 
2;  and  to  acute  ileo-colitis,  19.  The  proportion  of  primary  to  secondary 
forms  as  shown  in  this  list  is  probably  too  low. 

Primary  acute  broncho-pneumonia,  like  the  lobar  form,  attacks  children 
in  good  health,  usually  under  two  years.  The  etiological  factors  are  very 
much  those  of  ordinary  pneumonia,  and  probably  the  pneumococcus  is  more 
often  associated  with  it. 

Secondary  broncho-pneumonia  occurs  in  two  great  groups:  1.  As  a  se- 
quence of  the  infectious  fevers — measles,  diphtheria,  whooping-cough,  scar- 
let fever,  and,  less  frequently,  small-pox,  erysipelas,  and  typhoid  fever.  In 
children  it  forms  the  most  serious  complication  of  these  diseases,  and  in 
reality  causes  more  deaths  than  are  due  directly  to  the  fevers.  In  large 
cities  it  ranks  next  in  fatality  to  infantile  diarrhoea.  Following,  as  it  does, 
the  contagious  diseases  which  principally  affect  children,  we  find  that  a 
large  majority  of  cases  occur  during  early  life.  According  to  Morrill's  Bos- 
ton statistics,  it  is  most  fatal  during  the  first  two  years  of  life.  The  number 
of  cases  in  a  community  increases  or  decreases  with  the  prevalence  of 
measles,  scarlet  fever,  and  diphtheria.     It  is  most  prevalent  in  the  winter 


642  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

and  spring  months.  In  the  febrile  affections  of  adults  broncho-pneumonia 
is  not  very  common.  Thus  in  typhoid  fever  it  is  not  so  frequent  as  lobar 
pneumonia^  though  isolated  areas  of  consolidation  at  the  bases  are  by  no 
means  rare  in  protracted  cases  of  this  disease.  In  old  people  it  is  an  ex- 
tremely common  affection,  following  debilitating  causes  of  any  sort,  and 
supervening  in  the  course  of  chronic  Bright's  disease  and  various  acute  and 
chronic  maladies. 

2.  In  the  second  division  of  this  affection  are  embraced  the  cases  of 
so-called  aspiration  or  deglutition  pneumonia.  Whenever  the  sensitiveness 
of  the  larynx  is  benumbed,  as  in  the  coma  of  apoplexy  or  urgemia,  minute 
particles  of  food  or  drink  are  allowed  to  pass  the  rima,  and,  reaching  finally 
the  smaller  tubes,  excite  an  intense  inflammation  similar  to  the  vagus  pneu- 
monia which  follows  the  section  of  the  pneumogastrics  in  the  dog.  Cases 
are  very  common  after  operations  about  the  mouth  and  nose,  after  tracheot- 
omy, and  in  cancer  of  the  larynx  and  oesophagus.  The  aspirated  particles 
in  some  instances  induce  such  an  intense  broncho-pneumonia  that  suppura- 
tion or  even  gangrene  supervenes.  The  ether  pneumonia,  already  described 
(p.  129),  is  often  lobular  in  type. 

An  aspiration  broncho-pneumonia  may  follow  haemoptysis  (which  has 
been  already  considered),  the  aspiration  of  material  from  a  bronchiec- 
tatic  cavity,  and  occasionally  the  material  from  an  empyema  which  has 
ruptured  into  the  lung. 

A  common  and  fatal  form  of  broncho-pneumonia  is  that  excited  by  the 
tubercle  bacillus,  which  has  already  been  considered. 

Among  general  predisposing  causes  may  be  mentioned  age.  As  just 
noted,  it  is  prone  to  attack  infants,  and  a  majority  of  cases  of  pneumonia 
in  children  under  five  years  of  age  are  of  this  form.  Of  370  cases  in  chil- 
dren under  five  years  of  age,  75  per  cent  were  broncho-pneumonia  (Holt).  At 
the  opposite  extreme  of  life  it  is  also  common,  in  association  with  various  de- 
bilitating circumstances  and  with  the  chronic  diseases  incident  to  the  old. 
In  children,  rickets  and  diarrhoea  are  marked  predisposing  causes,  and  bron- 
cho-pneumonia is  one  of  the  most  frequent  post-mortem-room  lesions  in 
infants'  homes  and  foundling  asylums.  The  disease  prevails  most  exten- 
sively among  the  poorer  classes. 

Morbid  Anatomy. — On  the  pleural  surfaces,  particularly  toward  the 
base,  are  seen  depressed  bluish  or  blue-brown  areas  of  collapse,  between 
which  the  lung  tissue  is  of  a  lighter  color.  Here  and  there  are  projecting 
portions  over  which  the  pleura  may  be  slightly  turbid  or  granular.  The 
lung  is  fuller  and  firmer  than  normal,  and,  though  in  great  part  crepitant, 
there  can  be  felt  in  places  throughout  the  substance  solid,  nodular  bodies. 
The  dark  depressed  areas  may  be  isolated  or  a  large  section  of  one  lobe  may 
be  in  the  condition  of  collapse  or  atelectasis.  Gradual  inflation  by  a  blow- 
pipe inserted  in  the  bronchus  will  distend  a  great  majority  of  these  col- 
lapsed areas.  On  section,  the  general  surface  has  a  dark  reddish  color  and 
usually  drips  blood.  Projecting  above  the  level  of  the  section  are  lighter 
red  or  reddish-gray  areas  representing  the  patches  of  broncho-pneumonia. 
These  may  be  isolated  and  separated  from  each  other  by  tracts  of  unin- 
flamed  tissue  or  they  may  be  in  groups;  or  the  greater  part  of  a  lobe  may 


BRONCHO-PNEUMONIA.  643 

be  involved.  Study  of  a  favorable  section  of  an  isolated  patch  shows:  (a) 
A  dilated  central  bronchiole  full  of  tenacious  purulent  mucus.  A  fortu- 
nate section  parallel  to  the  long  axis  may  show  a  racemose  arrangement — 
the  alveolar  passages  full  of  muco-pus.  (&)  Surrounding  the  bronchus  for 
from  3  to  5  mm.  or  even  more,  an  area  of  grayish-red  consolidation,  usu- 
ally elevated  above  the  surface  and  firm  to  the  touch.  Unlike  the  con- 
solidation of  lobar  pneumonia,  it  may  present  a  perfectly  smooth  surface, 
though  in  some  instances  it  is  distinctly  granular.  In  a  late  stage  of  the 
disease  small  grayish-white  points  may  be  seen,  which  on  pressure  may  be 
squeezed  out  as  purulent  droplets.  A  section  in  the  axis  of  the  lobule  may 
present  a  somewhat  grape-like  arrangement,  the  stalks  and  stems  repre- 
senting the  bronchioles  and  alveolar  passages  filled  with  a  yellowish  or 
grayish-white  pus,  while  surrounding  them  is  a  reddish-brown  hepatized 
tissue,  (c)  In  the  immediate  neighborhood  of  this  peribronchial  inflam- 
mation the  tissue  is  dark  in  color,  smooth,  airless,  at  a  somewhat  lower 
level  than  the  hepatized  portion,  and  differs  distinctly  in  color  and  ap- 
pearance from  the  other  portions  of  the  lung.  This  is  the  condition  to 
which  the  term  splenization  has  been  given.  It  really  represents  a  tissue 
in  the  early  stage  of  inflammation,  and  it  perhaps  would  be  as  well  to  give 
up  the  use  of  this  term  and  also  that  of  carnification,  which  is  only  a  more 
advanced  stage.  The  condition  of  collapse  probably  always  precedes  this, 
and  it  is  difiicult  in  some  instances  to  tell  the  diflerence,  as  one  shades  into 
the  other.  In  fact,  collapse,  splenization,  and  carnification  are  but  prelim- 
inary steps  in  broncho-pneumonia. 

While,  in  many  cases,  the  areas  of  broncho-pneumonia  present  a  red- 
dish-brown color  and  are  indistinctly  granular,  in  others,  particularly  in 
adults,  the  nodules  may  resemble  more  closely  gray  hepatization  and  the 
air-cells  are  filled  with  a  grayish,  muco-purulent  material.  Minute  hasm- 
orrhages  are  sometimes  seen  in  the  neighborhood  of  the  inflamed  areas  or 
on  the  pleural  surfaces.  Emphysema  is  commonly  seen  at  the  anterior 
borders  and  upper  portions  of  the  lung  or  in  lobules  adjacent  to  the  in- 
flamed ones.  In  many  cases  following  diphtheria  and  measles  the  process 
is  so  extensive  that  the  greater  part  of  a  lobe  is  involved,  and  it  looks  like 
a  case  of  lobar  hepatization.  It  has  not,  however,  the  uniformity  of  this 
affection,  and  collapsed  dark  strands  may  be  seen  between  extensive  areas 
of  hepatized  tissue. 

There  are  three  groups  of  cases:  (1)  Those  in  which  the  bronchitis  and 
bronchiolitis  are  most  marked,  and  in  which  there  may  be  no  definite  con- 
solidation, and  yet  on  microscopical  examination  many  of  the  alveolar  pas- 
sages and  adjacent  air-cells  appear  filled  with  inflammatory  products.  (2) 
The  disseminated  broncho-pneumonia,  in  which  there  are  scattered  areas 
of  peribronchial  hepatization  with  patches  of  collapse,  while  a  considerable 
proportion  of  the  lobe  is  still  crepitant.  This  is  by  far  the  most  common 
condition.  (3)  The  pseudo-lobar  form,  in  which  the  greater  portion  of  the 
lobe  is  consolidated,  but  not  uniformly,  for  intervening  strands  of  dark 
congested  lung  tissue  separate  the  groups  of  hepatized  lobules. 

Microscopically,  the  centre  of  the  bronchus  is  seen  filled  with  a  plug 
of  exudation,  consisting  of  leucocytes  and  swollen  epithelium.     Section  in 


644  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  long  axis  may  show  irregular  dilatations  of  the  tube.  The  hronchial 
wall  is  swollen  and  infiltrated  with  cells.  Under  a  low  power  it  is  readily 
seen  that  the  air-cells  next  the  bronchus  are  most  densely  filled,  while 
toward  the  periphery  of  the  focus  the  alveolar  exudation  becomes  less.  The 
contents  of  the  air-cells  are  made  up  of  leucocytes  and  swollen  endothelial 
cells  in  varying  proportions.  Eed  corpuscles  are  not  often  present  and  a 
fibrin  network  is  rarely  seen,  though  it  may  be  present  in  some  alveoli.  In 
the  swollen  walls  are  seen  distended  capillaries  and  numerous  leucocytes. 
As  Delafield  has  pointed  out,  the  interstitial  inflammation  of  the  bronchi 
and  alveolar  walls  is  the  special  feature  of  broncho-pneumonia. 

The  histological  changes  in  the  aspiration  or  deglutition  broncho-pneu- 
monia differ  from  the  ordinary  post-febrile  form  in  a  more  intense  infiltra- 
tion of  the  air-cells  with  leucocytes,  producing  suppuration  and  foci  of 
softening;  even  gangrene  may  be  present. 

Bacteriology  of  Broncho-pnewmonia. — The  organisms  most  commonly 
found  in  broncho-pneumonia  are  the  micrococcus  lanceolatus,  the  strepto- 
coccus pyogenes  (either  alone  or  with  the  pneumococcus),  the  staphylococcus 
aureus  et  albus,  and  Friedlander's  iacillus  pneumonioe.  The  Klebs- 
Loeffler  bacillus  is  not  infrequently  found  in  the  secondary  lesions  of 
diphtheria.  Except  the  pneumococcus  these  microbes  are  rarely  found  in 
pure  cultures.  In  the  lobular  type  the  streptococcus  is  the  most  constant 
organism,  in  the  pseudo-lobar  the  pneumococcus.  Mixed  infections  are  al- 
most the  rule  in  broncho-pneumonia. 

M.  Wollstein,  in  17  primary  cases,  found  the  micrococcus  lanceolatus 
alone  in  9,  with  the  streptococcus  in  7.  Of  14  secondary  cases  the  micro- 
coccus lanceolatus  was  found  alone  in  2  and  with  other  organisms  in  9.  The 
primary  form  is  the  result  of  infection  with  the  pneumococcus,  the  sec- 
ondary most  often  with  the  streptococcus. 

Terminations  of  Broncho-pneumonia. — (1)  In  resolution,  which  when  it 
once  begins  goes  on  more  rapidly  than  in  fibrinous  pneumonia.  Broncho- 
pneumonia of  the  apices,  in  a  child,  persisting  for  three  or  more  weeks, 
particularly  if  it  follows  measles  or  diphtheria,  is  often  tuberculous.  In 
these  instances,  when  resolution  is  supposed  to  be  delayed,  caseation  has  in 
reality  taken  place.  (2)  In  suppuration,  which  is  rarely  seen  apart  from 
the  aspiration  and  deglutition  forms,  in  which  it  is  extremely  common.  (3) 
In  gangrene,  which  occurs  under  the  same  conditions.  (4)  In  fibroid 
changes — chronic  Ironcho-pneumonia — a  rare  termination  in  the  simple,  a 
common  sequence  of  the  tuberculous,  disease.  Formerly  it  was  thought 
that  one  of  the  most  common  changes  in  broncho-pneumonia,  particularly 
in  children,  was  caseation;  but  this  is  really  a  tuberculous  process,  the 
natural  termination  of  an  originally  specific  broncho-pneumonia.  It  is  of 
course  quite  possible  that  a  broncho-pneumonia,  simple  in  its  origin,  may 
subsequently  be  the  seat  of  infection  by  the  bacillus  tuberculosis. 

Symptoms. — The  primary  form  sets  in  abruptly  with  a  chill  or  a  con- 
vulsion. The  child  has  not  had  a  previous  illness,  but  there  may  have  been 
slight  exposure.  The  temperature  rises  rapidly  and  is  more  constant;  the 
physical  signs  are  more  local  and  there  is  not  the  widespread  diffuse  catarrh 
of  the  smaller  tubes.     Many  cases  are  mistaken  for  lobar  pneumonia.     In 


BRONCHO-PNEUMONIA.  645 

others  the  pulmonary  features  are  in  the  background  or  are  overlooked  in 
the  intensity  of  the  general  or  cerebral  symptoms.  The  termination  is  often 
by  crisis,  and  the  recovery  is  prompt.  The  mortality  of  this  form  is  slight. 
S.  West  has  recently  (British  Medical  Journal,  1898,  i)  called  attention  to 
the  importance  of  recognizing  these  primary  cases  and  to  their  resemblance 
in  clinical  features  with  acute  lobar  pneumonia.  The  secondary  form  begins 
usually  as  a  bronchitis  of  the  smaller  tubes.  Much  confusion  has  arisen 
from  the  description  of  capillary  bronchitis  as  a  separate  affection,  whereas 
it  is  only  a  part,  though  a  primary  and  important  one,  of  broncho-pneu- 
monia. At  the  outset  it  may  be  said  that  if  in  convalescence  from  measles 
or  in  whooping-cough  a  child  has  an  accession  of  fever  with  cough,  rapid 
pulse,  and  rapid  breathing,  and  if,  on  auscultation,  fine  rales  are  heard  at 
the  bases,  or  widely  spread  throughout  the  lungs,  even  though  neither  con- 
solidation nor  blowing  breathing  can  be  detected,  the  diagnosis  of  broncho- 
pneumonia may  safely  be  made.  I  have  never  seen  in  a  fatal  case  after 
diphtheria  or  measles  a  capillary  bronchitis  as  the  sole  lesion.  The  onset 
is  rarely  sudden,  or  with  a  distinct  chill;  but  after  a  day  or  so  of  indispo- 
sition the  child  gets  feverish  and  begins  to  cough  and  to  get  short  of  breath. 
The  fever  is  extremely  variable;  a  range  of  from  102°  to  104°  is  common. 
The  skin  is  very  drj^  and  pungent.  The  cough  is  hard,  distressing,  and 
may  be  painful.  Dyspnoea  gradually  becomes  a  prominent  feature.  Ex- 
piration may  be  jerky  and  grunting.  The  respirations  may  rise  as  high 
as  60  or  even  80  per  minute.  Within  the  first  forty-eight  hours  the  per- 
cussion resonance  is  not  impaired;  the  note,  indeed,  may  be  very  full  at  the 
anterior  borders  of  the  lungs.  On  auscultation,  many  rales  are  heard, 
chiefly  the  fine  subcrepitant  variety,  with  sibilant  rhonchi.  There  may 
really  be  no  signs  indicating  that  the  parenchyma  of  the  lung  is  involved, 
and  yet  even  at  this  early  stage,  within  forty-eight  hours  of  the  onset  of  the 
pulmonary  symptoms,  I  have  repeatedly,  after  diphtheria,  found  scattered 
nodules  of  lobular  hepatization.  Korthrup,  in  a  case  in  which  death  oc- 
curred within  the  first  twenty-four  hours,  in  addition  to  the  extensive  in- 
volvement of  the  smaller  bronchi,  found  the  intralobular  tissue  also  in- 
volved in  places.  The  dyspnoea  is  constant  and  progressive  and  soon  signs 
of  deficient  aeration  of  the  blood  are  noted.  The  face  becomes  a  little  suf- 
fused and  the  finger-tips  bluish.  The  child  has  an  anxious  expression  and 
gradually  enters  upon  the  most  distressing  stage  of  asphyxia.  At  first  the 
urgency  of  the  symptoms  is  marked,  but  soon  the  benumbing  influence  of 
the  carbon  dioxide  on  the  nerve-centres  is  seen  and  the  child  no  longer  makes 
strenuous  efforts  to  breathe.  The  cough  subsides  and,  with  a  gradual  in- 
crease in  lividity  and  a  drowsy  restlessness,  the  right  ventricle  becomes  more 
and  more  distended,  the  bronchial  rales  become  more  liquid  as  the  tabes 
fill  with  mucus,  and  death  occurs  from  heart  paralysis.  These  are  symp- 
toms of  a  severe  case  of  broncho-pneumonia,  or  what  the  older  writers  called 
suffocative  catarrh. 

The  physical  signs  may  at  first  be  those  of  capillary  bronchitis,  as  in- 
dicated by  the  absence  of  dulness,  the  presence  of  fine  subcrepitant  and 
whistling  rales.  In  many  cases  death  takes  place  before  any  definite  pneu- 
monic signs  are  detected.     When  these  exist  they  are  much  more  frequent 


646  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

at  the  bases,  where  there  may  be  areas  of  impaired  resonance  or  even  of 
positive  dulness.  When  numerous  foci  involve  the  greater  part  of  a  lobe 
the  breathing  may  become  tubular,  but  in  the  scattered  patches  of  ordi- 
nary broncho-pneumonia,  following  the  fevers,  the  breathing  is  more  com- 
monly harsh  than  blowing.  In  grave  cases  there  is  retraction  of  the  base 
of  th€  sternum  and  of  the  lower  costal  cartilages  during  inspiration,  point- 
ing to  deficient  lung  expansion. 

Diagnosis. — With  lobar  pneumonia  it  may  readily  be  confounded  if 
the  areas  of  consolidation  are  large  and  merged  together.  It  is  to  be  re- 
membered, as  Holt's  figures  well  show,  that  broncho-pneumonia  occurs 
chiefly  in  children  under  one  year,  whereas  lobar  pneumonia  is  more  common 
after  the  third  year.  No  writer  has  so  clearly  brought  out  the  difference 
between  pneumonia  at  these  periods  as  Gerhard,*  of  Philadelphia,  whose 
papers  on  this  subject,  though  published  nearly  sixty  years  ago,  have  the 
freshness  and  accuracy  which  characterize  all  the  writings  of  that  eminent 
physician.  Between  lobar  pneumonia  and  the  secondary  form  of  broncho- 
pneumonia the  diagnosis  is  easy.  The  mode  of  onset  is  essentially  different 
in  the  two  infections,  the  one  developing  insidiously  in  the  course  or  at  the 
conclusion  of  another  disease,  the  other  setting  in  abruptly  in  a  child  in 
good  health.  In  lobar  pneumonia  the  disease  is  almost  always  unilateral, 
in  broncho-pneumonia  bilateral.  The  chief  trouble  arises  in  cases  of  pri- 
mary broncho-pneumonia,  which  by  aggregation  of  the  foci  involves  the 
greater  part  of  one  lobe.  Here  the  difEiculty  is  very  great,  and  the  physical 
signs  may  be  practically  identical,  but  in  broncho-pneumonia  it  is  much 
more  likely  that  a  lesion,  however  slight,  will  be  found  on  the  other  side. 

A  still  more  difficult  question  to  decide  is  whether  an  existing  broncho- 
pneumonia is  simple  or  tuberculous.  In  many  instances  the  decision  can- 
not be  made,  as  the  circumstances  under  which  the  disease  occurs,  the 
mode  of  onset,  and  the  physical  signs  may  be  identical.  It  has  often  been 
my  experience  that  a  case  has  been  sent  down  from  the  children's  ward  to 
the  dead-house  with  the  diagnosis  of  post-febrile  broncho-pneumonia  in 
which  there  was  no  suspicion  of  the  existence  of  tuberculosis;  but  on  sec- 
tion there  were  found  tuberculous  bronchial  glands  and  scattered  areas  of 
broncho-pneumonia,  some  of  which  were  distinctly  caseous,  while  others 
showed  signs  of  softening.  I  have  already  spoken  fully  of  this  in  the  sec- 
tion on  tuberculosis,  but  it  is  well  to  emphasize  the  fact  that  there  are 
many  cases  of  broncho-pneumonia  in  children  which  time  alone  enables 
us  to  distinguish  from  tuberculosis.  The  existence  of  extensive  disease 
at  the  apices  or  central  regions  is  a  suggestive  indication,  and  signs  of  soft- 
ening may  be  detected.  In  the  vomited  matter,  which  is  brought  up  after 
severe  spells  of  coughing,  sputum  may  be  picked  out  and  elastic  tissue  and 
bacilli  detected. 

It  is  a  superfluous  refinement  to  make  a  diagnosis  between  capillary 
bronchitis  and  catarrhal  pneumonia,  for  the  two  conditions  are  part  and 
parcel  of  the  same  disease.  In  simple  bronchitis  involving  the  larger  tubes 
urgent  dyspnoea  and  pulmonary  distress  are  rarely  present  and  the  rales 


*  American  Journal  of  the  Medical  Sciences,  vols,  xir  and  xt. 


BRONCHO-PNEUMONIA.  647 

are  coarser  and  more  sibilant.  It  must  not  be  forgotten  that,  as  in  lobar 
pneumonia,  cerebral  symptoms  may  mask  the  true  nature  of  the  disease, 
and  may  even  lead  to  the  diagnosis  of  meningitis.  I  recall  more  than  one 
instance  in  which  it  could  not  be  satisfactorily  determined  whether  the 
infant  had  tuberculous  meningitis  or  a  cerebral  complication  of  an  acute 
pulmonary  affection. 

Prognosis. — In  the  primary  form  the  outlook  is  good.  In  children 
enfeebled  by  constitutional  disease  and  prolonged  fevers  broncho-pneumonia 
is  terribly  fatal,  but  in  cases  coming  on  in  connection  with  whooping- 
cough  or  after  measles  recovery  may  take  place  in  the  most  desperate  cases. 
It  is  in  this  disease  that  the  truth  of  the  old  maxim  is  shown — "  Never 
despair  of  a  sick  child.'^  The  death-rate  in  children  under  five  has  been 
variously  estimated  at  from  30  to  50  per  cent.  After  diphtheria  and 
measles  thin,  wiry  children  seem  to  stand  broncho-pneumonia  much  better 
than  fat,  flabby  ones.  In  adults  the  aspiration  or  deglutition  pneumonia 
is  a  very  fatal  disease. 

Prophylaxis. — Much  can  be  done  to  reduce  the  probability  of  attack 
after  febrile  affections.  Thus,  in  the  convalescence  from  measles  and 
whooping-cough,  it  is  very  important  that  the  child  should  not  be  exposed 
to  cold,  particularly  at  night,  when  the  temperature  of  the  room  naturally 
falls.  In  a  nocturnal  visit  to  the  nursery — sometimes,  too,  I  am  sorry  to 
Bay,  to  a  children's  hospital — how  often  one  sees  children  almost  naked, 
having  kicked  aside  the  bedclothes  and  having  the  night-clothes  up  about 
the  arms!  The  use  of  light  flannel  "combinations"  obviates  this  noctur- 
nal chill,  which  is,  I  am  sure,  an  important  factor  in  the  colds  and  pulmo- 
nary affections  of  young  children,  both  in  private  houses  and  in  institu- 
tions. The  catarrhal  troubles  of  the  nose  and  throat  should  be  carefully 
attended  to,  and  during  fevers  the  mouth  should  be  washed  two  or  three 
times  a  day  with  an  antiseptic  solution. 

Treatment. — The  frequency  and  the  seriousness  of  broncho-pneu- 
monia render  it  a  disease  which  taxes  to  the  utmost  the  resources  of  the 
practitioner.  There  is  no  acute  pulmonary  affection  over  which  he  at  times 
so  greatly  despairs.  On  the  other  hand,  there  it  not  one  in  which  he  will 
be  more  gratified  in  saving  cases  which  have  seemed  past  all  succor.  The 
general  arrangements  should  receive  special  attention.  The  room  should 
be  kept  at  an  even  temperature — about  65°  to  68° — and  the  air  should  be 
kept  moist  with  vapor. 

At  the  outset  the  bowels  should  be  opened  by  a  mild  purge,  either 
castor  oil  or  small  doses  of  calomel,  one  twelfth  to  one  sixth  of  a  grain 
hourly  until  a  movement  is  obtained,  and  care  should  be  taken  throughout 
the  attack  to  secure  a  daily  movement.  The  common  saline  fever  mixture 
of  citrate  of  potash,  liquor  amraonii  acetatis,  and  aromatic  spirits  of  am- 
monia may  be  given  every  two  or  three  hours.  If  the  disease  comes  on 
abruptly  with  high  fever,  minim  or  minim  and  a  half  doses  of  the  tincture 
of  aconite  may  be  given  with  it.  The  pain,  the  distressing  symptoms,  and 
the  incessant  cough  often  demand  opium,  which  must  of  course  be  used 
with  care  and  judgment  in  the  case  of  young  children,  but  which  is  cer- 
tainly not  contra-indicated  and  may  be  usefully  given  in  the  form  of 


648  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Dover's  powder.  Blisters  are  now  rarely  if  ever  employed,  and  even  the 
Jacket  poultice  has  gone  out  of  fashion.  For  the  latter,  however,  I  con- 
fess to  a  strong  prejudice,  and  when  lightly  made  and  frequently  changed 
it  undoubtedly  gives  great  relief.  Much  more  commonly  we  now  see, 
both  in  private  and  in  hospital  practice,  the  jacket  of  cotton-batting. 
Ice-poultices  to  the  chest  I  have  seen  used  apparently  with  great  bene- 
fit, and  they  are  warmly  recommended  by  many  German  physicians  as 
well  as  by  Goodhart  and  others  in  England.  The  diet  should  consist 
of  milk,  broths,  and  egg  albumen.  Milk  often  curds  and  is  disagreeable. 
Egg-white  is  particularly  suitable  and  very  acceptable  when  given  in  cold 
water  with  a  little  sugar.  It  forms,  indeed,  an  excellent  medium  for  the  ad- 
ministration of  the  stimulants.  If  the  pulse  shows  signs  of  failing,  it  is  best 
to  begin  early  with  brandy.  As  in  all  febrile  affections  of  children,  cold 
water  should  be  constantly  at  the  bedside,  and  the  child  should  be  encour- 
aged to  drink  freely.  With  these  measures,  in  many  cases  the  disease  pro- 
gresses to  a  favorable  termination,  but  too  often  other  and  more  serious 
symptoms  arise.  Cough  becomes  more  distressing,  dyspnoea  increases,  the 
ominous  rattling  of  the  mucus  can  be  heard  in  the  tubes,  the  child's  color 
is  not  so  good,  and  there  is  greater  restlessness.  Under  these  circum- 
stances stimulant  expectorants — ammonia,  squills,  and  senega — should  be 
given.  Together  they  make  a  very  disagreeable  dose  for  a  young  child, 
particularly  with  the  carbonate  of  ammonia.  The  aromatic  spirits  of  am- 
monia is  somewhat  better.  If  the  carbonate  is  employed,  it  must  be  given 
in  small  doses,  not  more  than  a  grain  to  an  infant  of  eighteen  months.  If 
the  child  has  increasing  difficulty  in  getting  up  the  mucus,  an  emetic 
should  be  given — either  the  wine  of  ipecac  or,  if  necessary,  tartar  emetic. 
There  is  no  necessity,  however,  to  keep  the  child  constantly  nauseated. 
Enough  should  be  given  to  cause  prompt  emesis,  and  the  benefit  results  in 
the  expulsion  of  mucus  from  the  larger  tubes.'  In  this  stage,  too,  strych- 
nine is  undoubtedly  helpful  in  stimulating  the  depressed  respiratory  cen- 
tre. With  commencing  cyanosis,  inhalations  of  oxygen  may  be  employed, 
sometimes  with  great  benefit. 

With  rapid  failure  of  the  heart,  loud  mucous  rattles  in  the  throat,  and 
increasing  lividity,  every  measure  should  be  used  to  arouse  the  child  and 
excite  coughing.  Alternate  douches  of  hot  and  cold  water,  electricity, 
which  I  have  seen  applied  with  good  results  at  Wiederhofer's  clinic  in 
Vienna,  and  hypodermic  injections  of  ether  may  be  tried.  For  the  reduc- 
tion of  temperature,  particularly  if  cerebral  symptoms  are  prominent,  there 
is  nothing  so  satisfactory  as  the  wet  pack  or  the  cold  bath.  In  the  case 
of  children,  when  the  latter  is  used  it  should  be  graduated,  beginning  with 
a  temperature  which  is  pleasantly  warm  and  gradually  reducing  it  to  75° 
or  80°.  Even  when  the  temperature  is  not  high,  the  cerebral  symptoms 
are  greatly  relieved  by  the  bath  or  the  pack. 


CHRONIC   INTERSTITIAL   PNEUMONIA.  649 

III.    CHRONIC    INTERSTITIAL   PNEUMONIA 

{Cirrhosis  of  the  Lung — Fibroid  Phthisis). 

This  consists  in  the  gradual  substitution  to  a  greater  or  less  extent  of 
connective  tissue  for  the  normal  lung.  It  is  a  fibroid  change  which  may 
have  its  starting-point  in  the  tissue  about  the  bronchi  and  blood-vessels, 
the  interlobular  septa,  the  alveolar  walls,  or  in  the  pleura.  So  diverse  are 
the  different  forms  and  so  varied  the  conditions  under  which  this  change 
occurs  that  a  proper  classification  is  extremely  difficult.  We  may  reopg- 
nize,  however,  two  chief  forms — the  local,  which  involves  only  a  limited 
area  of  the  lung  substance,  and  the  diffuse,  invading  either  both  lungs  or 
an  entire  organ. 

Etiology. — Local  fibroid  change  in  the  lungs  is  common.  It  is  a 
constant  accompaniment  of  tubercle  and  in  every  ease  of  phthisis  the 
chronic  interstitial  changes  play  a  very  important  role.  In  tumors,  ab- 
scess, gummata,  hydatids,  and  emphysema  it  also  occurs.  Fibroid  pro- 
cesses are  frequently  met  with  at  the  apices  of  the  lung  and  may  be  due 
either  to  a  limited  healed  tuberculosis,  to  fibroid  induration  in  conse- 
quence of  pigment,  or,  in  a  few  instances,  may  result  from  thickening  of 
the  pleura.     They  have  been  described  at  page  331. 

Diffuse  interstitial  pneumonia  is  met  with  under  the  following  cir- 
cumstances: 1.  As  a  sequence  of  acute  fibrinous  pneumonia.  Although 
extremely  rare,  this  is  recognized  as  a  possible  termination.  From  un- 
known causes  resolution  fails  to  take  place.  A  gradual  process  of  organ- 
ization goes  on  in  the  fibrinous  plugs  within  the  air-cells  and  the  alveolar 
walls  become  greatly  thickened  by  a  new  growth,  first  of  nuclear  and 
subsequently  of  fibrillated  connective  tissue.  Macroscopically  there  is  pro- 
duced a  smooth,  grayish,  homogeneous  tissue  which  has  the  peculiar  trans- 
lucency  of  all  new-formed  connective  tissue.  This  has  been  called  gray  in- 
duration. A  majority  of  the  cases  terminate  within  a  few  months,  and  in- 
stances which  have  been  followed  from  the  outset  are  very  rare. 

2.  Chronic  Broncho-Pneumonia. — The  relation  of  broncho-pneumonia 
to  cirrhosis  of  the  lung  has  been  specially  studied  by  Charcot,  who  states 
that  it  may  follow  the  acute  or  subacute  form  of  this  disease,  particularly  in 
children.  The  fibrosis  extfends  from  the  bronchi,  which  are  usually  found 
dilated.  Bronchiectasis  itself  may  be  followed  by  fibrosis  of  the  lung. 
The  alveolar  walls  are  thickened  and  the  lobules  converted  into  firm  gray- 
ish masses,  in  which  there  is  no  trace  of  normal  lung  tissue.  This  process 
may  go  on  and  involve  an  entire  lobe  or  even  the  whole  lung.  Many  of 
these  cases  are  tuberculous  from  the  outset. 

3.  Pleurogenous  InterstUial  Pneumonia. — Charcot  applies  this  term 
to  that  form  of  cirrhosis  of  the  lung  which  follows  invasion  from  the  pleura. 
Doubt  has  been  expressed  by  some  writers  whether  this  really  occurs. 
While  Wilson  Fox  is  probably  correct  in  questioning  whether  an  entire 
lung  can  become  cirrhosed  by  the  gradual  invasion  from  the  pleura,  there 
can  be  no  doubt  that  there  are  instances  of  primitive  dry  pleurisy,  which. 


eSO  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

as  Sir  Andrew  Clark  has  pointed  out,  gradually  compresses  the  lung  and 
at  the  same  time  leads  to  interstitial  cirrhosis.  This  may  be  due  in  part 
to  the  fibroid  change  which  follows  prolonged  compression.  In  some 
eases  there  seems  to  be  a  distinct  connection  between  the  greatly  thick- 
ened pleura  and  the  dense  strands  of  fibrous  tissue  passing  from  it  into 
the  lung  substance.  Instances  occur  in  which  one  lobe  or  the  greater 
part  of  it  presents,  on  section,  a  mottled  appearance,  owing  to  the  in- 
creased thickness  of  the  interlobar  septa — a  condition  which  may  exist 
without  a  trace  of  involvement  of  the  pleura.  In  many  other  cases, 
however,  the  extension  seems  to  be  so  definitely  associated  with  pleurisy 
that  there  is  no  doubt  as  to  the  causal  connection  between  the  two 
processes.  In  these  instances  the  lung  is  removed  with  great  difficulty, 
owing  to  the  thickness  and  close  adhesion  of  the  pleura  to  the  chest 
wall. 

4.  Chronic  interstitial  pneumonia,  due  to  inhalation  of  dust,  which  is 
considered  in  a  separate  section. 

6.  Syphilis  of  the  lung  presents  the  features  of  a  chronic  fibrosis  of  the 
organ  (see  p.  247). 

6.  Indurative  changes  in  the  lung  may  follow  the  compression  by 
aneurism  or  new  growth  or  the  irritation  of  a  foreign  body  in  a  bronchus. 

Morbid  Anatomy. — There  are  two  chief  forms,  the  massive  or  lobar 
and  the  insular  or  broncho-pneumonic  form.  In  the  massive  type  the  dis- 
ease is  unilateral;  the  chest  of  the  affected  side  is  sunken,  deformed,  and  the 
shoulder  much  depressed.  On  opening  the  thorax  the  heart  is  seen  drawn 
far  over  to  the  affected  side.  The  unaffected  lung  is  emphysematous  and 
covers  the  greater  portion  of  the  mediastinum.  It  is  scarcely  credible  in 
how  small  a  space,  close  to  the  spine,  the  cirrhosed  lung  may  lie.  The 
adhesions  between  the  pleural  membranes  may  be  extremely  dense  and 
thick,  particularly  in  the  pleurogenous  cases;  but  when  the  disease  has 
originated  in  the  lung  there  may  be  little  thickening  of  the  pleura.  The 
organ  is  airless,  firm,  and  hard.  It  strongly  resists  cutting,  and  on  section 
shows  a  grayish  fibroid  tissue  of  variable  amount,  through  which  pass  the 
blood-vessels  and  bronchi.  The  latter  may  be  either  slightly  or  enor- 
mously dilated.  There  are  instances  in  which  the  entire  lung  is  converted 
into  a  series  of  bronchiectatic  cavities  and  the  cirrhosis  is  apparent  only 
in  certain  areas  or  at  the  root.  The  tuberculous  cases  can  usually  be  dif- 
ferentiated by  the  presence  of  an  apical  cavity,  not  bronchiectatic,  and 
often  large;  and  the  other  lung  almost  invariably  shows  tuberculous 
lesions.  Pulmonary  aneurisms  are  not  infrequent  in  the  cavities.  The 
other  lung  is  always  greatly  enlarged  and  emphysematous.  The  heart  is 
hypertrophied,  particularly  the  right  ventricle,  and  there  may  be  marked 
atheromatous  changes  in  the  pulmonary  artery.  An  amyloid  condition 
of  the  viscera  is  found  in  some  cases. 

In  the  broncho-pneumonic  form  the  areas  are  smaller,  often  centrally 
placed,  and  most  frequently  in  the  lower  lobes.  They  are  deeply  pigmented, 
show  dilated  bronchi,  and  when  multiple  are  separated  by  emphysematous 
lung  tissue. 

A  reticular  form  of  fibrosis  of  the  lung  has  been  described  by  Percy 


CHRONIC  INTERSTITIAL  PNEUMONIA.  651 

Kidd  and  W.  McColliim,  in  which  the  lungs  are  intersected  by  grayish 
fibroid  strands  following  the  lines  of  the  interlobular  septa. 

Symptoms  and  Course. — The  disease  is  essentially  chronic,  ex- 
tending over  a  period  of  many  years,  and  when  once  the  condition  is  estab- 
lished the  health  may  be  fairly  good.  In  a  well-marked  case  the  patient 
complains  only  of  his  chronic  cough,  perhaps  a  slight  shortness  of  breath. 
In  other  respects  he  is  quite  well,  and  is  usually  able  to  do  light  work. 
The  cases  are  commonly  regarded  as  phthisical,  though  there  may  be 
scarcely  a  symptom  of  that  affection  except  the  cough.  There  are  in- 
stances, however,  of  fibroid  phthisis  which  cannot  be  distinguished  from 
cirrhosis  of  the  lung  except  by  the  presence  of  tubercle  bacilli  in  the 
expectoration.  As  the  bronchi  are  usually  dilated,  the  symptoms  and 
physical  signs  may  be  those  of  bronchiectasis.  The  cough  is  paroxysmal 
and  the  expectoration  is  generally  copious  and  of  a  muco-purulent  or  sero- 
purulent  nature.  It  is  sometimes  fetid.  Hemorrhage  is  by  no  means 
infrequent,  and  occurred  in  more  than  one  half  of  the  cases  analyzed  by 
Bastian.  Walking  on  the  level  and  in  the  ordinary  affairs  of  life  the  patient 
may  show  no  shortness  of  breath,  but  in  the  ascent  of  stairs  and  on  exer- 
tion there  may  be  dyspnoea. 

Physical  Signs. — Inspection. — The  affected  side  is  immobile,  retracted, 
and  shrunken,  and  contrasts  in  a  striking  way  with  the  voluminous  sound 
side.  The  intercostal  spaces  are  obliterated  and  the  ribs  may  even  over- 
lap. The  shoulder  is  drawn  down  and  from  behind  it  is  seen  that  the 
spine  is  bowed.  The  heart  is  greatly  displaced,  being  drawn  over  by  the 
shrinkage  of  the  lung  to  the  affected  side.  When  the  left  lung  is  affected 
there  may  be  a  large  area  of  visible  impulse  in  the  second,  third,  and 
fourth  interspaces.  Mensuration  shows  a  great  diminution  in  the  affected 
side,  and  with  the  saddle-tape  the  expansion  may  be  seen  to  be  negative. 
The  percussion  note  varies  with  the  condition  of  the  bronchi.  It  may  be 
absolutely  flat,  particularly  at  the  base  or  at  the  apex.  In  the  axilla 
there  may  be  a  flat  tympany  or  even  an  amphoric  note  over  a  large  sac- 
culated bronchus.  On  the  opposite  side  the  percussion  note  is  usually 
hyperresonant.  On  auscultation  the  breath-sounds  have  either  a  cavern- 
ous or  amphoric  quality  at  the  apex,  and  at  the  base  are  feeble,  with 
mucous,  bubbling  rales.  The  voice-sounds  are  usually  exaggerated.  Car- 
diac murmurs  are  not  uncommon,  particularly  late  in  the  disease,  when 
the  right  heart  fails.  These  are,  of  course,  the  physical  signs  of  the  dis- 
ease when  it  is  well  established.  They  naturally  vary  considerably,  ac- 
cording to  the  stage  of  the  process.  The  disease  is  essentially  chronic, 
and  may  persist  for  fifteen  or  twenty  years.  Death  occurs  sometimes  from 
haemorrhage,  more  commonly  from  gradual  failure  of  the  right  heart  with 
dropsy,  and  occasionally  from  amyloid  degeneration  of  the  organs. 

The  diagnosis  is  never  difficult.  It  may  be  impossible  to  say,  without 
a  clear  history,  whether  the  origin  is  pleuritic  or  pneumonic.  Between 
cases  of  this  kind  and  fibroid  phthisis  it  is  not  always  easy  to  discriminate, 
as  the  conditions  may  be  almost  identical.  When  tuberculosis  is  present, 
however,  even  in  long-standing  cases,  bacilli  are  usually  present  in  the 
sputa,  and  there  may  be  signs  of  disease  in  the  other  lung.  , 


552  DISEASES  OF  THE  RESPIEATORY  SYSTEM. 

Treatment. — It  is  only  for  an  intercurrent  affection  or  for  an  aggra- 
vation of  the  cough  that  the  patient  seeks  relief.  Nothing  can  be  done 
for  the  condition  itself.  When  possible  the  patient  should  live  in  a  mild 
climate,  and  should  avoid  exposure  to  cold  and  damp.  A  distressing 
feature  in  some  cases  is  the  putrefaction  of  the  contents  of  the  dilated 
tubes,  for  which  the  same  measures  may  be  used  as  in  fetid  bronchitis. 


IV.    PNEUMONOKONIOSIS. 

Under  this  term,  introduced  by  Zenker,  are  embraced  those  forms  of 
fibrosis  of  the  lung  due  to  the  inhalation  of  dusts  in  various  occupations. 
They  have  received  various  names,  according  to  the  nature  of  the  inhaled 
particles — antJiracosis,  or  coal-miner's  disease;  siderosis,  due  to  the  inhala- 
tion of  metallic  dusts,  particularly  iron;  chalicosis,  due  to  the  inhalation 
of  mineral  dusts,  producing  the  so-called  stone-cutter's  phthisis,  or  the 
"  grinder's  rot "  of  the  Sheffield  workers. 

The  dust  particles  inhaled  into  the  lungs  are  dealt  with  extensively  by 
the  ciliated  epithelium  and  by  the  phagocytes,  which  exist  normally  in  the 
respiratory  organs.  The  ordinary  mucous  corpuscles  take  in  a  large  num- 
ber of  the  particles,  which  fall  upon  the  trachea  and  main  bronchi.  The 
cilia  sweep  the  mucus  out  to  a  point  from  which  it  can  be  expelled  by 
coughing.  It  is  doubtful  if  the  particles  ever  reach  the  air-cells,  but  the 
swollen  alveolar  cells  (in  which  they  are  in  numbers)  probably  pick  them 
up  on  the  way.  The  mucous  and  the  alveolar  cells  are  the  normal  respira- 
tory scavengers.  In  dwellers  in  the  country,  in  which  the  air  is  pure, 
they  are  able  to  prevent  the  access  of  dust  particles  to  the  lung  tissue, 
so  that  even  in  adults  these  organs  present  a  rosy  tint,  very  different  from 
the  dark,  carbonized  appearance  of  the  lungs  of  dwellers  in  cities.  When 
the  impurities  in  the  air  are  very  abundant,  a  certain  proportion  of  the 
dust  particles  escapes  these  cells  and  penetrates  the  mucosa,  reaching  the 
lymph  spaces,  where  they  are  attacked  at  once  by  the  cells  of  the  connec- 
tive-tissue stroma,  which  are  capable  of  ingesting  and  retaining  a  large  quan- 
tity. In  coal-miners,  coal-heavers,  and  others  whose  occupations  neces- 
sitate the  constant  breathing  of  a  very  dusty  atmosphere  even  these  forces 
are  insufficient.  IMany  of  the  particles  enter  the  lymph  stream  and,  as 
Arnold  has  shown  in  his  beautiful  researches,  are  carried  (1)  to  the  lymph 
nodules  surrounding  the  bronchi  and  blood-vessels;  (2)  to  the  interlobular 
septa  beneath  the  pleura,  where  they  lodge  in  and  between  the  tissue  ele- 
ments; and  (3)  along  the  larger  lymph  channels  to  the  substernal,  bronchial 
and  tracheal  glands,  in  which  the  stroma  cells  of  the  follicular  cords  dis- 
pose of  them  permanently  and  prevent  them  from  entering  the  general 
circulation.  Occasionally  in  anthracosis  the  carbon  grains  do  reach  the 
general  circulation,  and  the  coal  dust  is  found  in  the  liver  and  spleen.  As 
Weigert  has  shown,  this  occurs  when  the  densely  pigmented  bronchial 
glands  closely  adhere  to  the  pulmonary  veins,  through  the  walls  of  which 
the  carbon  particles  pass  to  the  general  circulation.  The  lung  tissue  has 
a  remarkable  tolerance  for  these  particles,  probably  because  a  large  propor- 


PNEUMONOKONIOSIS.  653 

tion  of  them  is  warehoused,  so  to  speak,  in  protoplasmic  cells.  By  con- 
stant exposure  a  limit  is  reached,  and  there  is  brought  about  a  very  definite 
pathological  condition,  an  interstitial  sclerosis.  In  coal-miners  this  may 
occur  in  patches,  even  before  the  lung  tissue  is  uniformly  infiltrated  with 
the  dust.  In  others  it  appears  only  after  the  entire  organs  have  become 
so  laden  that  they  are  dark  in  color,  and  an  ink-like  juice  flows  from  the 
cut  surface.  The  lungs  of  a  miner  may  be  black  throughout  and  yet  show 
no  local  lesions  and  be  everywhere  crepitant. 

As  already  mentioned,  the  particles  are  deposited  in  large  numbers  in 
the  follicular  cords  of  the  tracheal  and  bronchial  glands  and  of  the  peri- 
bronchial and  peri-arterial  lymph  nodules,  and  in  these  they  finally  excite 
proliferation  of  the  connective-tissue  elements.  It  is  by  no  means  un- 
common to  find  in  persons  whose  lungs  are  only  moderately  carbonized 
the  bronchial  glands  sclerosed  and  hard.  In  anthracosis  the  fibroid 
changes  usually  begin  in  the  peri-bronchial  lymph  tissue,  and  in  the  early 
stage  of  the  process  the  sclerosis  may  be  largely  confined  to  these  regions. 
A  Nova  Scotian  miner,  aged  thirty-six,  died  under  my  care,  at  the  Mont- 
real General  Hospital,  of  black  small-pox,  after  an  illness  of  a  few  days. 
In  his  lungs  (externally  coal-black)  there  were  round  and  linear  patches 
ranging  in  size  from  a  pea  to  a  hazel-nut,  of  an  intensely  black  color,  air- 
less and  firm,  and  surrounded  by  a  crepitant  tissue,  slate-gray  in  color. 
In  the  centre  of  each  of  these  areas  was  a  small  bronchus.  Many  of  them 
were  situated  just  beneath  the  pleura,  and  formed  typical  examples  of 
limited  fibroid  broncho-pneumonia.  In  addition  there  is  usually  thicken- 
ing of  the  alveolar  walls,  particularly  in  certain  areas.  By  the  gradual 
coalescence  of  these  fibroid  patches  large  portions  of  the  lung  may  be 
converted  into  firm  grayish-black,  in  the  case  of  the  coal-miner — steel- 
gray,  in  the  case  of  the  stone-worker — areas  of  cirrhosis.  In  the  case  of  a 
Cornish  miner,  aged  sixty-three,  who  died  under  my  care,  one  of  these 
fibroid  areas  measured  18  by  6  cm.  and  4.5  cm.  in  depth. 

A  second  important  factor  in  these  cases  is  chronic  bronchitis,  which 
is  present  in  a  large  proportion  and  really  causes  the  chief  symptoms.  A 
third  is  the  occurrence  of  emphysema,  which  is  almost  invariably  associ- 
ated with  long-standing  cases  of  pneumonokoniosis.  With  the  changes  so 
far  described,  unless  the  cirrhotic  area  is  unusually  extensive,  the  case  may 
present  the  features  of  chronic  bronchitis  with  emphysema,  but  finally 
another  element  comes  into  play.  In  the  fibroid  areas  softening  occurs, 
probably  a  process  of  necrosis  similar  to  that  by  which  softening  is  pro- 
duced in  fibro-myomata  of  the  uterus.  At  first  these  are  small  and  con- 
tain a  dark  liquid.  Charcot  calls  them  ulceres  du  poumon.  They  rarely 
attain  a  large  size  unless  a  communication  is  formed  with  the  bronchus, 
in  which  case  they  may  become  converted  into  suppurating  cavities.  The 
question  has  been  much  discussed  of  late  as  to  what  part  the  tubercle  bacil- 
lus plays  in  these  cases  of  pneumonokoniosis  with  cavity  formation.  In 
some  instances  there  is  certainly  a  tuberculous  process  ingrafted,  but 
that  large  excavations  may  occur,  or  in  other  instances  bronchiectasis 
without  the  presence  of  bacilli,  I  have  convinced  myself  by  the  examina- 
tion of  several  characteristic  specimens. 


664  DISEASES  OP  THE  RBSPIRATOEY  SYSTEM. 

The  siderosis  induced  by  the  oxide  of  iron  causes  an  interstitial  pneu- 
monia similar  to  anthracosis.  Workers  in  brass  and  in  bronze  are  liable 
to  a  like  affection. 

Chalicosis,  due  to  the  deposit  of  particles  of  silex  and  alumina,  is 
found  in  the  makers  of  mill-stones,  particularly  the  French  mill-stones, 
and  also  in  knife  and  axe  grinders  and  stone-cutters.  Anatomically,  this 
form  is  characterized  by  the  production  of  nodules  of  various  sizes,  which 
are  cut  with  the  greatest  difficulty  and  sometimes  present  a  curious  gray- 
ish, even  glittering,  crystalloid  appearance. 

Workers  in  flax  and  in  cotton,  and  grain-shovellers  "are  also  subject  to 
these  chronic  interstitial  changes  in  the  lungs.  In  all  these  occupations, 
as  shown  by  Greenhow,  to  whose  careful  studies  we  owe  so  much  of  our 
knowledge  of  these  diseases,  the  condition  of  the  lung  may  ultimately  be 
almost  identical. 

The  symptoms  do  not  come  on  until  the  patient  has  worked  for  a  vari- 
able number  of  years  in  the  dusty  atmosphere.  As  a  rule  there  are  cough 
and  failing  health  for  a  prolonged  period  of  time  before  complete  disa- 
bility. The  coincident  emphysema  is  responsible  in  great  part  for  the 
shortness  of  breath  and  wheezy  condition  of  these  patients.  The  expec- 
toration is  usually  muco-purulent,  often  profuse;  in  a  case  of  anthra- 
cosis, very  dark  in  color — the  so-called  "  black  spit  "  ;  in  a  case  of  chalicosis 
there  may  be  seen  under  the  microscope  the  bright  angular  particles  of 
silica. 

Even  when  there  are  physical  signs  of  cavity,  tubercle  bacilli  are  not 
necessarily,  and  indeed  in  my  experience  are  not  usually  present.  It  is 
remarkable  for  how  long  a  time  a  coal-miner  may  continue  to  bring  up 
sputum  laden  with  coal  particles  even  when  there  are  only  signs  of  a 
chronic  bronchitis.  Many  of  the  particles  are  contained  in  the  cells  of  the 
alveolar  epithelium.  In  these  instances  it  appears  that  an  attempt  is  made 
by  the  leucocytes^  to  rid  the  lungs  of  some  of  the  carbon  grains. 

The  diagnosis  of  the  condition  is  rarely  difficult;  the  expectoration  is 
usually  characteristic.  It  must  always  be  borne  in  mind  that  chronic 
bronchitis  and  emphysema  form  essential  parts  of  the  process  and  that  in 
late  stages  there  may  be  tuberculous  infection. 

The  treatment  of  the  condition  is  practically  that  of  chronic  bronchitis 
and  emphysema. 

V.    EMPHYSEMA. 

Definition. — The  condition  in  which  the  infundibjilar  passages  and 
the  alveoli  are  dilated  and  the  alveolar  walls  atrophied. 

A  practical  division  may  be  made  into  compensatory,  hypertrophic, 
and  atrophic  forms,  the  acute  vesicular  emphysema,  and  the  interstitial 
forms.  The  last  two  do  not  in  reality  come  under  the  above  definition,  but 
for  convenience  they  may  be  considered  here. 


EMPHYSEMA.  655 

I.  Compensatory   Emphysema. 

Whenever  a  region  of  the  lung  does  not  expand  fully  in  inspiration, 
either  another  portion  of  the  lung  must  expand  or  the  chest  wall  sink  in 
order  to  occupy  the  space.  The  former  almost  invariably  occurs.  We 
have  already  mentioned  that  in  broncho-pneumonia  there  i^  a  vicarious 
distention  of  the  air-vesicles  in  the  adjacent  healthy  lobules^  and  the  same 
happens  in  the  neighborhood  of  tuberculous  areas  and  cicatrices.  In  gen- 
eral pleural  adhesions  there  is  often  compensatory  emphysema,  particu- 
larly at  the  anterior  margins  of  the  lung.  The  most  advanced  example  of 
this  form  is  seen  in  cirrhosis,  when  the  unaffected  lung  increases  greatly 
in  size,  owing  to  distention  of  the  air-vesicles.  A  similar  though  less 
marked  condition  is  seen  in  extensive  pleurisy  with  effusion  and  in  pneu- 
mothorax. 

At  first,  this  distention  of  the  air-vesicles  is  a  simple  physiological 
process  and  the  alveolar  walls  are  stretched  but  not  atrophied.  Ulti- 
mately, however,  in  many  cases  they  waste  and  the  contiguous  air-cells 
fuse,  producing  true  emphysema. 

II.  Hypeetkophic  Emphysema. 

The  large-lunged  emphysema  of  Jenner,  also  known  as  substantive  or 
idiopathic  emphysema,  is  a  well-marked  clinical  affection,  characterized  by 
enlargement  of  the  lungs,  due  to  distention  of  the  air-cells  and  atrophy  of 
their  walls,  and  clinically  by  imperfect  aeration  of  the  blood  and  more  or 
less  marked  dyspnoea. 

Etiology. — Emphysema  is  the  result  of  persistently  high  intra- 
alveolar  tension  acting  upon  a  congenitally  weak  lung  tissue.  If  the 
mechanical  views  as  to  its  origin,  which  have  prevailed  so  long,  were  true, 
the  disease  would  certainly  be  much  more  common;  since  violent  respira- 
tory efforts,  believed  to  be  the  essential  factor,  are  performed  by  a  majority 
of  the  working  classes.  Strongly  in  favor  of  the  view,  that  the  nutritive 
change  in  the  air-cells  is  the  primary  factor,  is  the  markedly  hereditary 
character  of  the  disease  and  the  frequency  with  which  it  starts  early  in 
life.  These  are  two  points  upon  which  scarcely  sufficient  stress  has  been 
laid.  To  James  Jackson,  Jr.,  of  Boston,  we  owe  the  first  observations 
on  the  hereditary  character  of  emphysema.  Working  under  Louis'  direc- 
tions, he  found  that  in  18  out  of  28  cases  one  or  both  parents  were  af- 
fected. 

I  have  been  impressed  by  the  frequency  of  its  origin  in  childhood.  It 
may  follow  recurring  asthmatic  attacks  due  to  adenoid  vegetations.  It 
may  develop,  too,  in  several  members  of  the  same  family.  We  are  still 
ignorant  as  to  the  nature  of  this  congenital  pulmonary  weakness.  Cohn- 
heim  thinks  it  probably  due  to  a  defect  in  the  development  of  the  elastic- 
tissue  fibres — a  statement  which  is  borne  out  by  Eppinger's  observations. 

Heightened  pressure  within  the  air-cells  may  be  due  to  forcilile  in- 
spiration or  expiration.     Much  discussion  has  taken  place  as  to  the  part 

played  by  these  two  acts  in  the  production  of  the  disease.    The  inspiratory 
41 


656  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

theory  was  advanced  by  Laennec  and  subsequently  modified  by  Gairdner, 
who  held  that  in  chronic  bronchitis  areas  of  collapse  were  induced,  and  com- 
pensatory distention  took  place  in  the  adjacent  lobules.  This  unques- 
tionably does  occur  in  the  vicarious  or  compensatory  emphysema,  but 
it  probably  is  not  a  factor  of  much  momentun  the  form  now  under  con- 
sideration. The  expiratory  theory,  which  was  supported  by  Mendelssohn 
and  Jenner,  accounts  for  the  condition  in  a  much  more  satisfactory  way. 
In  all  straining  efforts  and  violent  attacks  of  coughing,  the  glottis  is  closed 
and  the  chest  walls  are  strongly  compressed  by  muscular  efforts,  so  that 
the  strain  is  thrown  upon  those  parts  of  the  lung  least  protected,  as  the 
apices  and  the  anterior  margins,  in  which  we  always  find  the  emphy- 
sema most  advanced.  The  sternum  and  costal  cartilages  gradually  yield 
to  the  heightened  intrathoracic  pressure  and  are,  in  advanced  cases,  pushed 
forward,  giving  the  characteristic  rotundity  to  the  thorax.  The  cartilages 
gradually  become  calcified.  .One  theory  of  the  disease  is  that  there  is  a 
gradual  enlargement  of  the  thorax  and  the  lungs  increase  in  volume  to 
fill  up  the  space. 

Of  other  etiological  factors  occupation  is  the  most  important.  The 
disease  is  met  with  in  players  on  wind  instruments,  in  glass-blowers,  and 
in  occupations  necessitating  heavy  lifting  or  straining.  Whooping-cough 
and  bronchitis  play  an  important  role,  not  so  much  in  the  changes  which 
they  induce  in  the  bronchi  as  in  consequence  of  the  prolonged  attacks  of 
coughing. 

Morbid  Anatomy. — The  thorax  is  capacious,  usually  barrel-shaped, 
and  the  cartilages  are  calcified.  On  removal  of  the  sternum,  the  anterior 
mediastinum  is  found  completely  occupied  by  the  edges  of  the  lungs,  and 
the  pericardial  sac  may  not  be  visible.  The  organs  are  very  large  and 
have  lost  their  elasticity,  so  that  they  do  not  collapse  either  in  the  thorax 
or  when  placed  on  the  table.  The  pleura  is  pale  and  there  is  often  an 
absence  of  pigment,  sometimes  in  patches,  termed  by  Virehow  albinism  of 
the  lung.  To  the  touch  they  have  a  peculiar,  downy,  feathery  feel,  and 
pit  readily  on  pressure.  This  is  one  of  the  most  marked  features.  Be- 
neath the  pleura  greatly  enlarged  air-vesicles  may  be  readily  seen.  They 
vary  in  size  from  -J  to  3  mm.,  and  irregular  bullse,  the  size  of  a  walnut 
or  larger,  may  project  from  the  free  margins.  The  best  idea  of  the  ex- 
treme rarefaction  of  the  tissue  is  obtained  from  sections  of  a  lung  dis- 
tended and  dried.  At  the  anterior  margins  the  structure  may  form  an 
irregular  series  of  air-chambers,  lesembling  the  frog's  lung.  On  careful 
inspection  with  the  hand-lens,  remnants  of  the  interlobular  septa  or  even 
of  the  alveoli  may  be  seen  on  these  large  emphysematous  vesicles.  Though 
general  throughout  the  organs,  the  distention  is  inore  marked,  as  a  rule, 
at  the  anterior  margins,  and  is  often  specially  developed  at  the  inner  sur- 
face of  the  lobe  near  the  root,  where  in  extreme  cases  air-spaces  as  large 
as  an  egg  may  sometimes  be  found.  Microscopically  there  is  seen  atrophy 
of  the  alveolar  walls,  by  which  is  produced  the  coalescence  of  neighboring 
air-cells.  In  this  process  the  capillary  network  disappears  before  the 
walls  are  completely  atrophied.  The  loss  of  the  elastic  tissue  is  a  special 
feature.     It  is  stated,  indeed,  that  in  certain  cases  there  is  a  congenital 


EMPHYSEMA.  65Y 

defect  in  the  development  of  this  tissue.  The  epithelium  of  the  air-cells 
undergoes  a  fatty  change,  but  the  large  distended  air-spaces  retain  a  pave- 
ment layer. 

The  bronchi  show  important  changes.  In  the  larger  tubes  the  mucous 
membrane  may  be  rough  and  thickened  from  chronic  bronchitis;  often  the 
longitudinal  lines  of  submucous  elastic  tissue  stand  out  prominently.  In 
the  advanced  cases  many  of  the  smaller  tubes  are  dilated,  particularly 
when,  in  addition  to  emphysema,  there  are  peri-bronchial  fibroid  changes. 
Bronchiectasis  is  not,  however,  an  invariable  accompaniment  of  emphy- 
sema, but,  as  Laennec  remarks,  it  is  difficult  to  understand  why  it  is  not 
more  common.  Of  associated  morbid  changes  the  most  important  are 
found  in  the  heart.  The  right  chambers  are  dilated  and  hypertrophied, 
the  tricuspid  orifice  is  large,  and  the  valve  segments  are  often  thickened 
at  the  edges.  In  advanced  oases  the  cardiac  hypertrophy  is  general.  The 
pulmonary  artery  and  its  branches  may  be  wide  and  show  marked  atherom- 
atous changes. 

The  changes  in  the  other  organs  are  those  commonly  associated  with 
prolonged  venous  congestion. 

Symptoms. — The  disease  may  be  tolerably  advanced  before  any  spe- 
cial symptoms  develop.  A  child,  for  instance,  may  be  somewhat  short  of 
breath  on  going  up-stairs  or  may  be  unable  to  run  and  play  as  other  chil- 
dren without  great  discomfort;  or,  perhaps,  has  attacks  of  slight  lividity. 
Doubtless  much  depends  upon  the  completeness  of  cardiac  compensation. 
When  this  is  perfect,  there  may  be  no  special  interruption  of  the  pulmonary 
circulation  and,  except  with  violent  exertion,  there  is  no  interference  with 
the  aeration  of  the  blood.  In  well-developed  cases  the  following  are  the 
most  important  symptoms:  Dyspncea,  which  may  be  felt  only  on  slight 
exertion,  or  may  be  persistent,  and  aggravated  by  intercurrent  attacks  of 
bronchitis.  The  respirations  are  often  harsh  and  wheezy,  and  expiration 
is  distinctly  prolonged. 

Cyanosis  of  an  extreme  grade  is  more  common  in  emphysema  than  in 
other  affections  with  the  exception  of  congenital  heart-disease.  So  far  as  I 
know  it  is  the  only  disease  in  which  a  patient  may  be  able  to  go  about  and 
even  to  walk  into  the  hospital  or  consulting-room  with  a  lividity  of  star- 
tling intensity.  The  contrast  between  the  extreme  cyanosis  and  the  com- 
parative comfort  of  the  patient  is  very  striking.  In  other  affections  of  the 
heart  and  lungs  associated  with  a  similar  degree  of  cyanosis  the  patient  is 
invariably  in  bed  and  usually  in  a  state  of  orthopncea.  One  condition  must 
be  here  referred  to,  viz.,  the  extraordinary  cyanosis  in  cases  of  poisoning 
by  aniline  products,  which  is  in  most  part  due  to  the  conversion  of  the 
haemoglobin  into  methasmoglobin. 

Bronchitis  with  associated  cough  is  a  frequent  symptom  and  often  the 
direct  cause  of  the  pulmonary  distress.  The  contrast  between  empliy- 
sematous  patients  in  the  winter  and  summer  is  marked  in  this  respect. 
In  the  latter  they  may  be  comfortable  and  able  to  attend  to  their 
work,  but  with  the  cold  and  changeable  weather  they  are  laid  up  with 
attacks  of  bronchitis.  Finally,  in  fact,  the  two  conditions  become  in- 
separable and  the  patient  has  persistently  more  or  less  cough.     The  acute 


658  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

bronchitis  may  produce  attacks  not  unlike  asthma.  In  some  instances 
this  is  true  spasmodic  asthma,  with  which  emphysema  is  frequently  asso- 
ciated. 

As  age  advances,  and  with  successive  attacks  of  bronchitis,  the  condi- 
tion gets  slowly  worse.  In  hospital  practice  it  is  common  to  admit  pa- 
tients over  sixty  with  well-marked  signs  of  advanced  emphysema.  The 
affection  can  generally  be  told  at  a  glance — the  rounded  shoulders,  barrel 
chest,  the  thin  yet  oftentimes  muscular  form,  and  sometimes,  I  think,  a  very 
characteristic  facial  expression. 

There  is  another  group,  however,  of  younger  patients  from  twenty-five 
to  forty  years  of  age  who,  winter  after  winter,  have  attacks  of  intense  cya- 
nosis in  consequence  of  an  aggravated  bronchial  catarrh.  On  inquiry  we 
find  that  these  patients  have  been  short-breathed  from  infancy,  and  they 
belong,  I  believe,  to  a  category  in  which  there  has  been  a  primary  defect 
of  structure  in  the  lung  tissue. 

Physical  Signs. — Inspection. — The  thorax  is  markedly  altered  in  shape; 
the  antero-posterior  diameter  is  increased  and  may  be  even  greater  than 
the  lateral,  so  that  the  chest  is  barrel-shaped.  The  appearance  is  some- 
what as  if  the  chest  was  in  a  permanent  inspiratory  position.  The  sternum 
and  costal  cartilages  are  prominent.  The  lower  zone  of  the  thorax  looks 
large  and  the  intercostal  spaces  are  much  widened,  particularly  in  the  hypo- 
chondriac regions.  The  sternal  fossa  is  deep,  the  clavicles  stand  out  with 
great  prominence,  and  the  neck  looks  shortened  from  the  elevation  of  the 
thorax  and  the  sternum.  A  zone  of  dilated  venules  may  be  seen  along  the 
line  of  attachment  of  the  diaphragm.  Though  this  is  common  in  emphy- 
sema, it  is  by  no  means  peculiar  to  it  or  indeed  to  any  special  affection. 
Andrew,  of  Bartholomew's  Hospital,  and,  according  to  Duckworth,  Laycock 
called  attention  to  it. 

The  curve  of  the  spine  is  increased  and  the  back  is  remarkably  rounded, 
so  that  the  scapulge  seem  to  be  almost  horizontal.  Mensuration  shows  the 
rounded  form  of  the  chest  and  the  very  slight  expansion  on  deep  inspira- 
tion. The  respiratory  movements,  which  may  look  energetic  and  forcible, 
exercise  little  or  no  influence.  The  chest  does  not  expand,  but  there  is  a 
general  elevation.  The  inspiratory  effort  is  short  and  quick;  the  expiratory 
movement  is  prolonged.  There  may  be  retraction  instead  of  distention 
in  the  upper  abdominal  region  during  inspiration,  and  there  is  sometimes 
seen  a  transverse  curve  crossing  the  abdomen  at  the  level  of  the  twelfth 
rib.  The  apex  beat  of  the  heart  is  not  visible,  and  there  is  usually  marked 
pulsation  in  the  epigastric  region.  The  cervical  veins  stand  out  promi- 
nently and  may  pulsate. 

Palpation. — The  vocal  fremitus  is  somewhat  enfeebled  but  not  lost. 
The  apex  beat  can  rarely  be  felt.  There  is  a  marked  shock  in  the  lower 
sternal  region  and  very  distinct  pulsation  in  the  epigastrium.  Percussion 
gives  greatly  increased  resonance,  full  and  drum-like — what  is  sometimes 
called  hyperresonance.  The  note  is  not  often  distinctly  tympanitic  in 
quality.  The  percussion  note  is  greatly  extended,  the  heart  dulness  may 
be  obliterated,  the  upper  limit  of  liver  dulness  is  greatly  lowered,  and  the 
resonance  may  extend  to  the  costal  margin.     Behind,  a  clear  percussion  note 


EMPHYSEMA.      '  659 

extends  to  a  much  lower  level  than  normal.  The  level  of  splenic  dulness, 
too,  may  be  lowered. 

On  auscultation  the  breath-sounds  are  usually  enfeebled  and  may  be 
masked  by  bronchitic  rales.  The  most  characteristic  feature  is  the  pro- 
longation of  the  expiration,  and  the  normal  ratio  may  be  reversed — 4  to  1 
instead  of  1  to  4.  It  is  often  wheezy  and  harsh  and  associated  with  coarse 
rales  and  sibilant  rhonchi.  It  is  said  that  in  interstitial  emphysema  there 
may  be  a  friction  sound  heard,  not  unlike  that  of  pleurisy.  The  heart- 
sounds  are  usually  clear;  but  in  advanced  cases,  when  there  is  marked 
cyanosis,  a  tricuspid  regurgitant  murmur  may  be  heard.  Accentuation  of 
the  pulmonary  second  sound  is  present. 

The  course  of  the  disease  is  slow  but  progressive,  the  recurring  attacks 
of  bronchitis  aggravating  the  condition.  Death  may  occur  from  intercur- 
rent pneumonia,  either  lobar  or  lobular,  and  dropsy  may  supervene  from 
cardiac  failure.  Occasionally  death  results  from  overdistention  of  the  heart, 
with  extreme  cyanosis.  Duckworth  has  called  attention  to  the  occasional 
occurrence  of  fatal  hsemorrhage  in  emphysema.  In  an  old  emphysematous 
patient  at  the  Montreal  General  Hospital  death  followed  the  erosion  of  a 
main  branch  of  the  pulmonary  artery  by  an  ulcer  near  the  bifurcation  of  the 
trachea. 

Treatment. — Practically,  the  measures  mentioned  in  connection  with 
bronchitis  should  be  employed.  In  children  with  asthma  and  developing 
emphysema  the  nose  should  be  carefully  examined.  No  remedy  is  known 
which  has  any  influence  over  the  progress  of  the  condition  itself.  Bron- 
chitis is  the  great  danger  of  these  patients,  and  therefore  when  possible  they 
should  live  in  an  equable  climate.  In  consequence  of  the  venous  engorge- 
ment they  are  liable  to  gastric  and  intestinal  disturbance,  and  it  is  par- 
ticularly important  to  keep  the  bowels  regulated  and  to  avoid  flatulency 
which  often  seriously  aggravates  the  dyspnoea.  Patients  who  come  into  the 
hospital  in  a  state  of  urgent  dyspnoea  and  lividity,  with  great  engorgement 
of  the  veins,  particularly  if  they  are  young  and  vigorous,  should  be  bled 
freely.  On  more  than  one  occasion  I  have  saved  the  lives  of  persons  in  this 
condition  by  venesection.  Inhalation  of  oxygen  may  be  used  and  the  reme- 
dies given  already  mentioned  in  connection  with  bronchitis.  Strychnine 
will  be  found  specially  useful. 

III.  Atrophic  Emphysema. 

This  is  really  a  senile  change  and  is  called  by  Sir  William  Jenner  small- 
lunged  emphysema.  It  is  really  a  primary  atrophy  of  the  lung,  coming 
on  in  advanced  life,  and  scarcely  constitutes  a  special  affection.  It  occurs 
in  "withered-looking  old  persons"  who  may  perhaps  have  had  a  winter 
cough  and  shortness  of  breath  for  years.  In  striking  contrast  to  the  essen- 
tial or  hypertrophic  emphysema,  the  chest  in  this  form  is  small.  The  ribs 
are  obliquely  placed,  the  decrease  in  the  diameter  being  due  to  greatly  in- 
creased obliquity  in  the  position  of  the  ribs.  The  thoracic  muscles  are 
usually  atrophied.  In  advanced  cases  of  this  affection  the  lung  presents  a 
remarkable  appearance,  being  converted  into  a  series  of  large  vesicles,  on 


660  DISEASES  OP  THE  KESPIRATORY  SYSTEM. 

the  walls  of  whicli  the  remnants  of  air-cells  may  be  seen.     It  is  a  condition 
for  which  nothing  can  be  done. 

IV.  Acute  Yesiculae  Emphysema. 

When  death  occurs  from  bronchitis  of  the  smaller  tubes,  or  from  cyanosis 
when  strong  inspiratory  efforts  have  been  made,  the  lungs  are  large  in  vol- 
ume and  the  air-cells  are  much  distended.  Clinically,  this  condition  may 
develop  rapidly  in  cases  of  cardiac  asthma  and  angina  pectoris.  The  lungs 
are  voluminous,  the  area  of  pulmonary  resonance  is  much  increased,  and  on 
auscultation  there  are  heard  everywhere  piping  rales  and  prolonged  expira- 
tion. It  is  the  condition  to  which  von  Basch  has  given  the  names  Lungen- 
scliwellung  and  Lungenstarrheit.  A  similar  condition  may  follow  pressure 
on  the  vagi, 

Y.  Intekstitial  Emphysema. 

In  this  form  beads  of  air  are  seen  in  the  interlobular  and  subpleural 
tissue;  sometimes  they  form  large  bullae  beneath  the  pleura.  A  rare  event 
is  rupture  close  to  the  root  of  the  lung,  and  the  passage  of  air  along  the 
trachea  into  the  subcutaneous  tissues  of  the  neck.  After  tracheotomy  just 
the  reverse  may  occur  and  the  air  may  pass  from  the  tracheotomy  wound 
along  the  wind-pipe  and  bronchi  and  appear  beneath  the  surface  of  the 
pleura.  From  this  interstitial  emphysema  spontaneous  pneumothorax  may 
arise  in  healthy  persons. 


VI.    GANGRENE    OF   THE    LUNG. 

Etiology. — Gangrene  of  the  lung  is  not  an  affection  per  se,  but  occurs 
in  a  variety  of  conditions  when  necrotic  areas  undergo  putrefaction.  It 
it  not  easy  to  say  why  s;phacelus  should  occur  in  one  case  and  not  in  an- 
other, as  the  germs  of  putrefaction  are  always  in  the  air-passages,  and  yet 
necrotic  territories  rarely  become  gangrenous.  Total  obstruction  of  a  pul- 
monary artery,  as  a  rule,  causes  infarction,  and  the  area  shut  off  does  not 
often,  though  it  may,  sphacelate.  Another  factor  would  seem  to  be  neces- 
sary— probably  a  lowered  tissue  resistance,  the  result  of  general  or  local 
causes.  It  is  metwi±h  (1)  as  a  sequence  of  lobar  pneumonia.  This  rarely 
occurs  in  a  previously  healthy  person — more  commonly  in  the  debilitated 
or  in  the  diabetic  subject.  (2)  Gangrene  is  very  prone  to  follow  the  as- 
piration pneumonia,  since  the  foreign  particles  rapidly  undergo  putrefac- 
tive changes.  Of  a  similar  nature  are  the  cases  of  gangrene  due  to  perfora- 
tion of  cancer  of  the  oesophagus  into  the  lung  or  into  a  bronchus.  (3)  The 
putrid  contents  of  a  bronchiectatic,  more  commonly  of  a  tuberculous,  cav- 
ity may  excite  gangrene  in  the  neighboring  tissues.  The  pressure  bronchi- 
ectasis following  aneurism  or  tumor  may  lead  to  extensive  sloughing.  (4) 
Gangrene  may  follow  simple  embolism  of  the  pulmonary  artery.  More 
commonly,  however,  the  embolus  is  derived  from  a  part  which  is  morti- 
fied or  comes  from  a  focus  of  bone  disease.     In  typhus  and  in  t}^hoid  fever 


GANGREKE   OF  THE  LUXG.  661 

gangrene  of  the  lung  may  follow  thrombosis  of  one  of  the  larger  branches 
of  the  pulmonary  artery.  A  case  occurred  in  my  wards  in  October,  1897, 
in  connection  with  a  typhoid  septicgemia.  Typhoid  bacilli  were  isolated 
from  the  lung.  /Lastly,  gangrene  of  the  lung  may  occur  in  conditions  of 
debility  during  TOnvalescence  from  protracted  fever — occasionally,  indeed, 
without  our  being  able  to  assign  any  reasonable  cause.  | 

Morbid  Anatomy. — Laennec,  who  first  accurately  described  pul- 
monary gangrene,  recognized  a  diffuse  and  a  circumscribed  form.  The  for- 
mer, though  rare,  is  sometimes  seen  in  connection  with  pneumonia,  more 
rarely  after  obliteration  of  a  large  branch  of  the  pulmonary  artery.  It  may 
involve  the  greater  part  of  a  lobe,  and  the  lung  tissue  is  converted  into  a  hor- 
ribly offensive  greenish-black  mass,  torn  and  ragged  in  the  centre.  In  the 
circumscribed  form  there  is  well-marked  limitation  between  the  gangrenous 
area  and  the  surrounding  tissue.  The  focus  may  be  single  or  there  may  be 
two  or  more.  The  lower  lobe  is  more  commonly  affected  than  the  upper, 
and  the  peripheral  more  than  the  central  portion  of  the  lung.  A  gan- 
grenous area  is  at  first  uniformly  greenish  brown  in  color;  but  softening  rap- 
idly takes  place  with  the  formation  of  a  cavity  with  shredd}^,  irregular  walls 
and  a  greenish,  offensive  fluid.  The  lung  tissue  in  the  immediate  neigh- 
borhood shows  a  zone  of  deep  congestion,  often  consolidation,  and  outside 
this  an  intense  oedema.  In  the  embolic  cases  the  plugged  artery  can  some- 
times be  found.  When  rapidly  extending,  vessels  may  be  opened  and  a 
copious  hgemorrhage  ensue.  Perforation  of  the  pleura  is  not  uncommon. 
The  irritating  decomposing  material  usually  excites  the  most  intense  bron- 
chitis. Embolic  processes  are  not  infrequent.  There  is  a  remarkable  asso- 
ciation in  some  cases  between  circumscribed  gangrene  of  the  lung  and 
abscess  of  the  brain.  It  has  been  referred  to  under  the  section  on  bron- 
chiectasis. 

Symptoms  and  Course. — Usually  definite  symptoms  of  local  pul- 
monary disease  precede  the  characteristic  features  of  gangrene.  These,  of 
course,  are  very  varied,  depending  on  the  nature  of  the  trouble.  The  sputum 
is  very  characteristic.  It  is  intensely  fetid — usually  profuse — and,  if  ex- 
pectorated into  a  conical  glass,  separates  into  three  layers — a  greenish-brown, 
heavy  sediment;  an  intervening  thin  liquid,  which  sometimes  has  a  greenish 
or  a  brownish  tint;  and,  on  top,  a  thick,  frothy  layer.  Spread  on  a  glass 
plate,  the  shreddy  debris  of  lung  tissue  can  readily  be  picked  out.  Even 
large  fragments  of  lung  may  be  coughed  up.  Eobertson,  of  Onancock, 
Va.,  sent  me  one  several  centimetres  in  length,  which  had  been  expecto- 
rated by  a  lad  of  eighteen,  who  had  severe  gangrene  and  recovered.  Mi- 
croscopically, elastic  fibres  are  found  in  abundance,  with  granular  matter, 
pigment  grains,  fatty  crystals,  bacteria,  and  leptothrix.  It  is  stated  that 
elastic  tissue  is  sometimes  absent,  but  I  have  never  met  with  such  an  in- 
stance. The  peculiar  plugs  of  sputum  which  occur  in  bronchiectasy  are  not 
found.  Blood  is  often  present,  and,  as  a  rule,  is  much  altered.  The  spu- 
tum has,  in  a  majority  of  the  cases,  an  intensely  fetid  odor,  which  is  com- 
municated to  the  breath  and  may  permeate  the  entire  room.  It  is  much 
more  offensive  tlian  in  feij^  bronchitis  or  in  abscess  of  the  lung.  The 
fetor  is  particularly  marked  when  there  is  free  communication  between  the 


662 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


gangrenous  cavities  and  the  bronchi.  On  several  occasions  I  have  found, 
post  mortem,  localized  gangrene,  which  had  been  unsuspected  during  life, 
and  in  which  there  had  been  no  fetor  of  the  breath. 

_----T?he  physical  signs,  when  extensive  destruction  has  occurred,  are  those 
of  cavity,  but  the  limited  circumscribed  areas  may  be  difficult  to  detect. 
Bronchitis  is  always  present. 

Among  the  general  symptoms  may  be  mentioned  fever,  usually  of  mod- 
erate grade;  the  pulse  is  rapid,  and  very  often  the  constitutional  depression 
is  severe.  But  the  only  special  features  indicative  of  gangrene  are  the 
sputa  and  the  fetor  of  the  breath.  The  patient  generally  sinks  from  exhaus- 
tion.    Fatal  hsemorrhage  may  ensue. 

Treatment. — The  treatment  of  gangrene  is  very  unsatisfactory.  The 
indications,  of  course,  are  to  disinfect  the  gangrenous  area,  but  this  is  often 
impossible.  An  antiseptic  spray  of  carbolic  acid  may  be  employed.  A 
good  plan  is  for  the  patient  to  use  over  the  mouth  and  nose  an  inhaler, 
which  may  be  charged  with  a  solution  of  carbolic  acid  or  with  guaiacol; 
the  latter  drug  has  also  been  used  hypodermically,  with,  it  is  said,  happy 
results  in  removing  the  odor.  If  the  signs  of  cavity  are  distinct  an  attempt 
should  be  made  to  cleanse  it  by  direct  injections  of  an  antiseptic  solution. 
If  the  patient's  condition  is  good  and  the  gangrenous  region  can  be  local- 
ized, surgical  interference  may  be  indicated.  Successful  cases  have  been 
reported.  The  general  condition  of  the  patient  is  always  such  as  to  demand 
the  greatest  care  in  the  matter  of  diet  and  nursing. 


VII.    ABSCESS    OF   THE    LUNG. 

Etiology. — Suppuration  occurs  in  the  lung  under  the  following  con- 
ditions: (1)  As  a  sequence  of  inflammation,  either  lobar  or  lobular.  Apart 
from  the  purulent  infiltration  this  is  unquestionably  rare,  and  even  in 
lobar  pneumonia  the  abscesses  are  of  small  size  and  usually  involve,  as 
Addison  remarked,  several  points  at  the  same  time.  On  the  other  hand, 
abscess  formation  is  extremely  frequent  in  the  deglutition  and  aspiration 
forms  of  lobular  pneumonia.  After  wounds  of  the  neck  or  operations 
upon  the  throat,  in  suppurative  disease  of  the  nose  or  larynx,  occasionally 
even  of  the  ear  (Volkmann),  infective  particles  reach  the  bronchial  tubes 
by  aspiration  and  excite  an  intense  inflammation  which  often  ends  in 
abscess.  Cancer  of  the  oesophagus,  perforating  the  root  of  the  lung  or  into 
the  bronchi,  may  produce  extensive  suppuration.  The  abscesses  vary  in 
size  from  a  walnut  to  an  orange,  and  have  ragged  and  irregular  walls,  and 
purulent,  sometimes  necrotic,  contents. 

(2)  Embolic,  so-called  metastatic,  abscesses,  the  result  of  infectious 
emboli,  are  extremely  common  in  a  large  proportion  of  all  cases  of  pysemia. 
They  may  occur  in  enormous  numbers  and  present  very  definite  char- 
acters. As  a  rule  they  are  superficial,  beneath  the  pleura,  and  often 
wedge-shaped.  At  first  firm,  grayish  red  in  color,  and  surrounded  by  a 
zone  of  intense  hypersemia,  suppuration  soon  follows'^vith  the  forma- 
tion of  a  definite  abscess.     The  pleura  is  usually  covered  with  greenish. 


NEW  GROWTHS  IN  THE  LUNGS.  663 

lymph,   and  perforation  sometimes  takes  place  with   the   production   of 
pneumothorax. 

(3)  Perforation  of  the  lung  from  without,  lodgment  of  foreign  bodies, 
and,  in  the  right  lung,  perforation  from  abscess  of  the  liver  or  a  suppurat- 
ing echinococcus  cyst  are  occasional  causes  of  pulmonary  abscess. 

(4)  Suppurative  processes  play  an  important  part  in  chronic  pulmonary 
tuberculosis,  many  of  the  symptoms  of  which  are  due  to  them. 

Symptoms. — Abscess  following  pneumonia  is  easily  recognized  by 
an  aggravation  of  the  general  symptoms  and  by  the  physical  signs  of  cavity 
and  the  characters  of  the  expectoration.  Embolic  abscesses  cannot  often 
be  recognized,  and  the  local  symptoms  are  generally  masked  in  the  gen- 
eral pygemic  manifestations.  The  characters  of  the  sputum  are  of  great 
importance  in  determining  the  presence  of  abscess.  The  odor  is  offensive, 
yet  it  rarely  has  the  horrible  fetor  of  gangrene  or  of  putrid  bronchitis. 
In  the  pus  fragments  of  lung  tissue  can  be  seen,  and  the  elastic  tissue  may 
be  very  abundant.  The  presence  of  this  with  the  physical  signs  rarely 
leaves  any  question  as  to  the  nature  of  the  trouble.  Embolic  cases  usually 
run  a  fatal  course.  Eecovery  occasionally  occurs  after  pneumonia.  In  a 
case  following  typhoid  fever  which  I  saw  at  the  Garfield  Hospital,  Kerr 
removed  two  ribs  and  found  free  in  the  pus  of  a  localized  empyema  a 
sequestrated  piece  of  lung,  the  size  of  the  palm  of  the  hand,  which  had 
sloughed  off  clearly  from  the  lower  lobe.  The  patient  made  a  good  re- 
covery. 

Medicinal  treatment  is  of  little  avail  in  abscess  of  the  lung.  When 
well  defined  and  superficial,  an  attempt  should  always  be  made  to 
open  and  drain  it.  A  number  of  successful  cases  have  already  been 
treated  in  this  way. 


VIII.    NEW   GROWTHS    IN    THE    LUNGS. 

Etiology  and  Morbid  Anatomy. — While  primary  tumors  are 
rare,  secondary  growths  are  not  uncommon. 

The  primary  growths  of  the  lung  are  either  encephaloid,  scirrhus  or 
epithelioma.  Eecent  observations  show  that  the  last  is  the  most  common 
form.  Sarcoma  also  is  occasionally  found  as  a  primary  growth,  and  still 
more  rarely  enchondroma. 

The  secondary  growths  may  be  of  various  forms.  Most  commonly  they 
follow  tumors  in  the  digestive  or  genito-urinary  organs;  not  infrequently 
also  tumors  of  the  bone.  There  may  be  encephaloid,  scirrhus,  epithelioma, 
colloid,  melano-sarcoma,  enchondroma,  or  osteoma. 

Primary  cancer  or  sarcoma  usually  involves  only  one  lung.  The  sec- 
ondary growths  are  distributed  in  both.  The  primary  growth  generally 
forms  a  large  mass,  which  may  occupy  the  greater  part  of  a  lung.  Occasion- 
ally the  secondary  growths  are  solitary  and  confined  chiefly  to  the  pleura. 
The  metastatic  growths  are  nearly  always  disseminated.  Occasionally  they 
occupy  a  large  portion  of  the  pulmonary  tissue.  In  a  case  of  colloid  cancer 
secondary  to  cancer  of  the  pancreas,  I  found  both  lungs  voluminous,  heavy 


QQ4:  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

only  slightly  crepitant,  and  occupied  by  circular  translucent  masses,  vary- 
ing in  size  from  a  pea  to  a  large  walnut. 

There  are  numerous  accessory  lesions  in  the  pulmonary  new  growths. 
There  may  be  pleurisy,  either  cancerous  or  sero-fibrinous.  The  effusion 
may  be  hgemorrhagic,  but  in  200  cases  of  cancer,  primary  or  secondary,  of 
the  lungs  and  pleura  analyzed  by  Moutard-Martin,  hgemorrhagic  efEusion 
occurred  in  only  12  per  cent.  The  tracheal  and  bronchial  glands  are  usu- 
ally affected,  the  cervical  glands  not  infrequently,  and  occasionally  even 
the  inguinal. 

The  disease  is  most  common  in  the  middle  period  of  life.  The  pri- 
mary form  affects  the  sexes  equally,  but  secondary  cancer  is  much  more 
frequent  in  women  than  in  men.  The  conditions  which  predispose  to  it 
are  quite  unknown.  It  is  a  remarkable  fact  that  the  workers  in  the 
Schneeberg  cobalt  mines  are  very  liable  to  primary  cancer  of  the  lungs. 
It  is  stated  that  in  this  region  a  considerable  proportion  of  all  deaths  in 
persons  over  forty  are  due  to  this  disease. 

Symptoms. — The  clinical  features  of  neoplasms  of  the  lungs  are  by 
no  means  distinctive,  particularly  in  the  case  of  primary  growths.  The 
patient  may,  indeed,  as  noted  by  Walshe,  present  no  symptoms  pointing 
to  intrathoracic  disease.  Among  the  more  important  symptoms  are  pain, 
particularly  when  the  pleura  is  involved;  dyspnoea,  which  is  apt  to  be 
paroxysmal  when  due  to  pressure  upon  the  trachea;  cough,  which  may  be 
dry  and  painful  and  accompanied  by  the  expectoration  of  a  dark  mucoid 
sputum.  This  so-called  prune-juice  expectoration,  which  was  present  10 
times  in  18  cases  of  primary  cancer  of  the  lung,  was  thought  by  Stokes 
to  be  of  great  diagnostic  value. 

In  many  instances  there  are  signs  of  compression  of  the  large  veins, 
producing  lividity  of  the  face  and  upper  extremities,  or  occasionally  of 
only  one  arm.  Compression  of  the  trachea  and  bronchi  may  give  rise  to 
urgent  dyspnoea.  The  heart  may  be  pushed  over  to  the  opposite  side. 
The  pneumogastric  and  recurrent  laryngeal  nerves  are  occasionally  in- 
volved in  the  growth. 

Physical  Signs. — The  patient,  according  to  Walshe,  usually  lies  on 
the  affected  side.  On  inspection  this  side  may  be  enlarged  and  immo- 
bile and  the  intercostal  spaces  are  obliterated.  This  is  more  commonly 
due  to  the  effusion  than  to  the  growth  itself.  The  external  lymph- 
glands  may  be  enlarged,  particularly  the  clavicular.  The  signs,  on  per- 
cussion and  auscultation,  are  varied,  depending  much  upon  the  pres- 
ence or  absence  of  fluid.  Signs  of  consolidation  are,  of  course,  present; 
the  tactile  fremitus  is  absent  and  the  breath-sounds  are  usually  dimin- 
ished in  intensity.  Occasionally  there  is  typical  bronchial  breathing. 
Among  other  symptoms  may  be  mentioned  fever,  which  is  present 
in  a  certain  number  of  cases.  Emaciation  is  not  necessarily  extreme. 
The  duration  of  the  disease  is  from  six  to  eight  months.  Occasion- 
ally it  runs  a  very  acute  course,  as  noted  by  Carswell.  Cases  are  re- 
ported in  which  death  occurred  in  a  month  or  six  weeks,  and  in  one  in- 
stance (Jaccoud)  the  patient  died  in  a  week  from  the  onset  of  the  symp- 
toms. 


ACUTE  PLEURISY.  665 

Diagnosis. — In  secondary  growths  this  is  not  difficult.  The  develop- 
ment of  pulmonary  symptoms  within  a  year  or  two  after  the  removal  of 
a  cancer  of  the  breast,  or  after  the  amputation  of  a  limb  for  osteo-sarcoma, 
or  the  onset  of  similar  symptoms  in  connection  wdth  cancer  of  the  liver, 
or  of  the  uterus,  or  of  the  rectum,  would  be  extremely  suggestive.  In 
primary  cases  the  unilateral  involvement,  the  anomalous  character  of  the 
physical  signs,  the  occurrence  of  prune-juice  expectoration,  the  progressive 
wasting,  and  the  secondary  involvement  of  the  cervical  glands  are  the  im- 
portant points  in  the  diagnosis. 

New  growths  are  occasionally  primary  in  the  pleura  (Harris,  Journal 
of  Pathology,  vol.  ii). 


Y.    DISEASES   OF  THE  PLETJKA. 
I.    ACUTE    PLEURISY. 

Anatomically,  the  cases  may  be  divided  into  dry  or  adhesive  pleurisy 
and  pleurisy  with  effusion.  Another  classification  is  into  primary  or  sec- 
ondary forms.  According  to  the  course  of  the  disease,  a  division  may  be 
made  into  acute  and  chronic  pleurisy,  and  as  it  is  impossible,  at  present, 
to  group  the  various  forms  etiologically,  this  is  perhaps  the  most  satisfac- 
tory division.    The  following  forms  of  acute  pleurisy  may  be  considered: 

I.  FiBEiNous    OK   Plastic    Pleukist. 

In  this  the  pleural  membrane  is  covered  by  a  sheeting  of  lymph  of 
variable  thickness,  which  gives  it  a  turbid,  granular  appearance,  or  the 
fibrin  may  exist  in  distinct  layers.  It  occurs  (1)  as  an  independent  affec- 
tion, following  cold  or  exposure.  This  form  of  acute  plastic  pleurisy 
without  fluid  exudate  is  not  common  in  perfectly  healthy  individuals. 
Cases  are  met  with,  however,  in  which  the  disease  sets  in  with  the  usual 
symptoms  of  pain  in  the  side  and  slight  fever,  and  there  are  the  physical 
signs  of  pleurisy  as  indicated  by  the  friction.  After  persisting  for  a  few 
days,  the  friction  murmur  disappears  and  no  exudation  occurs.  Union 
takes  place  between  the  membranes,  and  possibly  the  pleuritic  adhesions 
which  are  found  in  such  a  large  percentage  of  all  bodies  examined  after 
death  originate  in  these  slight  fibrinous  pleurisies. 

Fibrinous  pleurisy  occurs  (2)  as  a  secondary  process  in  acute  diseases 
of  the  lung,  such  as  pneumonia,  which  is  always  accompanied  by  a  certain 
amount  of  pleurisy,  usually  of  this  form.  Cancer,  abscess,  and  gangrene 
also  cause  plastic  pleurisy  when  the  surface  of  the  lung  becomes  involved. 
This  condition  is  specially  associated  in  a  large  number  of  cases  with 
tuberculosis.  Pleural  pain,  stitch  in  the  side,  and  a  dry  cough,  with 
marked  friction  sounds  on  auscultation  are  the  initial  phenomena  in 
many  instances  of  phthisis.  The  signs  are  usually  basic,  but  Burney  Yeo 
has  recently  called  attention  to  the  frequency  with  which  they  occur  at 
the  apex. 


QQQ  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

II.  Seeo-fibeinous    Pleueisy. 

In  a  majority  of  cases  of  inflammation  of  the  pleura  there  is,  with  the 
fibrin,  a  variable  amount  of  fluid  exudate,  which  produces  the  condition 
known  as  pleurisy  with  effusion. 

Etiology. — For  generations  physicians  have  considered  cold  the 
potent  factor  in  inducing  pleurisy.  This  may  be  true  in  many  cases,  but 
modern  views  of  serous  inflammations  scarcely  recognize  cold  as  anything 
more  than  a  predisposing  agent,  which  permits  the  action  of  various  micro- 
organisms. We  have  not  yet,  however,  brought  all  the  acute  pleurisies  into 
the  category  of  microbic  affections,  and  the  fact  remains  that  pleurisy 
does  follow  with  great  rapidity  a  sudden  wetting  or  a  chill.  Of  late 
years  an  attempt  has  been  made,  particularly  by  French  writers,  to  show 
that  the  majority  of  acute  pleurisies  are  tuberculous.  In  this  connection 
the  following  facts  may  be  admitted:  (1)  In  a  large  number  of  cases 
of  pleurisy  coming  on  abruptly  in  healthy  persons  the  disease  has  been 
shown — (a)  by  post-mortem,  in  cases  of  accidental  or  sudden  death,  (&)  by 
the  subsequent  history — to  be  tuberculous;  (2)  in  a  larger  proportion  of 
those  cases  which  come  on  insidiously  in  persons  who  have  been  in  failing 
health  or  who  are  delicate  the  disease  is  tuberculous  from  the  outset;  (3) 
the  acute  pleurisy,  which  occurs  as  a  secondary,  often  a  terminal,  event  in 
chronic  affections,  such  as  cirrhosis  of  the  liver,  Bright's  disease,  and  can- 
cer, is  very  frequently  tuberculous.  The  subsequent  history  of  cases  of 
acute  pleurisy  forces  us  to  conclude  that  in  at  least  two  thirds  of  the  cases 
it  is  a  curable  affection.  Several  years  ago  I  looked  over  the  post-mortem 
records  of  101  successive  cases  which  had  died  in  my  wards  with  pleurisy 
— fibrinous,  sero-fibrinous,  hgemorrhagic,  or  purulent.  Of  these,  there 
were  only  32  in  which  the  pleurisy  was  definitely  tuberculous.  One  of 
the  most  interesting  contributions  to  this  question  has  been  made  from  the 
records  of  Henry  I.  Bowditch,  of  Boston.  Of  90  cases  of  acute  pleurisy 
which  had  been  under  observation  between  1849  and  1879,  32  died  of  or 
had  phthisis — a  percentage  large  enough  to  indicate  what  an  important 
role  tuberculosis  plays  in  the  etiology  of  this  disease.  In  a  recent  series 
of  130  patients  with  primary  pleurisy  with  effusion,  followed  for  a  period 
of  seven  years  by  Hedges,  40  per  cent  became  tuberculous. 

Of  300  uncomplicated  cases  of  pleural  effusion  in  the  Massachusetts 
G-eneral  Hospital,  followed  by  E.  C.  Cabot,  the  subsequent  history  was  ascer- 
tained in  221;  followed  five  years  until  death  or  phthisis,  117;  well  after  five 
years,  96.  •# 

Bacteriology  of  Acute  Pleurisy. — From  a  bacteriological  standpoint  we 
may  recognize  three  groups  of  cases  of  acute  pleurisy,  caused  by  the  tubercle 
bacillus,  the  pneumococcus,  and  the  streptococcus,  respectively. 

Bacillus  tuberculosis  is  present  in  a  very  large  proportion  of  all  cases 
of  primary  or  so-called  idiopathic  pleurisy.  The  exudate  is  usually  sterile 
on  cover-slips  or  in  the  culture  and  inoculation  tests  made  in  the  ordinary 
way,  as  the  bacilli  are  very  scanty.  It  has  been  demonstrated  clearly 
that  a  large  amount  of  the  exudate  must  be  taken  to  make  the  test 
complete,  either  in  cultures  or  in  the  inoculation  of  animals.     Eichhorst 


ACUTE  PLEURISY.  667 

found  that  more  that  62  per  cent  were  demonstrated  as  tuberculous  when 
as  much  as  15  cc.  of  the  exudate  was  inoculated  into  test  animals,  while 
less  than  10  per  cent  of  the  cases  showed  tuberculosis  when  only  1  cc.  of  the 
exudate  was  used.  This  is  a  point  to  which  observers  should  pay  very 
special  attention.  Le  Damany  has  recently  in  55  primary  pleurisies  demon- 
strated the  tuberculous  character  of  all  but  4.  He  has  used  large  quantities 
of  the  fluid  for  his  inoculation  experiments. 

The  pneumococcus  pleurisy  is  almost  always  secondary  to  a  focus  of 
inflammation  in  the  lung.  It  may,  however,  be  primary.  The  exudate  is 
usually  purulent  and  the  outlook  is  very  favorable. 

The  streptococcus  pleurisy  is  the  typical  septic  form  which  may  occur 
either  from  direct  infection  of  the  pleura  through  the  lung  in  broncho- 
pneumonia, or  in  cases  of  streptococcus  pneumonia;  in  other  instances  it 
follows  infection  of  more  distant  parts.  The  acute  streptococcus  pleurisy  is 
the  most  serious  and  fatal  of  all  forms. 

Among  other  bacteria  which  have  been  found  are  the  staphylococcus, 
Friedlander's  bacillus,  the  typhoid  bacillus,  and  the  diphtheria  bacillus. 

Morbid  Anatomy. — In  sero-fibrinous  pleurisy  the  serous  exudate  is 
abundant  and  the  fibrin  is  found  on  the  pleural  surfaces  and  scattered 
through  the  fluid  in  the  form  of  flocculi.  The  proportions  of  these 
constituents  vary  a  great  deal.  In  some  instances  there  is  very  little 
membranous  fibrin;  in  others  it  forms  thick,  creamy  layers  and  exists 
in  the  dependent  part  of  the  fluid  as  whitish,  curd-like  masses.  The 
fluid  of  sero-fibrinous  pleurisy  is  of  a  lemon  color,  either  clear  or  slightly 
turbid,  depending  on  the  number  of  formed  elements.  In  some  instances 
it  has  a  dark-brown  color.  The  microscopical  examination  of  the  fluid 
shows  leucocytes,  occasional  swollen  cells,  which  may  possibly  be  derived 
from  the  pleural  endothelium,  shreds  of  fibrillated  fibrin,  and  a  variable 
number  of  red  blood-corpuscles.  On  boiling,  the  fluid  is  found  to  be  rich 
in  albumin.  Sometimes  it  coagulates  spontaneously.  Its  composition 
closely  resembles  that  of  blood-serum.  Cholesterin,  uric  acid,  and  sugar 
are  occasionally  found.  The  amount  of  the  effusion  varies  from  -J  to  4 
litres. 

The  lung  in  acute  sero-fibrinous  pleurisy  is  more  or  less  compressed.  If 
the  exudation  is  limited  the  lower  lobe  alone  is  atelectatic;  but  in  an  exten- 
sive effusion  which  reaches  to  the  clavicle  the  entire  lung  will  be  found 
lying  close  to  the  spine,  dark  and  airless,  or  even  bloodless — i.  e.,  car- 
nified. 

In  large  exudations  the  adjacent  organs  are  displaced.  In  large  right- 
sided  pleurisies  the  liver  is  much  depressed.  Eather  varying  statements 
are  made  with  reference  to  the  position  of  the  heart  and  as  to  whether  or 
not  it  rotates  on  its  axis.  In  a  number  of  post-mortems  I  have  carefully 
studied  its  position,  both  in  pneumothorax  and  in  large  effusions,  and  can 
speak  with  some  degree  of  certainty  on  the  following  points:  (1)  Even  in 
the  most  extensive  left-sided  exudation  there  is  no  rotation  of  the  apex 
of  the  heart,  which  in  no  case  was  to  the  right  of  the  mid-sternal  line; 
(2)  the  relative  position  of  the  apex  and  base  is  usually  maintained;  in 
some  instances  the  apex  is  lifted,  in  others  the  whole  heart  lies  more  trans- 


668  DISEASES  OF  THE  RESPIRATORY  SYSTEM.  

versely;  (3)  the  right  chambers  of  the  heart  occupy  the  greater  portion  of 
the  front,  so  that  the  displacement  is  rather  a  definite  dislocation  of  the 
mediastinum,  with  the  pericardium,  to  the  right,  than  any  special  twisting 
of  the  heart  itself;  (4)  the  kink  or  twist  in  the  inferior  vena  cava  described 
by  Bartels  was  not  present  in  any  of  the  cases. 

Symptoms. — Prodromes  are  not  uncommon,  but  the  disease  may  set 
in  abruptly  with  a  chill,  followed  by  fever  and  a  severe  pain  in  the  side. 
In  very  many  cases,  however,  the  onset  is  insidious.  Washbourn  has  called 
attention  to  the  frequency  with  which  the  pneumococcus  pleurisy  sets  in 
with  the  features  of  pneumonia.  The  pain  in  the  side  is  the  most  distress- 
ing symptom,  and  is  usually  referred  to  the  nipple  or  axillary  regions.  It 
must  be  remembered,  however,  that  pleuritic  pain  may  be  felt  in  the  abdo- 
men or  low  down  in  the  back,  particularly  when  the  diaphragmatic  sur- 
face of  the  pleura  is  involved.  It  is  lancinating,  sharp,  and  severe,  and  is 
aggravated  by  cough.  At  this  early  stage,  on  auscultation,  sometimes  in- 
deed on  palpation,  a  dry  friction  rub  can  be  detected.  The  fever  rarely 
rises  so  rapidly  as  in  pneumonia,  and  does  not  reach  the  same  grade.  A 
temperature  of  from  102°  to  103°  is  an  average  pyrexia.  It  may  drop  to 
normal  at  the  end  of  a  week  or  ten  days  without  the  appearance  of  any 
definite  change  in  the  physical  signs,  or  it  may  persist  for  several  weeks. 
The  temperature  of  the  affected  is  higher  than  that  of  the  sound  side. 
Cough  is  an  early  symptom  in  acute  pleurisy,  but  is  rarely  so  distressing  or 
so  frequent  as  in  pneumonia.  There  are  instances  in  which  it  is  absent. 
The  expectoration  is  usually  slight  in  amount,  mucoid  in  character,  and 
occasionally  streaked  with  blood. 

At  the  outset  there  may  be  dyspnoea,  due  partly  to  the  fever  and  partly 
to  the  pain  in  the  side.  Later  it  results  from  the  compression  of  the  lung, 
particularly  if  the  exudation  has  taken  place  rapidly.  When,  however, 
the  fluid  is  effused  slowly,  one  lung  may  be  entirely  compressed  without 
inducing  shortness  of  breath,  except  on  exertion,  and  the  patient  will  lie 
quietly  in  bed  without  evincing  the  slightest  respiratory  distress.  When  the 
effusion  is  large  the  patient  usually  prefers  to  lie  upon  the  affected  side. 

Physical  Signs. — Inspection  shows  some  degree  of  immobility  on  the 
affected  side,  depending  upon  the  amount  of  exudation,  and  in  large  effu- 
sions an  increase  in  volume,  which  may  appear  to  be  much  more  than  it 
really  is  as  determined  by  mensuration.  The  intercostal  spaces  are  obliter- 
ated. In  right-sided  effusions  the  apex  beat  may  be  lifted  to  the  fourth 
interspace  or  be  pushed  beyond  the  left  nipple,  or  may  even  be  seen  in  the 
axilla.  When  the  exudation  is  on  the  left  side,  the  heart's  impulse  may 
not  be  visible;  but  if  the  effusion  is  large  it  is  seen  in  the  third  and  fourth 
spaces  on  the  right  side,  and  sometimes  as  far  out  as  the  nipple,  or  even 
beyond  it. 

Palpation  enables  us  more  successfully  to  determine  the  deficient  move- 
ments on  the  affected  side,  and  the  obliteration  of  the  intercostal  spaces, 
and  more  accurately  to  define  the  position  of  the  heart's  impulse.  In  sim- 
ple sero-fibrinous  effusion  there  is  rarely  any  oedema  of  the  chest  walls. 
It  is  scarcely  ever  possible  to  obtain  fluctuation.  Tactile  fremitus  is  greatly 
diminished  or  abolished.     If  the  effusion  is  slight  there  may  be  only  en- 


ACUTE  PLEURISY.  669 

feeblement.  The  absence  of  the  voice  vibrations  in  effusions  of  any  size 
constitutes  one  of  the  most  valuable  of  physical  signs.  In  children  there 
may  be  much  effusion  with  retention  of  fremitus.  In  rare  cases  the  vibra- 
tions may  be  communicated  to  the  chest  walls  through  localized  pleural 
adhesions. 

Mensuration. — With  the  cyrtometer,  if  the  effusion  is  excessive,  a  dif- 
ference of  from  half  an  inch  to  an  inch,  or  even,  in  large  effusions,  an 
inch  and  a  half,  may  be  found  between  the  two  sides.  Allowance  must 
be  made  for  the  fact  that  the  right  side  is  naturally  larger  than  the  left. 
With  the  saddle-tape  the  difference  in  expansion  between  the  two  sides 
can  be  conveniently  measured. 

Percussion. — Early  in  the  disease,  when  the  pain  in  the  side  is  severe 
and  the  friction  murmur  evident,  there  may  be  no  alteration,  but  with 
the  gradual  accumulation  of  the  fluid  the  resonance  becomes  defective, 
and  finally  gives  place  to  absolute  flatness.  From  day  to  day  the  gradual 
increase  in  height  of  the  fluid  may  be  studied.  In  a  pleuritic  effusion 
rising  to  the  fourth  rib  in  front,  the  percussion  signs  are  usually  very 
suggestive.  In  the  subclavicular  region  the  attention  is  often  aroused  at 
once  by  a  tympanitic  note,  the  so-called  Skoda's  resonance,  which  is  heard 
perhaps  more  commonly  in  this  situation  with  pleural  effusion  than  in 
any  other  condition.  It  shades  insensibly  into  a  flat  note  in  the  lower 
mammary  and  axillary  regions.  Skoda's  resonance  may  be  obtained  also 
behind,  just  above  the  limit  of  effusion.  The  dulness  has  a  peculiarly 
resistant,  wooden  quality,  differing  from  that  of  pneumonia  and  readily 
recognized  by  skilled  fingers.  It  has  long  been  known  that  when  the 
patient  is  in  the  erect  posture  the  upper  line  of  dulness  is  not  horizontal, 
but  is  higher  behind  than  it  is  in  front,  forming  a  parabola.  The  curve 
marking  the  intersection  of  the  plane  of  contact  of  lung  and  fluid  with 
the  chest  wall  has  been  variously  described.  The  "  Ellis  line  of  flatness," 
Avhich  Garland  has  verified  clinically  and  by  animal  experiments,  is  per- 
haps the  most  characteristic.  With  medium-sized  effusions  "  this  line  begins 
lowest  behind,  advances  upward  and  forward  in  a  letter-S  curve  to  the 
axillary  region,  whence  it  proceeds  in  a  straight  decline  to  the  sternum." 
Such  a  curve  is  present  only  when  the  patient  is  in  the  erect  position, 
when  the  lung  is  in  fairly  normal  condition,  since  then  by  its  elastic  ten- 
sion it  controls  the  position  and  shape  of  the  mass  of  fluid,  even  supporting 
the  entire  weight  of  a  considerable  exudate,  and  when  the  pleurre  are  free 
from  adhesions.  With  larger  exudates  the  curve  flattens  much,  but  the  S  can 
be  detached  with  the  fluid  as  high  as  the  third  rib.  Garland  emphasizes 
that  the  line  can  be  accurately  determined  only  by  light  percussion.  (Gar- 
land's exhaustive  work  on  Pneumo-dynamics.) 

On  the  right  side  the  dulness  passes  without  change  into  that  of  the 
liver.  On  the  left  side  in  the  nipple  line  it  extends  to  and  may  obliterate 
Traube's  semilunar  space.  If  the  effusion  is  moderate,  the  phenomenon 
of  movable  dulness  may  be  obtained  by  marking  carefully,  in  the  sitting 
posture,  the  upper  limit  in  the  mammary  region,  and  then  in  tlie  recum- 
bent posture,  noting  the  change  in  the  height  of  dulness.  This  infallible 
sign  of  fluid  cannot  always  be  obtained.     In  very  copious  exudation  the 


670  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

dulness  may  reach  the  clavicle  and  even  extend  beyond  the  sternal  margin 
of  the  opposite  side. 

Auscultation. — Early  in  the  disease  a  friction  rub  can  usually  be  heard, 
which  disappears  as  the  fluid  accumulates.  It  is  a  to-and-fro  dry  rub,  close 
to  the  ear,  and  has  a  leathery,  creaking  character.  There  is  another  pleural 
friction  sound  which  closely  resembles,  and  is  scarcely  to  be  distinguished 
from,  the  fine  crackling  crepitus  of  pneumonia.  This  may  be  heard  at  the 
commencement  of  the  disease,  and  also,  as  pointed  out  in  1844  by  Mac- 
Donnell,  Sr.,  of  Montreal,  when  the  effusion  has  receded  and  the  pleural 
layers  come  together  again. 

With  even  a  slight  exudation  there  is  weakened  or  distant  breathing. 
Often  inspiration  and  expiration  are  distinctly  audible,  though  distant,  and 
have  a  tubular  quality.  Sometimes  only  a  puffing  tubular  expiration  is 
heard,  which  may  have  a  metallic  or  amphoric  quality.  Loud  resonant 
rales  accompanying  this  may  forcibly  suggest  a  cavity.  These  pseudo- 
cavernous  signs  are  met  with  more  frequently  in  children,  and  often  lead 
to  error  in  diagnosis.  Above  the  line  of  dulness  the  breath-sounds  are  usu- 
ally harsh  and  exaggerated,  and  may  have  a  tubular  quality. 

The  vocal  resonance  is  usually  diminished  or  absent.  The  whispered 
voice  is  said  to  be  transmitted  through  a  serous  and  not  through  a  puru- 
lent exudate  (Baccelli^s  sign).  This  author  advises  direct  auscultation  in 
the  antero-lateral  region  of  the  chest.  There  may,  however,  be  intensifica- 
tion— bronchophony.  The  voice  sometimes  has  a  curious  nasal,  squeaking 
character,  which  was  termed  by  Laennec  cegophony,  from  its  supposed  re- 
semblance to  the  bleating  of  a  goat.  In  typical  form  this  is  not  common, 
but  it  is  by  no  means  rare  to  hear  a  curious  twang-like  quality  in  the  voice, 
particularly  at  the  outer  angle  of  the  scapula. 

In  the  examination  of  the  heart  in  cases  of  pleuritic  effusion  it  is  well 
to  bear  in  mind  that  when  the  apex  of  the  heart  lies  beneath  the  sternum 
there  may  be  no  impulse.  The  determination  of  the  situation  of  the  organ 
may  rest  with  the  position  of  maximum  loudness  of  the  sounds.  Over  the 
displaced  organ  a  systolic  murmur  may  be  heard.  When  the  lappet  of  lung 
over  the  pericardium  is  involved  on  either  side  there  may  be  a  pleuro-peri- 
cardial  friction.     A  leucocytosis  is  usually  present. 

The  course  of  acute  sero-fibrinous  pleurisy  is  very  variable.  After  per- 
sisting for  a  week  or  ten  days  the  fever  subsides,  the  cough  and  pain  dis- 
appear, and  a  slight  effusion  may  be  quickly  absorbed.  In  cases  in  which 
the  effusion  reaches  as  high  as  the  fourth  rib  recovery  is  usually  slower. 
Many  instances  come  under  observation  for  the  first  time,  after  two  or  three 
weeks'  indisposition,  with  the  fluid  at  a  level  with  the  clavicle.  The  fever 
may  last  from  ten  to  twenty  days  without  exciting  anxiety,  though,  as  a 
rule,  in  ordinary  pleurisy  from  cold,  as  we  say,  the  temperature  in  cases  of 
moderate  severity  is  normal  within  eight  or  ten  days.  Left  to  itself  the 
natural  tendency  is  to  resorption;  but  this  may  take  place  very  si  owl)". 
With  the  absorption  of  the  fluid  there  is  a  redux-friction  crepitus,  either 
leathery  and  creaking  or  crackling  and  rale-like,  and  for  months,  or  even 
longer,  the  defective  resonance  and  feeble  breathing  are  heard  at  the  base. 
Hare  modes  of  termination  are  perforation  and  discharge  through  the  lung. 


ACUTE  PLEURISY.  6Tl 

and  externally  through  the  chest  wall,  examples  of  which  have  been  re- 
corded by  Sahli. 

The  immediate  prognosis  in  pleurisy  with  effusion  is  good.  Of  320 
cases  at  St.  Bartholomew's  Hospital,  only  6.1  per  cent  died  before  leaving 
the  hospital  (Hedges). 

A  sero-fibrinous  exudate  may  persist  for  months  without  change,  par- 
ticularly in  tuberculous  cases,  and  will  sometimes  reaccumulate  after  aspi- 
ration and  resist  all  treatment.  After  persistence  for  more  than  twelve 
months,  in  spite  of  repeated  tapping,  a  serous  effusion  was  cured  by  inci- 
sion without  deformity  of  the  chest  (S.  West).  When  one  pleura  is  full  and 
the  heart  is  greatly  dislocated,  the  condition,  although  in  a  majority  of  cases 
producing  remarkably  little  disturbance,  is  not  without  risk.  Sudden  death 
may  occur,  and  its  possibility  under  these  circumstances  should  always  be 
considered.  I  have  seen  two  instances— one  in  right  and  the  other  in  left 
sided  effusion — both  due,  apparently,  to  syncope  following  slight  exertion, 
such  as  getting  out  of  bed.  In  neither  case,  however,  was  the  amount  of 
fluid  excessive.  Weil,  who  has  studied  carefully  this  accident,  concludes  as 
follows:  (1)  That  it  may  be  due  to  thrombosis  or  embolism  of  the  heart  or 
pulmonary  artery,  oedema  of  the  opposite  lung,  or  degeneration  of  the  heart 
muscle;  (2)  such  alleged  causes  as  mechanical  impediment  to  the  circulation, 
owing  to  dislocation  of  the  heart  or  twisting  of  the  great  vessels,  require 
further  investigation.  Death  may  occur  without  any  premonitory  symptoms. 

III.  PuEULENT  Pleueist  (Empyema). 

Etiology. — Pus  in  the  pleura  is  met  with  under  the  following  condi- 
tions: (a)  As  a  sequence  of  acute  sero-fibrinous  pleurisy.  It  is  not  always 
easy  to  say  why,  in  certain  cases,  the  exudate  becomes  purulent.  It  rarely 
does  so  in  the  acute  pleurisies  of  healthy  individuals.  In  children  many 
cases  are  probably  purulent  from  the  onset.  Aspiration,  which  is  said  to 
favor  the  occurrence  of  empyema,  in  my  experience  does  so  very  rarely. 
(&)  Purulent  pleurisy  is  common  as  a  secondary  inflammation  in  various 
infectious  diseases,  among  which  scarlet  fever  takes  the  first  place.  It  has 
long  been  known  that  the  pleurisy  supervening  in  the  convalescence  of  this 
disease  is  almost  always  purulent.  It  should  be  remembered  that  it  is  latent 
in  its  onset,  and  that  there  may  be  no  pulmonary  symptoms.  The  pleurisy 
following  typhoid  fever  is  also  usually  purulent.  Other  infectious  diseases 
— measles  and  whooping-cough — are  more  rarely  followed  by  this  compli- 
cation. Of  late  years  especial  attention  has  been  paid  to  the  connection 
of  pneumonia  with  empyema,  and  it  has  been  shown  that  very  many  cases 
come  on  insidiously  either  in  the  course  of  or  during  convalescence  from 
this  disease;  and,  lastly,  a  limited  number  of  tuberculous  pleurisies  early 
become  purulent,  (c)  Empyema  results  from  local  causes — fracture  of  the 
rib,  penetrating  wounds,  malignant  disease  of  the  lung  or  oesophagus,  and, 
perhaps  most  frequently  of  all,  the  perforation  of  the  pleura  by  tuberculous 
cavities. 

The  bacteriology  of  empyema  is  of  great  importance.  A  sterile  exudate 
suggests  tuberculosis.  In  many  cases  the  pneumococci  are  present,  and  these 
cases,  as  a  rule,  run  a  very  favorable  course.  The  streptococci  are  found 
42 


gY2  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

most  commonly  in  the  secondary  cases  in  connection  with  septic  processes. 
In  a  few  instances  psorosperms  have  been  present. 

Morbid  Anatomy. — On  opening  an  empyema  post  mortem,  we  usu- 
ally find  that  the  effusion  has  separated  into  a  clear,  greenish-yellow  serum 
above  and  the  thick,  cream-like  pus  below.  The  fluid  may  be  scarcely 
more  than  turbid,  with  flocculi  of  fibrin  through  it.  In  the  pneumococcus 
empyema  the  pus  is  usually  thick  and  creamy.  It  usually  has  a  heavy, 
sweetish  odor,  but  in  some  instances — particularly  those  following  wounds 
— it  is  fetid.  In  cases  of  gangrene  of  the  lung  or  pleura  the  pus  has  a 
horribly  stinking  odor.  Microscopically  it  has  the  characters  of  ordinary 
pus.  The  pleural  membranes  are  greatly  thickened,  and  present  a  grayish- 
white  layer  from  1  to  2  mm.  in  thickness.  On  the  costal  pleura  there  may 
be  erosions,  and  in  old  cases  fistulous  communications  are  common.  The 
lung  may  be  compressed  to  a  very  small  limit,  and  the  visceral  pleura  also 
may  show  perforations. 

Symptoms. — Purulent  pleurisy  may  begin  abruptly,  with  the  symp- 
toms already  described.  More  frequently  it  comes  on  insidiously  in  the 
course  of  other  diseases  or  follows  an  ordinary  sero-fibrinous  pleurisy.  There 
may  be  no  pain  in  the  chest,  very  little  cough,  and  no  dyspnoea,  unless  the 
side  is  very  full.  Symptoms  of  septic  infection  are  rarely  wanting.  If 
in  a  child,  there  is  a  gradually  developing  pallor  and  weakness;  sweats  occur, 
and  there  is  irregular  fever.  A  cough  is  by  no  means  constant.  The  leu- 
cocytes are  usually  much  increased;  in  one  fatal  case  they  numbered  115,- 
000  per  cubic  millimetre. 

Physical  Signs. — Practically  they  are  those  already  considered  in  pleu- 
risy with-  effusion.  There  are,  however,  one  or  two  additional  points  to  be 
mentioned.  In  empyema,  particularly  in  children,  the  disproportion  be- 
tween the  sides  may  be  extreme.  The  intercostal  spaces  may  not  only  be 
obliterated,  but  may  bulge.  Not  infrequently  there  is  oedema  of  the  chest 
walls.  The  network  of  subcutaneous  veins  may  be  very  distinct.  It  must 
not  be  forgotten  that  in  children  the  breath-soimds  may  be  loud  and  tubular 
over  a  purulent  effusion  of  considerable  size.  Whispered  pectoriloquy  is 
usually  not  heard  in  empyema  (Baccelli's  sign).  The  dislocation  of  the 
heart  and  the  displacement  of  the  liver  are  more  marked  in  empyema  than 
in  sero-fibrinous  effusion — probably,  as  Senator  suggests,  owing  to  the 
greater  weight  of  the  fluid. 

A  curious  phenomenon  associated  generally  with  empyema,  but  which 
may  occur  in  the  sero-fibrinous  exudate,  is  pulsating  pleurisy,  first  described 
by  MacDonnell,  Sr.,  of  Montreal.  Of  42  cases  39  occurred  on  the  left  side. 
In  all  but  one  case  the  fluid  was  purulent.  Pneumothorax  may  be  present. 
There  are  two  groups  of  cases,  the  intrapleural  pulsating  pleurisy  and  the 
pulsating  empyema  necessitatis,  in  which  there  is  an  external  pulsating 
tumor.  No  satisfactory  explanation  has  been  offered  how  the  heart  im- 
pulse is  thus  forcibly  communicated  through  the  effusion. 

Empyema  is  a  chronic  affection,  which  in  a  few  instances  terminates 
naturally  in  recovery,  but  a  majority  of  cases,  if  left  alone,  end  in  death. 
The  following  are  some  modes  of  natural  cure:  {a)  By  absorption  of  the 
fluid.     In  small  effusions  this  may  take  place  gradually.     The  chest  wall 


ACUTE  PLEURISY.  673 

sinks.  The  pleural  layers  become  greatly  thickened  and  enclose  between 
them  the  inspissated  pus,  in  which  lime  salts  are  gradually  deposited.  Such 
a  condition  may  be  seen  once  or  twice  a  year  in  the  post-mortem  room  of 
any  large  hospital,  (h)  By  perforation  of  the  lung.  Although  in  this 
event  death  may  take  place  rapidly,  by  suffocation,  as  Aretgeus  says,  yet 
in  cases  in  which  it  occurs  gradually  recovery  may  follow.  Since  1873, 
when  I  saw  a  case  of  this  kind  in  Traube's  clinic,  and  heard  his  remarks 
on  the  subject,  I  have  seen  a  number  of  instances  of  the  kind  and  can 
corroborate  his  statement  as  to  the  favorable  termination  of  many  of  them. 
Empyema  may  discharge  either  by  opening  into  the  bronchus  and  forming 
a  fistula,  or,  as  Traube  pointed  out,  by  producing  necrosis  of  the  pulmonary 
pleura,  sufficient  to  allow  the  soakage  of  the  pus  through  the  spongy  lung 
tissue  into  the  bronchi.  In  the  first  way  pneumothorax  usually,  though 
not  always,  develops.  In  the  second  way  the  pus  is  discharged  without 
formation  of  pneumothorax.  Even  with  a  bronchial  fistula  recovery  is  pos- 
sible, (c)  By  perforation  of  the  chest  wall — empyema  necessitatis.  This 
is  by  no  means  an  unfavorable  method,  as  many  cases  recover.  The  per- 
foration may  occur  anywhere  in  the  chest  wall,  but  is,  as  Cruveilhier  re- 
marked, more  common  in  front.  It  may  be  anywhere  from  the  third  to 
the  sixth  interspace,  usually,  according  to  Marshall,  in  the  fifth.  It  may 
perforate  in  more  than  one  place,  and  there  may  be  a  fistulous  communica- 
tion which  opens  into  the  pleura  at  some  distance  from  the  external  orifice. 
The  tumor,  when  near  the  heart,  may  pulsate.  The  discharge  may  persist 
for  years.  In  Copeland's  Dictionary  is  mentioned  an  instance  of  a  Ba- 
varian physician  who  had  a  pleural  fistula  for  thirteen  years  and  enjoyed 
fairly  good  health. 

An  empyema  may  perforate  the  neighboring  organs,  the  oesophagus, 
peritonaeum,  pericardium,  or  the  stomach.  Very  remarkable  cases  are  those 
which  pass  down  the  spine  and  along  the  psoas  into  the  iliac  fossa,  and 
simulate  a  psoas  or  lumbar  abcess. 

IV.    TUBEHCULOUS    PlEUEIST. 

This  has  already  been  considered  (p.  284),  and  the  symptoms  and  phys- 
ical signs  do  not  require  any  description  other  than  that  already  given  in 
connection  with  the  sero-fibrinous  and  purulent  forms. 

V.  Other  Varieties  of  Pleurisy. 

Haemorrliagic  Pleurisy.— A  bloody  effusion  is  met  with  under  the  fol- 
lowing conditions:  (a)  In  the  pleurisy  of  asthenic  states,  such  as  cancer, 
Bright's  disease,  and  occasionally  in  the  malignant  fevers.  It  is  interest- 
ing to  note  the  frequency  with  which  hemorrhagic  pleurisy  is  found  in 
cirrhosis  of  the  liver.  It  occurred  in  the  very  patient  in  whom  Laennec 
first  accurately  described  this  disease.  While  this  may  be  a  simple  hemor- 
rhagic pleurisy,  in  a  majority  of  the  cases  which  I  have  seen  it  has  been 
tuberculous,  (b)  Tuberculous  pleurisy,  in  which  the  bloody  effusion  may 
result  from  the  rupture  of  newly  formed  vessels  in  the  soft  exudate  accom- 


674  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

pan}ing  the  eruption  of  miliary  tubercles,  or  it  may  come  from  more  slowly 
formed  tubercles  in  a  pleurisy  secondary  to  extensive  pulmonary  disease. 
(c)  Cancerous  pleurisy,  whether  primary  or  secondary,  is  frequently  haemor- 
rhagic.  (d)  Occasionally  ligemorrhagic  exudation  is  met  with  in  perfectly 
healthy  individuals,  in  AA'hom  there  is  not  the  slightest  suspicion  of  tuber- 
culosis or  cancer.  In  one  such  case,  a  large,  able-bodied  man,  the  patient 
was  to  my  knowledge  healthy  and  strong  eight  years  afterward.  And, 
lastly,  it  must  be  remembered  that  during  aspiration  the  lung  may  be 
wounded  and  blood  in  this  way  get  mixed  with  the  sero-fibrinous  exudate. 
The  condition  of  hsemorrhagic  pleurisy  is  to  be  distinguished  from  hemo- 
thorax, due  to  the  rupture  of  aneurism  or  the  pressure  of  a  tumor  on  the 
thoracic  veins. 

Diaphragmatic  Pleurisy. — The  inflammation  may  be  limited  partly  or 
chiefly  to  the  diaphragmatic  surface.  This  is  often  a  dry  pleurisy,  but 
there  may  be  effusion,  either  sero-fibrinous  or  purulent,  which  is  circum- 
scribed on  the  diaphragmatic  surface.  In  these  cases  the  pain  is  low  in 
the  zone  of  the  diaphragm  and  may  simulate  that  of  acute  abdominal  dis- 
ease. It  may  be  intensified  by  pressure  at  the  point  of  insertion  of  the 
diaphragm  at  the  tenth  rib.  The  diaphragm  is  fixed  and  the  respiration 
is  thoracic  and  short.  Andral  noted  in  certain  cases  severe  dyspnoea  and 
attacks  simulating  angina.  As  mentioned,  the  effusion  is  usually  plastic, 
not  serous.  Serous  or  purulent  effusions  of  any  size  limited  to  the  dia- 
phragmatic surface  are  extremely  rare.  Intense  subjective  with  trifling 
objective  features  are  always  suggestive  of  diaphragmatic  pleurisy. 

Encysted  Pleurisy. — The  effusion  may  be  circumscribed  by  adhesions  or 
separated  into  two  or  more  pockets  or  loculi,  which  communicate  with  each 
other.  This  is  most  common  in  empyema.  In  these  cases  there  have 
usually  been,  at  different  parts  of  the  pleura,  multiple  adhesions  by  which 
the  fluid  is  limited.  In  other  instances  the  recent  false  membranes  may 
encapsulate  the  exudation  on  the  diaphragmatic  surface,  for  example,  or  the 
part  of  the  pleura  posterior  to  the  mid-axillary  line.  The  condition  may 
be  very  puzzling  during  life,  and  present  special  difficulties  in  diagnosis. 
In  some  cases  the  tactile  fremitus  is  retained  along  certain  lines  of  adhe- 
sion.    The  exploratory  needle  should  be  freely  used. 

Interlobar  Pleurisy]  forms  an  interesting  and  not  uncommon  variety. 
In  nearly  every  instance  of  acute  pleurisy  the  interlobular  serous  surfaces 
are  also  involved  and  closely  agglutinated  together,  and  sometimes  the  fluid 
is  encysted  between  them.  In  this  position  tubercles  are  to  be  carefully 
looked  for.  In  a  case  of  this  kind  following  pneumonia  there  was  between 
the  lower  and  upper  and  middle  lobes  of  the  right  side  an  enormous  puru- 
lent collection,  which  looked  at  first  like  a  large  abscess  of  the  lung.  These 
collections  may  perforate  the  bronchi,  and  the  cases  present  special  diffi- 
culties in  diagnosis. 

Diagnosis  of  Pleurisy. — Acute  plastic  pleurisy  is  readily  recog- 
nized. In  the  diagnosis  of  pleuritic  effusion  the  first  question  is.  Does  a 
fluid  exudate  exist?  the  second,  "What  is  its  nature?  In  large  effusions 
the  increase  in  the  size  of  the  affected  side,  the  immobility,  the  absence  of 
tactile  fremitus,  together  with  the  displacement  of  organs,  give  infallible 


ACUTE  PLEURISY.  675 

indications  of  the  presence  of  fluid.  The  chief  difficulty  arises  in  effusions 
of  moderate  extent,  when  the  dulness,  the  presence  of  bronchophony,  and, 
perhaps,  tubular  breathing  may  simulate  pneumonia.  The  chief  points  to 
be  borne  in  mind  are:  (a)  Differences  in  the  onset  and  in  the  general  char- 
acters of  the  two  affections,  more  particularly  the  initial  chill,  the  higher 
fever,  more  urgent  dyspnoea,  and  the  rusty  expectoration,  which  charac- 
terize pneumonia.  As  already  mentioned,  some  of  the  cases  of  pneumo- 
coccus  pleurisy  set  in  like  pneumonia,  {b)  Certain  physical  signs — the  more 
wooden  character  of  the  dulness,  the  greater  resistance,  and  the  marked 
diminution  or  the  absence  of  tactile  fremitus  in  pleurisy.  The  auscultatory 
signs  may  be  deceptive.  It  is  usually,  indeed,  the  persistence  of  tubular 
breathing,  particularly  the  high-pitched,  even  amphoric  expiration,  heard 
in  some  cases  of  pleurisy,  which  has  raised  the  doubt.  The  intercostal 
spaces  are  more  commonly  obliterated  in  pleuritic  effusion  than  in  pneu- 
monia. As  already  mentioned,  the  displacement  of  organs  is  a  very  valuable 
sign.  Nowadays  with  the  hypodermic  needle  the  question  is  easily  settled. 
A  separate  small  syringe  with  a  capacity  of  two  drachms  should  be  reserved 
for  exploratory  purposes,  and  the  needle  should  be  longer  and  firmer  than 
in  the  ordinary  hypodermic  instrument.  With  careful  preliminary  disin- 
fection the  instrument  can  be  used  with  impunity,  and  in  cases  of  doubt 
the  exploratory  puncture  should  be  made  without  hesitation.  Pneumo- 
thorax is  an  occasional  sequence.  The  hypodermic  needle  is  especially 
useful  in  those  cases  in  which  there  are  pseudo-cavernous  signs  at  the  base. 
In  cases,  too,  of  massive  pneumonia,  in  which  the  bronchi  are  plugged  with 
fibrin,  if  the  patient  has  not  been  seen  from  the  outset,  the  diagnosis  may 
be  impossible  without  it. 

On  the  left  side  it  may  be  difficult  to  differentiate  a  very  large  peri- 
cardial from  a  pleural  effusion.  The  retention  of  resonance  at  the  base, 
the  presence  of  Skoda's  resonance  toward  the  axilla,  the  absence  of  dis- 
location of  the  heart-beat  to  the  right  of  the  sternum,  the  feebleness  of 
the  pulse  and  of  the  heart-sounds,  and  the  urgency  of  the  dyspnoea,  out 
of  all  proportion  to  the  extent  of  the  effusion,  are  the  chief  points  to  be 
considered.  Unilateral  hydrothorax,  which  is  not  at  all  uncommon  in 
heart-disease,  presents  signs  identical  with  those  of  sero-fibrinous  effusion. 
Certain  tumors  within  the  chest  may  simulate  pleural  effusion.  It  should 
be  remembered  that  many  intrathoracic  growths  are  accompanied  by  exu- 
dation. Malignant  disease  of  the  lung  and  of  the  pleura  and  hydatids  of 
the  pleura  produce  extensive  dulness,  with  suppression  of  the  breath-sounds, 
simulating  closely  effusion. 

On  the  right  side,  abscess  of  the  liver  and  hyrlatid  cysts  may  rise  high 
into  the  pleura  and  produce  dulness  and  enfeebled  breathing.  Often  in 
these  cases  there  is  a  friction  sound,  which  should  excite  suspicion,  and 
the  upper  outline  of  the  dulness  is  sometimes  plainly  convex.  In  a  case  of 
cancer  of  the  kidney  the  growth  involved  the  diaphragm  very  early,  and  for 
months  there  were  signs  of  pleurisy  before  our  attention  was  directed  to  the 
kidney.     In  all  these  instances  the  exploratory  puncture  should  be  made. 

The  second  question,  as  to  the  nature  of  the  fluid,  is  quickly  decided 
by  the  use  of  the  needle.     The  persistent  fever,  the  occurrence  of  sweats, 


676  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

a  leucocytosis,  and  the  increase  in  the  pallor  suggest  the  presence  of  pus. 
In  children  the  complexion  is  often  sallow  and  earthy.  In  protracted  cases, 
even  in  children,  when  the  general  symptoms  and  the  appearance  of  the 
patient  has  been  most  strongly  suggestive  of  pus,  the  syringe  has  withdrawn 
clear  fluid.  On  the  other  hand,  effusions  of  short  duration  may  be  puru- 
lent, even  when  the  general  symptoms  do  not  suggest  it.  The  following 
statement  may  be  made  with  reference  to  the  prognostic  import  of  the  bac- 
teriological examination  of  the  aspirated  fluid:  The  presence  of  the  pneumo- 
coccus  is  of  favorable  significance,  as  such  cases  usually  get  well  rapidly, 
even  with  a  single  aspiration.  The  streptococcus  empyema  is  the  most 
serious  form,  and  even  after  a  free  drainage  the  patient  may  succumb  to  a 
general  septicaemia.  A  sterile  fluid  indicates  in  a  majority  of  instances  a 
tuberculous  origin. 

Treatment. — At  the  onset  the  severe  pain  may  demand  leeches,  which 
usually  give  relief,  but  a  hypodermic  of  morphia  is  more  eft'ective.  The 
Paquelin  cautery  may  be  lightly  but  freely  applied.  It  is  well  to  adminis- 
ter a  mercurial  or  saline  purge.  Fixing  the  side  by  careful  strapping  with 
long  strips  of  adhesive  plaster,  which  should  pass  well  over  the  middle  line, 
drawn  tightly  and  evenly,  gives  great  relief,  and  I  can  corroborate  the 
statement  of  F.  T,  Eoberts  as  to  its  eflicacy.  Cupping,  wet  or  dry,  is  now 
seldom  employed.  Blisters  are  of  no  special  service  in  the  acute  stages, 
although  they  relieve  the  pain.  The  ice-bag  may  be  used  as  in  pneumonia. 
The  general  treatment  at  the  early  stage  should  be  rest  in  bed  and  a  liquid 
diet.  Medicines  are  rarely  required.  A  Dover's  powder  may  be  given  at 
night.     Mercurials  are  not  indicated. 

When  the  effusion  has  taken  place,  mustard  plasters  or  iodine,  pro- 
ducing slight  counter-irritation,  appear  useful,  particularly  in  the  later 
stages.  The  following  rational  plan  is  successful  in  some  cases.  It  is  based 
upon  the  idea  that  if  the  blood  serum  is  depleted  or,  if  it  is  kept  concen- 
trated, the  liquid  will  be  absorbed  from  the  lymph  spaces,  of  which  the 
pleura  is  one,  to  equalize  the  loss.  To  do  this  the  patient  should  have  the 
daily  amount  of  liquid  food  greatly  restricted.  If  there  is  no  fever,  a  meat 
diet,  with  an  egg  and  dry  bread  and  8  to  10  ounces  of  liquid  in  the  form  of 
milk  or  water,  should  be  given.  Salt  articles  of  food  may  be  used,  but  I 
do  not  think  it  necessary  to  give,  as  some  do,  doses  of  salt.  The  second 
element  in  the  treatment  is  the  active  depletion  of  blood  serum,  which  is 
effected  in  the  way  introduced  by  Matthew  Hay.  Every  morning,  if  the 
patient  is  robust,  otherwise  every  second  morning,  from  half  an  ounce  to 
an  ounce  and  a  half  of  Epsom  salts  is  given  an  hour  before  breakfast,  in  as 
concentrated  a  form  as  is  possible.  This  produces  copious  liquid  discharges. 
I  have  seen  large  exudations  disappear  rapidly  when  this  plan  was  fol- 
lowed. By  acting  upon  the  skin  and  kidneys,  the  same  end  may  be  ob- 
tained, but  with  much  less  certainty.  The  vapor  or  hot  bath  may  be 
used  and  an  occasional  dose  of  pilocarpin.  Diuretics,  such  as  digitalis, 
s(^uills,  and  acetate  of  potash,  may  sometimes  be  required.  I  rarely  resort, 
however,  to  diuretics  or  diaphoretics  in  the  treatment  of  pleurisy  with  effu- 
sion. Iodide  of  potassium  is  of  doubtful  benefit.  By  some  the  salicylates 
are  believed  to  be  of  special  efi&cacy. 


ACUTE   PLEURISY.  677 

Aspiration  of  the  fluid  is  the  most  thorough  and  satisfactory  method 
and  should  be  resorted  to  whenever  the  effusion  becomes  large  or  if  it  re- 
sists the  ordinary  methods  of  treatment.  The  credit  of  introducing  aspi- 
ration in  pleuritic  effusions  is  due  to  Morrill  Wyman^  of  Cambridge,  Mass., 
and  Henry  I.  Bowditch,  of  Boston.  Years  prior  to  Dieulafoy^s  work,  as- 
piration was  in  constant  use  at  the  Massachusetts  General  Hospital  and 
was  advocated  repeatedly  by  Bowditch.  As  the  question  is  one  of  some 
historical  interest,  I  give  Bowditch's  conclusions  concerning  aspiration, 
expressed  nearly  fifty  years  ago,  and  which  practically  represent  the  opinion 
of  to-day:  "  (1)  The  operation  is  perfectly  simple,  but  slightly  painful,  and 
can  be  done  with  ease  upon  any  patient  in  however  advanced  a  stage  of 
the  disease.  (2)  It  should  be  performed  forthwith  in  all  cases  in  which 
there  is  complete  filling  up  of  one  side  of  the  chest.  (3)  He  had  deter- 
mined to  use  it  in  any  case  of  even  moderate  effusion  lasting  more  than  a 
few  weeks  and  in  which  there  should  seem  to  be  a  disposition  to  resist 
ordinary  modes  of  treatment.  (4)  He  urged  this  practice  upon  the  profes- 
sion as  a  very  important  measure  in  practical  medicine;  believing  that  by 
this  method  death  may  frequently  be  prevented  from  ensuing  either  by 
sudden  attack  of  dyspnoea  or  subsequent  phthisis,  and,  finally,  from  the 
gradual  wearing  out  of  the  powers  of  life  or  inability  to  absorb  the  fluid. 
(5)  He  believed  that  this  operation  would  sometimes  prevent  the  occurrence 
of  those  tedious  cases  of  spontaneous  evacuation  of  purulent  fluid  and  those 
great  contractions  of  the  chest  which  occur  after  long-continued  effusion 
and  the  subsequent  discharge  or  absorption  of  a  fluid." 

There  is  scarcely  anything  to  be  added  to-day  to  these  observations. 
When  the  fluid  reaches  to  the  clavicle  the  indication  for  aspiration  is  im- 
perative, even  though  the  patient  be  comfortable  and  present  no  signs  of 
pulmonary  distress.  The  presence  of  fever  is  not  a  contra-indication;  in- 
deed, sometimes  with  serous  exudates  the  temperature  falls  after  aspiration. 

The  operation  is  extremely  simple  and  is  practically  without  risk.  The 
spot  selected  for  puncture  should  be  either  in  the  seventh  interspace  in  the 
mid-axilla  or  at  the  outer  angle  of  the  scapula  in  the  eighth  interspace. 
The  arm  of  the  patient  should  be  brought  forward  with  the  hand  on  the 
opposite  shoulder,  so  as  to  widen  the  interspaces.  The  needle  should  be 
thrust  in  close  to  the  upper  margin  of  the  rib,  so  as  to  avoid  the  intercostal 
artery,  the  wounding  of  which,  however,  is  an  excessively  rare  accident. 
The  fluid  should  be  withdrawn  slowly.  The  amount  will  depend  on  the 
size  of  the  exudate.  If  the  fluid  reaches  to  the  clavicle  a  litre  or  more  may 
be  withdrawn  with  safety.  In  chronic  cases  of  serous  pleurisy  after  re- 
peated tappings  S.  West  has  shown  the  great  value  of  free  incision  and 
drainage.  He  has  reported  cases  of  recovery  after  effusions  of  fifteen  and 
eighteen  months'  -standing. 

Symptoms  and  Accidents  during  Paracentesis. — Pain  is  usually  com- 
plained of  after  a  certain  amount  of  fluid  has  been  withdrawn;  it  is  sharp 
and  cutting  in  character.  Comjlilng  occurs  toward  the  close,  and  may  be 
severe  and  paroxysmal.'  Pneumothorax  may  follow  an  exploratory  puncture 
with  a  hypodermic  needle;  it  is  rare  during  aspiration.  Suhcutaneous  em- 
physema may  develop  from  the  point  of  puncture,  without  the  production 


678        ~  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

of  pneumothorax.  Albuminous  expectoration  is  a  remarkable  phenomenon 
described  by  French  writers.  It  usually  develops  after  the  tapping,  is  asso- 
ciated with  dyspnoea,  and  many  prove  suddenly  fatal.  Cerebral  symptoms. 
— Faintness  is  not  uncommon.  Epileptic  convulsions  may  occur  either 
during  the  withdrawal  or  while  irrigating  the  pleura.  I  have  seen  but  a 
single  instance.  They  are  very  difficult  to  explain  and  are  regarded  by  most 
authors  as  of  reflex  origin;  and  lastly  sudden  death  may  occur  either  from 
syncope  or  during  the  convulsions. 

Empyema  is  really  a  surgical  affection,  and  I  shall  make  only  a  few 
general  remarks  upon  its  treatment.  When  it  has  been  determined  by 
exploratory  puncture  that  the  fluid  is  purulent,  aspiration  should  not  be 
performed,  except  as  preliminary  to  operation  or  as  a  temporary  measure. 
Perhaps  it  is  better  not  to  have  an  exception  to  this  rule,  although  the 
empyemas  of  children  and  the  pneumonic  empyema  occasionally  get  well 
rapidly  after  a  single  tapping.  It  is  sad  to  think  of  the  number  of  lives 
which  are  sacriflced  annually  by  the  failure  to  recognize  that  empyema 
should  be  treated  as  an  ordinary  abscess,  by  free  incision.  The  operation 
dates  from  the  time  of  Hippocrates  and  is  by  no  means  serious.  A  ma- 
jority of  the  cases  get  well,  providing  that  free  drainage  is  obtained,  and 
it  makes  no  difference  practically  what  measures  are  followed  so  long  as 
this  indication  is  met.  The  good  results  in  any  method  depend  upon 
the  thoroughness  with  which  the  cavity  is  drained.  Irrigation  of  the 
cavity  is  rarely  necessary  unless  the  contents  are  fetid.  In  the  subsequent 
treatment  a  point  of  great  importance  in  facilitating  the  closure  of  the 
cavity  is  the  distention  of  the  lung  on  the  affected  side.  This  may  be 
accomplished  by  the  method  advised  by  Ralston  James,  which  has  been 
practised  with  great  success  in  the  surgical  wards  of  the  Johns  Hopkins 
Hospital.  The  patient  daily,  for  a  certain  length  of  time,  increasing  gradu- 
ally with  the  increase  of  his  strength,  transfers  by  air-pressure  water  from 
one  bottle  to  another.  The  bottles  should  be  large,  holding  at  least  a  gallon 
each,  and  by  the  arrangement  of  tubes,  as  in  the  "Wolff's  bottle,  an  expira- 
tory effort  of  the  patient  forces  the  water  from  one  bottle  into  the  other. 
In  this  way  expansion  of  the  compressed  lung  is  systematically  practised. 
The  abscess  cavity  is  gradually  closed,  partly  by  the  falling  in  of  the  chest 
wall  and  partly  by  the  expansion  of  the  lung.  In  some  instances  it  is 
necessary  to  resect  portions  of  one  or  more  ribs. 

The  physician  is  often  asked,  in  cases  of  empyema  with  emaciation, 
hectic  and  feeble  rapid  pulse,  whether  the  patient  could  stand  the  opera- 
tion. Even  in  the  most  desperate  cases  the  surgeon  should  never  hesitate 
to  make  a  free  incision. 


II.    CHRONIC    PLEURISY. 

This  affection  occurs  in  two  forms:  (1)  Chronic  pleurisy  with  effusion, 
in  which  the  disease  may  set  in  insidiously  or  may  follow  an  acute  sero- 
fibrinous pleurisy.  There  are  cases  in  which  the  liquid  persists  for  months 
or  even  years  without  undergoing  any  special  alteration  and  without  becom- 


CHKONIC  PLEURISY.  679 

ing  purulent.  Such  cases  have  the  characters  which  we  have  described 
under  pleurisy  with  effusion.  (3)  Chronic  dry  pleurisy.  The  cases  are  met 
with  (a)  as  a  sequence  of  ordinary  pleural  effusion.  When  the  exudate  is 
absorbed  and  the  layers  of  the  pleura  come  together  there  is  left  between 
them  a  variable  amount  of  fibrinous  material  which  gradually  undergoes 
organization,  and  is  converted  into  a  layer  of  firm  connective  tissue.  This 
process  goes  on  at  the  base,  and  is  represented  clinically  by  a  slight  grade  of 
flattening,  deficient  expansion,  defective  resonance  on  percussion,  and  en- 
feebled breathing.  After  recovery  from  empyema  the  flattening  and  re- 
traction may  be  still  more  marked.  In  both  cases  it  is  a  condition  which 
can  be  greatly  benefited  by  pulmonary  gymnastics.  In  these  firm,  fibrous 
membranes  calcification  may  occur,  particularly  after  empyema.  It  is 
not  very  uncommon  to  find  between  the  false  membranes  a  small  pocket 
of  fluid  forming  a  sort  of  pleural  cyst.  In  the  great  majority  of  these 
cases  the  condition  is  one  which  need  not  cause  anxiety.  There  may  be 
an  occasional  dragging  pain  at  the  base  of  the  lung  or  a  stitch  in  the  side, 
but  patients  may  remain  in  perfectly  good  health  for  years.  The  most 
advanced  grade  of  this  secondary  dry  pleurisy  is  seen  in  those  cases  of  em- 
pyema which  have  been  left  to  themselves  and  have  perforated  and  ulti- 
mately healed  by  a  gradual  absorption  or  discharge  of  the  pus,  with  retrac- 
tion of  the  side  of  the  chest  and  permanent  carnification  of  the  lung. 
Traumatic  lesions,  such  as  gunshot  wounds,  may  be  followed  by  an  identical 
condition.  Post  mortem,  it  is  quite  impossible  to  separate  the  layers  of  the 
pleura,  which  are  greatly  thickened,  particularly  at  the  base,  and  surround 
a  compressed,  airless,  fibroid  lung.  Bronchiectasis  may  gradually  develop, 
and  in  one  remarkable  case  which  I  have  seen  on  several  occasions  with 
Dr.  Blackader,  of  Montreal,  not  only  on  the  affected  side,  but  also  in  the 
lower  lobe  of  the  other  lung. 

(&)  Primitive  dry  pleurisy.  This  condition  may  directly  follow  the 
acute  plastic  pleurisy  already  described;  but  it  may  set  in  without  any 
acute  symptoms  whatever,  and  the  patient's  attention  may  be  called  to  it 
by  feeling  the  pleural  friction.  A  constant  effect  of  this  primitive  dry 
pleurisy  is  the  adhesion  of  the  layers.  This  is  probably  an  invariable  result, 
whether  the  pleurisy  is  primary  or  secondary.  The  organization  of  the  thin 
layer  of  exudation  in  a  pneumonia  will  unite  the  two  surfaces  by  delicate 
bands.  Pleural  adhesions  are  extremely  common,  and  it  is  rare  to  examine 
a  body  entirely  free  from  them.  They  may  be  limited  in  extent  or  univer- 
sal. Thin  fibrous  adhesions  do  not  produce  any  alteration  in  the  percussion 
characters,  and,  if  limited,  there  is  no  special  change  heard  on  ausculta- 
tion. Allien,  however,  there  is  general  synechia  on  both  sides  the  expansile 
movement  of  the  lung  is  considerably  impaired.  We  should  naturally 
think  that  universal  adhesions  would  interfere  materially  with  the  func- 
tion of  the  lungs,  but  practically  we  see  many  instances  in  which  there 
has  not  been  the  slightest  disturbance.  The  physical  signs  of  total  adhe- 
sion are  by  no  means  constant.  It  has  been  stated  that  there  is  a  marked 
disproportion  between  the  degree  of  expansion  of  the  chest  walls  and  the 
intensity  of  the  vesicular  murmur,  but  the  latter  is  a  very  variable  factor, 
and  under  perfectly  normal  conditions  the  breath-soundsj  with  very  full 


680  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

chest  expansion,  may  be  extremely  feeble.  The  diaphragm  phenomenon — 
Litten's  sign — is  absent. 

Is  there  a  primitive  dry  pleurisy  which  gradually  leads  to  great  thick- 
ening of  the  membranes,  and  which  ultimately  may  invade  the  lung  and 
induce  cirrhotic  change?  Upon  this  question  neither  pathologists  nor 
clinicians  agree.  I  think  that  Sir  Andrew  Clark,  in  his  Lumleian  lectures 
at  the  Eoyal  College  of  Physicians  (1885),  has  made  good  his  claim  that 
such  a  disease  does  exist.  Clinically  the  cases  are  of  great  interest,  and' 
should,  I  think,  be  separated,  on  the  one  hand,  from  the  condition  which 
follows  a  healed  empyema  or  old  pleurisy  with  effusion,  and,  on  the  other, 
from  the  rare  instances  of  primitive  cirrhosis  of  the  lung.  However,  in  all 
three  states  there  may  ultimately  be  an  almost  identical  clinical  picture. 
Anatomically  in  these  pleuritic  cases  the  pleura,  particularly  that  surround- 
ing the  lower  lobe,  sometimes  the  entire  membrane,  is  thickened,  the  two 
layers  are  intimately  united,  and  fibrinous  bands  passing  from  the  pleura 
traverse  the  lung  tissue,  sometimes  dividing  it  in  a  remarkable  way  into 
sections.  The  bronchi  may  present  marked  dilatations,  though  this  is 
not  always  the  case,  and  the  lung  tissue  is  more  or  less  sclerosed.  The 
cases  belong  to  the  group  of  chronic  pneumonias  called  by  Charcot  pleu- 
rogenous. 

Lastly,  there  is  a  primitive  dry  pleurisy  of  tuberculous  origin.  In  it 
both  parietal  and  costal  layers  are  greatly  thickened — perhaps  from  3  to 
3  mm.  each — and  present  firm  fibroid,  caseous  masses  and  small  tubercles, 
while  uniting  these  two  greatly  thickened  layers  is  a  reddish-gray  fibroid 
tissue,  sometimes  infiltrated  with  serum.  This  may  be  a  local  process  con- 
fined to  one  pleura,  or  it  may  be  in  both.  These  cases  are  sometimes  associ- 
ated with  a  similar  condition  in  the  pericardium  and  peritonseum. 

Occasionally  remarkable  vaso-motor  phenomena  occur  in  chronic  pleu- 
risy, whether  simple  or  in  connection  with  tuberculosis  of  an  apex.  Flush- 
ing or  sweating  of  one  cheek  or  dilatation  of  the  pupil  are  the  common 
manifestations.  They  appear  to  be  due  to  involvement  of  the  first  thoracic 
ganglion  at  the  top  of  the  pleural  cavity. 


III.    HYDROTHORAX. 

Hydrothorax  is  a  transudation  of  simple  non-inflammatory  fluid  into 
the  pleural  cavities,  and  occurs  as  a  secondary  process  in  many  affections. 
The  fluid  is  clear,  without  any  flocculi  of  fibrin,  and  the  membranes  are 
smooth.  It  is  met  with  more  particularly  in  connection  with  general 
dropsy,  either  renal,  cardiac,  or  h^mic.  It  may,  however,  occur  alone,  or 
with  only  slight  oedema  of  the  feet.  A  child  was  admitted  to  the  Mont- 
real General  Hospital  with  urgent  dyspnoea  and  cyanosis,  and  died  the 
night  after  admission.  She  had  extensive  bilateral  hydrothorax,  which 
had  come  on  early  in  the  nephritis  of  scarlet  fever.  In  renal  disease  hydro- 
thorax is  almost  always  bilateral,  but  in  heart  affections  one  pleura  is  more 
commonly  involved.  The  physical  signs  are  those  of  pleural  effusion,  but 
the  exudation  is  rarely  excessive.    In  kidney  and  heart-disease,  even  when 


PNEUMOTHORAX.  681 

there  is  no  general  dropsy,  the  occurrence  of  dyspnoea  should  at  once 
direct  attention  to  the  pleura,  since  many  patients  are  carried  off  by  a 
rapid  effusion.  Post-mortem  records  show  the  frequency  with  which  this 
condition  is  overlooked.  The  saline  purges  will  in  many  cases  rapidly 
reduce  the  effusion,  but,  if  necessary,  aspiration  should  repeatedly  be 
practised. 


IV.    PNEUMOTHORAX  {Hydro- Pneumothorax  and  Pyo-PneumotJiorax). 

Air  alone  in  the  pleural  cavity,  to  which  the  term  pneumothorax  is 
strictly  applicable,  is  an  extremely  rare  condition.  It  is  almost  invariably 
associated  with  a  serous  fluid — hydro-pneumothorax,  or  with  pus — pyo- 
pneumothorax. 

Etiology. — There  exists  normally  within  the  pleural  cavity  of  an  adult 
a  negative  pressure  of  several  millimetres  of  mercury,  due  to  the  recoil  of 
the  distended,  perfectly  elastic,  lung.  Hence  through  any  opening  con- 
necting the  pleural  cavity  with  the  external  air  we  should  expect  air  to 
rush  in  until  this  negative  pressure  is  relieved.  To  explain  the  absence  of 
pneumothorax  in  a  few  cases  in  which  it  would  be  expected,  S.  "West  has 
assumed  the  existence  of  a  cohesion  between  the  pleurae  which  overcomes 
the  tendency  of  the  chest  to  this  condition,  but  this  force  has  not  as  yet 
been  satisfactorily  demonstrated. 

In  a  case  of  pneumothorax,  if  the  opening  causing  it  remain  patent, 
the  intrathoracic  pressure  will  be  that  of  the  atmosphere,  the  lung  will  be 
found  to  have  collapsed  by  virtue  of  its  own  elastic  tension,  the  intercostal 
grooves  obliterated,  the  heart  displaced  to  the  other  side,  and  the  diaphragm 
lower  than  normal,  because  the  negative  pressure  by  reason  of  which  these 
organs  are  retained  in  their  ordinary  position  has  been  relieved.  If  the 
opening  becomes  closed  the  intrathoracic  pressure  may  rise  above  the  at- 
mospheric and  the  above-mentioned  displacements  be  much  increased. 
Some  of  the  reasons  for  this  rise  of  pressure  are,  the  valvular  action  of  the 
opening  during  violent  expiratory  efforts,  the  rise  of  temperature  of  the  im- 
prisoned gas,  and  the  compression  of  the  air  by  the  usual  effusion  into  the 
cavity. 

Pneumothorax  arises:  (1)  In  perforating  wounds  of  the  chest,  in  which 
case  it  is  sometimes  associated  with  extensive  cutaneous  emphysema.  It 
has  followed  exploratory  puncture.  Herman  Biggs  has  reported  two  cases 
and  I  have  seen  it  twice.  Pneumothorax  rarely  follows  fracture  of  the  rib, 
even  though  the  lung  may  be  torn.  (2)  In  perforation  of  the  pleura 
through  the  diaphragm,  usually  by  malignant  disease  of  the  stomach  or 
colon.  The  pleura  may  also  be  perforated  in  cases  of  cancer  of  the  oesoph- 
agus. (3)  When  the  lung  is  perforated.  This  is  by  far  the  most  com- 
mon cause,  and  may  occur:  (a)  In  a  normal  lung  from  rupture  of  the 
air-vesicles  during  straining  or  even  when  at  rest.  Special  attention  has 
been  called  to  this  accident  by  S.  West  and  De  H.  Hall.  The  air  may  be 
absorbed  and  no  ill  effect  follows.  It  does  not  necessarily  excite  pleurisy, 
as  pointed  out  many  yeare  ago  by  Gairdner,  but  inflammation  and  effusion 


582  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

are  the  usual  result.  In  a  recent  case  the  condition  developed  as  the  pa- 
tient was  going  down-stairs;  no  effusion  followed;  he  did  not  react  to 
tuberculin.  (6)  From  perforation  due  to  local  disease  of  the  lung,  either 
the  ■  softening  of  a  caseous  focus  or  the  breaking  of  a  tuberculous  cavity. 
According  to  S.  West,  90  per  cent  of  all  the  cases  are  due  to  this  cause. 
Less  common  are  the  cases  due  to  septic  broncho-pneumonia  and  to  gan- 
grene. A  rare  cause  is  the  breaking  of  a  hsemorrhagic  infarct  in  chronic 
heart-disease,  of  which  I  met  an  instance  a  few  years  ago.  (c)  Perfora- 
tion of  the  lung  from  the  pleura,  which  arises  in  certain  cases  of  empyema 
and  produces  a  pleuro-bronchial  fistula,  (d)  Spontaneously,  by  the  de- 
velopment in  pleural  exudates  of  the  gas  bacillus  (B.  aerogenes  capsulatus 
Welch). 

Pneumothorax  occurs  chiefly  in  adults,  though  cases  are  met  with  in 
very  young  children.    It  is  more  frequent  in  males  than  in  femalea.__ 

Morbid  Anatomy. — If  a  trocar  or  blow-pipe  is  inserted  between 
the  ribs,  there  may  be  a  jet  of  air  of  sufficient  strength  to  blow  out  a 
lighted  match.  On  opening  the  thorax  the  mediastinum  and  pericardium 
are  seen  to  be  pushed,  or  rather,  as  Douglas  Powell  pointed  out,  drawn 
over  to  the  opposite  side;  but,  as  before  mentioned,  the  heart  is  not 
rotated,  and  the  relation  of  its  parts  is  maintained  much  as  in  the  normal 
condition.  A  serous  or  purulent  fluid  is  usually  present,  and  the  mem- 
branes are  inflamed.  The  cause  of  the  pneumothorax  can  usually  be 
found  without  difficulty.  In  the  great  majority  of  instances  it  is  the 
perforation  of  a  tuberculous  cavity  or  a  breaking  of  a  superficial  caseous 
focus.  The  orifice  of  rupture  may  be  extremely  small.  In  chronic  cases 
there  may  be  a  fistula  of  considerable  size  communicating  with  the  bron- 
chi.   The  lung  is  usually  compressed  and  carnified. 

Symptoms. — The  onset  is  usually  sudden  and  characterized  by  severe 
pain  in  the  side,  urgent  dyspnoea,  and  signs  of  general  distress,  as  indicated 
by  slight  lividity  and  a  very  rapid  and  feeble  pulse.  There  may,  however, 
be  no  urgent  symptoms,  particularly  in  cases  of  long-standing  phthisis. 
On  more  than  one  occasion  I  have  found,  post  mortem,  a  pneumothorax 
which  was  unsuspected  during  life.  West  states  that  even  in  healthy 
adults  this  latent  pneumothorax  may  occasionally  occur. 

A  remarkable  recurrent  variety  has  been  described  by  S.  West,  Grood- 
hart,  and  Furney.  In  Goodhart's  case  the  pneumothorax  developed  first 
in  one  side  and  then  in  the  other. 

The  physical  sights  are  very  distinctive.  Inspection  shows  marked  en- 
largement of  the  affected  side  with  immobility.  The  heart  impulse  is 
usually  much  displaced.  On  palpation  the  fremitus  is  greatly  diminished 
or  more  commonly  abolished.  On  percussion  the  resonance  may  be  tym- 
panitic or  even  have  an  amphoric  quality.  This,  however,  is  not  always 
the  case.  It  may  be  a  flat  tympany,  resembling  Skoda's  resonance.  In 
some  instances  it  may  be  a  full,  hyperresonant  note,  like  emphysema; 
while  in  others — and  this  is  very  deceptive — there  is  dulness.  These 
extreme  variations  depend  doubtless  upon  the  degree  of  intrapleural  ten- 
sion. On  several  occasions  I  have  known  an  error  in  diagnosis  to  result 
from  ignorance  of  the  fact  that,  in  certain  instances,  the  percussion  note 


PNEUMOTHORAX.  683 

may  be  "muffled,  toneless,  almost  dull"  (Walshe).  There  is  usually  dul- 
ness  at  the  base  from  effused  fluid,  which  can  readily  be  made  to  change 
the  level  by  altering  the  position  of  the  patient.  Movable  dulness  can 
be  obtained  much  more  readily  in  pneumothorax  than  in  a  simple  pleu- 
risy. On  auscultation  the  breath-sounds  are  suppressed.  Sometimes 
there  is  only  a  distant  feeble  inspiratory  murmur  of  marked  amphoric 
quality.  The  contrast  between  the  loud  exaggerated  breath-sounds  on 
the  normal  side  and  the  absence  of  the  breath-sounds  on  the  other  is 
very  suggestive.  The  rales  have  a  peculiar  metallic  quality,  and  on 
coughing  or  deep  inspiration  there  may  be  what  Laennec  termed  the 
metallic  tinkling.  The  voice,  too,  has  a  curious  metallic  echo.  What  is 
sometimes  called  the  coin-sound,  termed  by  Trousseau  the  hruit  d'airaih, 
is  very  characteristic.  To  obtain  it  the  auscultator  should  place  one  ear 
on  the  back  of  the  chest  wall  while  the  assistant  taps  one  coin  on  another 
on  the  front  of  the  chest.  The  metallic  echoing  sound  which  is  produced 
in  this  way  is  one  of  the  most  constant  and  characteristic  signs  of  pneumo- 
thorax. And,  lastly,  the  Hippocratic  succussion  may  be  obtained  when 
the  auscultator's  head  is  placed  upon  the  chest  while  the  patient's  body  is 
shaken.  A  splashing  sound  is  produced,  which  may  be  audible  at  a  dis- 
tance. A  patient  may  himself  notice  it  in  making  abrupt  changes  in 
posture.  Of  other  symptoms  displacement  of  organs  is  most  constant. 
As  already  mentioned,  the  heart  may  be  drawn  over  to  the  opposite  side, 
and  the  liver  greatly  displaced,  so  that  its  upper  surface  is  below  the  level 
of  the  costal  margin,  a  degree  of  dislocation  never  seen  in  simple  effusion. 

The  diagnosis  of  pneumothorax  rarely  offers  any  difficulty,  as  the  signs 
are  very  characteristic.  In  cases  in  which  the  percussion  note  is  dull  the 
condition  may  be  mistaken  for  effusion.  I  made  this  mistake  in  a  case  of 
pulsating  pleurisy,  in  which  the  pneumothorax  followed  heavy  lifting,  and 
it  was  not  until  several  days  later,  after  some  of  the  fluid  had  been  with- 
drawn, that  a  tympanitic  note  developed.  Diaphragmatic  hernia  follow- 
ing a  crush  or  other  accident  may  closely  simulate  pneumothorax. 

In  cases  of  very  large  phthisical  cavities  with  tympanitic  percussion 
resonance  and  rales  of  an  amphoric,  metallic  quality,  the  question  of  pneu- 
mothorax is  sometimes  raised.  In  those  rare  instances  of  total  excava- 
tion of  one  lung  the  amphoric  and  metallic  phenomena  may  be  most  in- 
tense, but  the  absence  of  dislocation  of  the  organs,  of  the  succussion  splash, 
and  of  the  coin-sound  suffice  to  differentiate  this  condition.  While  this  is 
true  in  the  great  majority  of  cases,  I  have  recently  heard  the  hruit  d'airain 
over  large  cavities  of  the  right  upper  lobe.  The  condition  of  pyo-pneu- 
mothorax  subphrenicus  may  simulate  closely  true  pneumothorax. 

The  prognosis  in  cases  of  pneumothorax  depends  largely  upon  the  cause. 
S.  West  gives  a  mortality  of  70  per  cent.  The  tuberculous  cases  usually 
die  within  a  few  weeks.  Of  39  cases,  39  died  within  a  fortnight  (West); 
10  patients  died  on  the  first  day,  2  within  twenty  and  tliirty  minutes  re- 
spectively of  the  attack.  Pneumothorax  developing  in  a  healthy  individual 
often  ends  in  recovery.  There  are  tuberculous  cases  in  which  the  pneu- 
mothorax, if  occurring  early,  seems  to  arrest  the  progress  of  tlie  tubercu- 
losis.   This  appeared  to  be  the  case  in  a  man  with  chronic  pneumothorax 


684  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

who  was  under  my  care  in  Philadelphia  for  between  three  and  four  years. 
It  may  be  a  chronic  condition,  as  in  the  case  Just  mentioned,  and  a  fair 
measure  of  health  may  be  enjoyed. 

Treatment. — Practically  these  cases  should  be  dealt  with  as  ordinary 
pleurisy  with  effusion.  Of  course,  when  pneumothorax  develops  in  ad- 
vanced phthisis  the  indication  is  to  relieve  the  pain  and  distress  either  by 
morphia  or  chloroform;  but  in  cases  which  develop  early  the  fluid  should 
be  withdrawn  by  aspiration,  or,  if  purulent,  permanent  drainage  should  be 
obtained.  Even  when  the  condition  has  seemed  to  be  most  desperate  I 
have  known  recovery  to  take  place  after  thorough  drainage  of  the  sac. 
Portions  of  ribs  may  have  to  be  excised,  and  during  convalescence  it  is 
well  for  the  patient  to  practise  expansion  of '  the  lung  in  the  manner 
already  mentioned.  There  are  cases  of  pneumothorax  in  phthisis  in  which 
the  general  condition  is  so  good  and  the  inconvenience  so  slight  that  to 
let  well  enough  alone  seems  the  best  course.  In  such  an  occasional  as- 
piration may  be  performed  if  the  fluid  increases.  In  some  of  the  in- 
stances the  mere  tapping  of  the  chest  with  a  fine  needle,  so  as  to  allow 
the  escape  of  some  of  the  air,  seems  to  give  relief  by  reducing  the  intra- 
thoracic pressure.  Good  results  are  stated  to  have  followed  the  method 
introduced  by  Potain,  of  replacing  the  air  and  fluid  within  the  thorax  by 
sterilized  air. 


V.    AFFECTIONS   OF  THE   MEDIASTINUM. 

(1)  Simple  Lymphadenitis. — In  all  inflammatory  affections  of  the 
bronchi  and  of  the  lungs  the  groups  of  lymph-glands  in  the  mediastinum 
become  swollen.  In  the  bronchitis  of  measles,  for  example,  and  in  simple 
broncho-pneumonia  the  bronchial  glands  are  large  and  infiltrated,  the 
tissue  is  engorged  and  oedematous,  sometimes  intensely  hyperaemic.  Much 
stress  has  been  laid  by  some  writers  on  this  enlargement  of  the  glands  in 
the  posterior  mediastinum,  and  De  Mussy  held  that  it  was  an  important 
factor  in  inducing  paroxysms  of  whooping-cough.  They  may  attain  a 
size  suflicient  to  induce  dulness  beneath  the  manubrium  and  in  the  upper 
part  of  the  interscapular  regions  behind,  though  this  is  often  difficult  to 
determine.  In  reality  the  glands  lie  chiefly  upon  the  spine,  and  unless 
those  which  are  deep  in  the  root  of  the  lung  are  large  enough  to  induce 
compression  of  the  adjacent  lung  tissue,  I  doubt  if  the  ordinary  bronchial 
adenopathy  ever  can  be  determined  by  percussion  in  the  upper  interscapu- 
lar region.  I  have  never  met  with  an  instance  in  which  the  compression 
of  either  bronchus  seemed  to  have  resulted  from  the  glands,  however  large. 
Tuberculous  affection  of  these  glands  has  already  been  considered. 

(2)  Suppurative  Lymphadenitis. — Occasionally  abscess  in  the  bronchial 
or  tracheal  lymph-glands  is  found.  It  may  follow  the  simple  adenitis,  but 
is  most  frequently  associated  with  the  presence  of  tubercle.  The  liquid 
portion  may  gradually  become  absorbed  and  the  inspissated  contents  un- 
dergo calcification.  Serious  accidents  occasionally  occur,  as  perforation 
into  the  oesophagus  or  into  a  bronchus,  or  in  rare  instances,  as  in  the  case 


AFFECTIONS  OF  THE  MEDIASTINUM.  685 

reported  by  Sidney  Phillips,  perforation  of  the  aorta,  as  well  as  a  bronchus, 
which,  it  is  remarkable  to  say,  did  not  prove  fatal  rapidly,  but  caused  re- 
peated attacks  of  haemoptysis  during  a  period  of  sixteen  months. 

(3)  Tumors ;  Cancer  and  Sarcoma. — In  Hare's  elaborate  study  of  520 
cases  of  disease  of  the  mediastinum  *  there  were  134  cases  of  cancer,  98 
cases  of  sarcoma,  21  cases  of  lymphoma,  7  cases  of  fibroma,  11  cases  of 
dermoid  cysts,  8  cases  of  hydatid  cysts,  and  instances  of  lipoma,  gumma, 
and  enchondroma.  From  this  we  see  that  cancer  is  the  most  common 
form  of  growth.  The  tumor  occurred  in  the  anterior  mediastinum  alone 
in  48  of  the  cases  of  cancer  and  in  33  of  the  cases  of  sarcoma.  There  are 
three  chief  points  of  origin,  the  thymus,  the  lymph-glands,  and  the  pleura 
and  lung.  Sarcoma  is  more  frequently  primary  than  cancer.  Males  are 
more  frequently  affected  than  females.  The  age  of  onset  is  most  com- 
monly between  thirty  and  forty. 

Symptoms. — The  signs  of  mediastinal  tumor  are  those  of  intra- 
thoracic pressure.  Dyspnoea  is  one  of  the  earliest  and  most  constant 
symptoms,  and  may  be  due  either  to  pressure  on  the  trachea  or  on  the 
recurrent  laryngeal  nerves.  It  may  indeed  be  cardiac,  due  to  pressure 
upon  the  heart  or  its  vessels.  In  a  few  cases  it  results  from  the  pleural 
effusion  which  so  frequently  accompanies  intrathoracic  growths.  Asso- 
ciated with  the  dyspnoea  is  a  cough,  often  severe  and  paroxysmal  in  char- 
acter, with  the  brazen  quality  of  the  so-called  aneurismal  cough  when  a 
recurrent  nerve  is  involved.  The  voice  may  also  be  affected  from  a  simi- 
lar cause.  Pressure  on  the  vessels  is  common.  The  superior  vena  cava 
may  be  compressed  and  obliterated,  and  when  the  process  goes  on  slowly 
the  collateral  circulation  may  be  completely  effected.  Less  commonly  the 
inferior  vena  cava  or  one  or  other  of  the  subclavian  veins  is  compressed. 
The  arteries  are  much  more  rarely  obstructed.  There  may  be  dysphagia, 
due  to  compression  of  the  oesophagus.  In  rare  instances  there  are  pupillary 
changes,  either  dilatation  or  contraction,  due  to  involvement  of  the  sym- 
pathetic. Expectoration  of  blood,  pus,  and  hair  is  characteristic  of  the  der- 
moid cyst,  of  which  Christian  has  collected  40  cases. 

Physical  Signs. — On  inspection  there  may  be  orthopnoea  and  marked 
cyanosis  of  the  upper  part  of  the  body.  In  such  instances,  if  of  long 
duration,  there  are  signs  of  collateral  circulation  and  the  superficial  mam- 
mary and  epigastric  veins  are  enlarged.  In  these  cases  of  chronic  obstruc- 
tion the  finger-tips  may  be  clubbed.  There  may  be  bulging  of  the  ster- 
num or  the  tumor  may  erode  the  bone  and  form  a  prominent  subcutaneous 
growth.  The  rapidly  growing  lymphoid  tumors  more  commonly  than 
others  perforate  the  chest  wall.  In  4  of  13  cases  of  Hodgkin's  disease, 
there  was  mediastinal  growth,  and  in  3  instances  the  sternum  was  eroded 
and  perforated.  The  perforation  may  be  on  one  side  of  the  breast-bone. 
The  projecting  tumor  may  pulsate;  the  heart  may  be  dislocated  and  its 
impulse  much  out  of  place.  Contraction  of  one  side  of  the  thorax  has  been 
noted  in  a  few  instances.  On  palpation  the  fremitus  is  absent  wherever 
the  tumor  reaches  the  chest  wall.  If  pulsating,  it  rarely  has  the  forcible, 
(■ — . 

*  Fothergillian  Prize  Essay  of  the  Medical  Society  of  London,  Philadelphia,  1889. 


686  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

heaving  impulse  of  an  aneurismal  sac.  On  auscultation  there  is  usually 
silence  over  the  dull  region.  The  heart-sounds  are  not  transmitted  and 
the  respiratory  murmur  is  feeble  or  inaudible,  rarely  bronchial.  Vocal 
resonance  is,  as  a  rule,  absent.  Signs  of  pleural  effusion  occur  in  a  great 
many  instances  of  mediastinal  growth,  and  in  doubtful  cases  the  aspirator 
needle  should  be  used. 

Tumors  of  the  anterior  mediastinum  originate  usually  in  the  thymus; 
the  sternum  is  pushed  forward  and  often  eroded.  The  growth  may  be 
felt  in  the  suprasternal  fossa;  the  cervical  glands  are  usually  involved. 
The  pressure  symptoms  are  chiefly  upon  the  venous  trunks.  Dyspnoea  is 
a  prominent  feature. 

Intrathoracic  tumors  in  the  middle  and  posterior  mediastinum  originate 
most  commonly  in  the  lymph-glands.  The  symptoms  are  out  of  all  pro- 
portion to  the  physical  signs;  there  Is  urgent  dyspnoea  and  cough,  which 
is  sometimes  loud  and  ringing.  The  pressure  symptoms  are  chiefly  upon 
the  gullet,  the  recurrent  laryngeal,  and  sometimes  upon  the  azygos  vein. 

In  a  third  group,  tumors  originating  in  the  pleura  and  the  lung,  the 
pressure  symptoms  are  not  so  marked.  Pleural  exudate  is  very  much 
more  common;  the  patient  becomes  anaemic  and  emaciation  is  rapid. 
There  may  be  secondary  involvement  of  the  lymph-glands  in  the  neck. 
For  a  discussion  of  the  symptomatology  of  these  different  groups,  see 
PejDper  and  Stengel,  Transactions  of  the  Association  of  American  Physi- 
cians, vol.  X. 

The  diagnosis  of  mediastinal  tumor  from  aneurism  is  sometimes  ex- 
tremely difficult.  An  interesting  case  reported  and  figured  by  Sokolosski, 
in  Bd.  19  of  the  Deutsches  Archiv  flir  klinische  Medicin,  in  which 
Oppolzer  diagnosed  aneurism  and  Skoda  mediastinal  tumor,  illustrates 
how  in  some  instances  the  most  skilful  of  observers  may  be  unable  to 
agree.  Scarcely  a  sign  is  found  in  aneurism  which  may  not  be  duplicated 
in  mediastinal  tumor.  This  is  not  strange,  since  the  symptoms  in  both 
are  largely  due  to  pressure.  The  time  element  is  important.  If  a  case 
has  persisted  for  more  than  eighteen  months  the  disease  is  probably  aneu- 
rism. There  are,  however,  exceptions  to  this.  By  far  the  most  valuable 
sign  of  aneurism  is  the  diastolic  shock  so  often  to  be  felt,  and  in  a  majority 
of  cases  to  be  heard,  over  the  sac.  This  is  rarely,  if  ever,  present  in  medias- 
tinal growths,  even  when  they  perforate  the  sternum  and  have  communi- 
cated pulsation.  Tracheal  tugging  is  rarely  present  in  tumor.  Another 
point  of  importance  is  that  a  tumor,  advancing  from  the  mediastinum, 
eroding  the  sternum  and  appearing  externally,  if  aneurismal,  has  forcible, 
heaving,  and  distinctly  expansile  pulsations.  The  radiating  pain  in  the 
back  and  arms  and  neck  is  rather  in  favor  of  aneurism,  as  is  also  a  bene- 
ficial influence  on  it  of  iodide  of  potassium. 

The  frequency  of  pleural  effusion  in  connection  with  mediastinal  tumor 
is  to  be  constantly  borne  in  mind.  It  may  give  curiously  complex  char- 
acters to  the  physical  signs — characters  which  are  profoundly  modified 
after  aspiration  of  the  liquid. 

(4)  Abscess  of  the  Mediastinum. — Hare  collected  115  cases  of  medi- 
astinal abscess,  in  77  of  which  there  were  details  sufficient  to  permit  the 


AE'PBCTlONS  OP  THE  MEDIASTINUM.  68Y 

analysis.  Of  these  cases  the  great  majority  occurred  in  males.  Forty-four 
were  instances  of  acute  abscess.  The  anterior  mediastinum  is  most  com- 
monly the  seat  of  the  suppuration.  The  eases  are  most  frequently  associated 
with  trauma.  Some  have  followed  erysipelas  or  occurred  in  association 
with  eruptive  fevers.  Many  cases,  particularly  the  chronic  abscesses,  are 
of  tuberculous  origin.  Of  symptoms,  pain  behind  the  sternum  is  the  most 
common.  It  may  be  of  a  throbbing  character,  and  in  the  acute  cases  is 
associated  with  fever,  sometimes  with  chills  and  sweats.  If  the  abscess  is 
large  there  may  be  dyspncBa.  The  pus  may  burrow  into  the  abdomen, 
perforate  through  an  intercostal  space,  or  it  may  erode  the  sternum.  In- 
stances are  on  record  in  which  the  abscess  has  discharged  into  the  trachea 
or  oesophagus.  In  many  cases,  particularly  of  chronic  abscess,  the  pus 
becomes  inspissated  and  produces  no  ill  effect.  The  physical  signs  may 
be  very  indefinite.  A  pulsating  and  fluctuating  tumor  may  appear  at  the 
border  of  the  sternum  or  at  the  sternal  notch.  The  absence  of  hruit,  of 
the  diastolic  shock,  and  of  the  expansile  pulsation  usually  enables  a  cor- 
rect diagnosis  to  be  made.  When  in  doubt  a  fine  hypodermic  needle  may 
be  inserted. 

(5)  Indurative  Mediastino-Pericarditis. — Harris  has  recently  reviewed 
the  subject.  In  one  form  there  is  adherent  pericardium  and  great  increase 
in  the  fibrous  tissues  of  the  mediastinum;  in  another  there  is  adherent  peri- 
cardium with  union  to  surrounding  parts,  but  very  little  mediastinitis;  in 
a  third  the  pericardium  may  be  uninvolved.  The  disease  is  rare;  of 
22  cases  17  were  in  males;  only  2  were  above  thirty  years  of  age.  The 
symptoms  are  essentially  those  of  that  form  of  adhesive  pericardium  which 
is  associated  with  great  hypertrophy  and  dilatation  of  the  heart,  and  in 
which  the  patients  present  a  picture  of  cyanosis,  dyspnoea,  anasarca,  etc. 
The  pulsus  paradoxus,  described  by  Kussmaul,  is  not  distinctive.  Occa- 
sionally there  is  also  a  proliferative  peritonitis.  Mediastinal  friction  is 
sometimes  heard  in  patients  with  adhesive  mediastino-pericarditis — dry, 
coarse,  crackling  rales  heard  along  the  sternum,  particularly  when  the 
arms  are  raised. 

(6)  Miscellaneous  Affections. — In  Hare's  monograph  there  were  7  in- 
stances of  fibroma,  11  cases  of  dermoid  cyst,  8  cases  of  hydatid  cyst,  and 
cases  of  lipoma  and  gumma. 

(7)  Emphysema  of  the  Mediastinum.— Air  in  the  cellular  tissues  of  the 
mediastinum  is  met  with  in  cases  of  trauma,  and  occasionally  in  fatal  cases 
of  diphtheria  and  in  whooping-cough.  It  may  extend  to  the  subcutaneous 
tissues.  Champneys  has  called  attention  to  its  frequency  after  tracheotomy, 
in  which,  he  says,  the  conditions  favoring  the  production  are  division  of  the 
deep  fascia,  obstruction  in  the  air-passages,  and  inspiratory  efforts.  The 
deep  fascia,  he  says,  should  not  be  raised  from  the  trachea.  It  is  often 
associated  with  pneumothorax.  The  condition  seems  by  no  means  uncom- 
mon. Angel  Money  found  it  in  16  of  28  cases  of  tracheotomy,  and  in  2 
of  these  pneumothorax  also  was  present. 


43 


SECTION  VII. 
DISEASES  OF  THE  OIEOULATOEY  SYSTEM. 


I.    DISEASES   OF   THE   PEKICAKDIUM. 
I.    PERICARDITIS. 

Pericaeditis  is  the  result  of  infective  processes,  primary  or  secondary, 
or  arises  by  extension  of  inflammation  from  contiguous  organs. 

Etiology. — Primary,  so-called  idiopathic,  inflammation  is  rare;  but 
eases  occur,  chiefly  in  children,  in  whom  there  is  no  evidence  of  rheuma- 
tism or  of  any  local  or  general  disease.  Certain  of  these  cases  are  tuber- 
culous. 

Pericarditis  from  injury  usually  comes  under  the  care  of  the  surgeon 
in  connection  with  the  primary  wound.  The  trauma  may  be  from  within, 
due  to  the  passage  of  a  foreign  body — a  needle,  a  pin,  or  a  bone — through 
the  oesophagus — a  variety  exceedingly  common  in  cows  and  horses. 

As  a  secondary  process  pericarditis  occurs:  (a)  Most  frequently  in  con- 
nection with  rheumatism.  The  percentage  given  by  difilerent  authors 
ranges  from  thirty  to  seventy.  The  articular  trouble  may  be  slight  or,' 
indeed,  the  disease  may  be  associated  with  acute  tonsillitis  in  rheumatic 
subjects.  Certain  of  the  so-called  idiopathic  cases  have  their  origin  in  an 
acute  tonsillitis.  The  pericarditis  may  precede  the  arthritis.  (&)  In  septic 
processes;  in  the  acute  necrosis  of  bone  and  in  puerperal  fever  it  is  not  un- 
common, (c)  In  tuberculosis,  in  which  the  disease  may  be  primary  or  part 
of  a  general  involvement  of  the  serous  sacs  or  associated  with  extensive 
pulmonary  disease,  {d)  In  the  eruptive  fevers.  Not  infrequent  after 
scarlatina;  it  is  rare  in  measles,  small-pox,  typhoid  fever,  and  diphtheria. 
In  pneumonia  it  is  not  uncommon.  Pericarditis  sometimes  complicates 
chorea;  it  was  present  in  19  of  73  autopsies  which  I  collected;  in  only  8  of 
these  was  arthritis  present,  (e)  In  certain  altered  conditions  of  the  system, 
in  which  gout  takes  the  first  place.  Pericarditis  in  chronic  Bright's  dis- 
ease— the  pericardite  hrigJitique  of  the  French — is  one  of  the  most  impor- 
tant forms  in  persons  over  fifty  years  of  age,  and  is  most  frequent  in  the 
slow  interstitial  variety.  As  a  terminal  infection  pericarditis  is  a 
very  common  event  in  chronic  illnesses  of  all  sorts.  It  is  usually  over- 
looked, hence  the  incidence  of  acute  pericarditis  in  the  post-mortem  room 
is  greatly  in  excess  of  that  of  the  wards.  Pericarditis  has  been  met  with 
also  in  scurvy  and  diabetes. 
688 


PERICARDITIS.  689 

Pericarditis  hy  Extension. — In  pi  euro-pneumonia  it  forms  a  serious  com- 
plication, and  was  present  in  5  cases  of  100  post  mortems  in  this  disease 
which  I  made  at  the  Montreal-  General  Hospital.  It  is  most  often  met  with 
in  the  pleuro-pneumonia  of  children  and  of  alcoholics.  With  simple  pleu- 
risy it  is  rare.  In  ulcerative  endocarditis,  purulent  myocarditis,  and  in 
aneurism  of  the  aorta  pericarditis  is  occasionally  found.  It  may  also  follow 
extension  of  the  disease  from  the  bronchial  glands,  the  ribs,  sternum,  verte- 
bra, and  even  from  the  abdominal  viscera.  The  ordinary  pus  cocci,  the 
pneumococcus,  and  the  tubercle  bacillus  are  the  chief  organisms  met  with 
in  acute  pericarditis. 

Pericarditis  occurs  at  all  ages.  Cases  have  been  reported  in  the  foetus. 
In  the  new-born  it  may  result  from  septic  infection  through  the  navel. 
Throughout  childhood  the  incidence  of  rheumatism  and  scarlet  fever  makes 
it  a  frequent  affection,  whereas  late  in  life  it  is  most  often  associated  with 
tuberculosis,  Bright's  disease,  and  gout.  Males  are  somewhat  more  fre- 
quently attacked  than  females.  Climatic  and  seasonal  influences  have  been 
mentioned  by  some  writers.  The  so-called  epidemics  of  pericarditis  have 
been  outbreaks  of  pneumonia  with  this  as  a  frequent  complication. 

Of  100  consecutive  cases  at  the  Boston  City  Hospital  analyzed  by  Sears, 
in  54  the  exudate  was  dry,  in  41  serous,  in  4  hsemorrhagic,  and  in  5  puru- 
lent. Thirty-four  cases  showed  signs  of  old  valvular  disease;  rheumatism 
was  a  factor  in  51;  pneumonia  in  18;  and  in  7  chronic  nephritis.  Of  the 
100  cases  43  died. 

Anatomically  as  well  as  clinically  the  disease  may  be  considered  under 
the  following  divisions: 

1.  Acute,  plastic,  or  dry  pericarditis. 

2.  Pericarditis  w4th  effusion — sero-fibrinous,  haemorrhagic,  or  purulent. 

3.  Chronic  adhesive  pericarditis  (adherent  pericardium). 

Acute  Plastic  Pericarditis. — This,  the  most  common  form,  occurs  usu- 
ally as  a  secondary  process,  and  is  distinguished  by  the  small  amount  of 
fluid  exudation,  which  does  not,  as  in  the  next  variety,  give  special  charac- 
ters to  the  disease.    It  is  a  benign  form  and  never  of  itself  proves  fatal. 

Anatomically  it  may  be  partial  or  general.  In  the  mildest  grades  the 
serous  membrane  looks  lustreless  and  roughened.  This  is  due  to  the  pres- 
ence of  a  thin  fibrinous  sheeting,  which  can  be  lifted  with  the  knife,  showing 
the  membrane  beneath  to  be  injected  or  in  places  ecchymotic.  As  the 
fibrinous  sheeting  increases  in  thickness  the  constant  movement  of  the 
adjacent  surfaces  gives  to  it  sometimes  a  ridge-like,  at  others  a  honey- 
combed appearance.  With  more  abundant  fibrinous  exudation  the  mem- 
branes present  an  appearance  resembling  buttered  surfaces  which  have  been 
drawn  apart.  The  fibrin  is  in  long  shreds,  and  the  heart  presents  a  curiously 
shaggy  appearance — the  so-called  hairy  heart  of  old  writers — cor  viUosum. 

In  mild  grades  the  subjacent  muscle  looks  normal;  but  in  the  more 
prolonged  and  severe  cases  there  is  myocarditis,  and  for  2  or  3  mm.  be- 
neath the  visceral  layer  the  muscle  presents  a  pale,  turbid  appearance. 
Many  of  these  acute  cases  are  tuberculous;  covered  by  the  layers  of  lymph 
the  granulations  are  easily  overlooked  in  a  superficial  examination. 


690  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Slight  fluid  exudation  is  invariably  present,  entangled  in  the  meshes 
of  fibrin,  but  there  may  be  very  thick  fibrinous  layers  without  much  serous 
effusion. 

Symptoms. — The  majority  of  eases  of  simple  plastic  pericarditis,  like 
those  of  simple  endocarditis,  present  no  symptoms,  and  unless  sought  for 
there  are  no  objective  signs  indicating  its  existence.  In  the  post-mortem 
room  it  is  not  uncommon  to  find  it  in  cases  in  which  its  presence  has  been 
unsuspected  during  life. 

Pain  is  a  variable  symptom,  not  usually  intense,  and  in  this  form  rarely 
excited  by  pressure.  It  is  more  marked  in  the  early  stage,  and  may  be 
referred  either  to  the  prsecordia  or  to  the  region  of  the  xiphoid  cartilage. 
Instances  are  recorded  of  pain  of  an  aggravated  and  most  distressing  char- 
acter resembling  angina.  Fever  is  usually  present,  but  it  is  not  always  easy 
to  say  how  much  depends  upon  the  primary  febrile  affection,  and  how  much 
upon  the  pericarditis.  It  is  as  a  rule  not  high,  rarely  exceeding  102.5°. 
In  rheumatic  cases  hyperpj'^rexia  has  been  observed. 

Physical  Signs. — Inspection  is  negative;  palpation  may  reveal  the  pres- 
ence of  a  distinct  fremitus  caused  by  the  rubbing  of  the  roughened  peri- 
cardial surfaces.  This  is  usually  best  marked  over  the  right  ventricle.  It 
is  not  always  to  be  felt,  even  when  the  friction  sound  on  auscultation  is 
loud  and  clear.  Auscultation:  The  friction  sound,  due  to  the  movement 
of  the  pericardial  surfaces  upon  each  other,  is  one  of  the  most  distinctive 
of  physical  signs.  It  is  double,  corresponding  to  the  systole  and  diastole; 
but  the  synchronism  with  the  heart-sounds  is  not  accurate,  and  the  to-and- 
fro  murmur  usually  outlasts  the  time  occupied  by  the  first  and  second 
sound.  In  rare  instances  the  friction  is  single;  more  frequently  it  ap- 
pears to  be  triple  in  character — a  sort  of  canter  rhythm.  The  sounds  have 
a  peculiar  rubbing,  grating  quality,  characteristic  when  once  recognized, 
and  rarely  simulated  by  endocardial  murmurs.  Sometimes  instead  of 
grating  there  is  a  creaking  quality — the  Iruit  de  cuir  neuf — the  new-leather 
murmur  of  the  French.  The  pericardial  friction  appears  superficial,  very 
close  to  the  ear,  and  is  usually  intensified  by  pressure  with  the  stethoscope. 
It  is  best  heard  over  the  right  ventricle,  the  part  of  the  heart  which  is  most 
closely  in  contact  with  the  front  of  the  chest — that  is,  in  the  fourth  and 
fifth  interspaces  and  adjacent  portions  of  the  sternum.  There  are  instances 
in  which  the  friction  is  most  marked  at  the  base,  over  the  aorta,  and  at 
the  superior  reflection  of  the  pericardium.  Occasionally  it  is  best  heard 
at  the  apex.  It  may  be  limited  and  heard  over  a  very  narrow  area,  or  it 
may  be  transmitted  up  and  down  the  sternum.  There  are,  however,  no 
definite  lines  of  transmission  as  in  the  endocardial  murmur.  An  important 
point  is  the  variability  of  the  sounds,  both  in  position  and  quality;  they  may 
be  heard  at  one  visit  and  not  at  another.  The  maximum  of  intensity  will 
be  found  to  vary  with  position. 

Diagnosis. — There  is  rarely  any  difficulty  in  determining  the  pres- 
ence of  a  dry  pericarditis,  for  the  friction  sounds  are  distinctive.  The 
double  murmur  of  aortic  incompetency  may  simulate  closely  the  to-and- 
fro  pericardial  rub.  I  recall  one  instance  at  least  in  which  this  mistake  wa3 
made.    The  constant  character  of  the  aortic  murmur,  the  direction  of  trans- 


PERICARDITIS.  691 

mission,  the  phenomena  in  the  arteries,  and  the  associated  conditions  of 
the  disease  should  be  sufficient  to  prevent  this  error. 

I  have  never  known  an  instance  in  wliicli  pericarditis  was  mistaken  for 
acute  endocarditis,  though  writers  refer  to  such,  and  give  the  differential 
diagnosis  in  the  two  affections.  The  only  possible  mistake  could  be  made 
in  those  rare  instances  of  single  soft,  systolic,  pericardial  friction. 

Pleuro-pericardial  friction  is  very  common,  and  may  be  associated  with 
endo-pericarditis,  particularly  in  cases  of  pleuro-pneumonia.  It  is  fre- 
quent, too,  in  phthisis.  It  is  best  heard  over  the  left  border  of  the  heart, 
and  is  much  affected  by  the  respiratory  movement.  Holding  the  breath 
or  taking  a  deep  inspiration  may  annihilate  it.  The  rhythm  is  not  the  sim- 
ple to-and-fro  diastolic  and  systolic,  but  the  respiratory  rhythm  is  super- 
added, usually  intensifying  the  murmur  during  expiration  and  lessening 
it  on  inspiration.  In  phthisis  there  are  instances  in  which,  with  the  fric- 
tion, a  loud  systolic  click  is  heard,  due  to  the  compression  of  a  thin  layer 
of  lung  and  the  expulsion  of  a  bubble  of  air  from  a  small  softening  focus 
or  from  a  bronchus. 

And,  lastly,  it  is  not  very  uncommon,  in  the  region  of  the  apex  beat,  to 
hear  a  series  of  fine  crepitant  sounds,  systolic  in  time,  often  very  distinct, 
suggestive  of  pericardial  adhesions,  but  heard  too  frequently  for  this  cause. 

Course  and  Termination. — Simple  fibrinous  pericarditis  never  kills,  but 
it  occurs  so  often  in  connection  with  serious  affections  that  we  have  fre- 
quent opportunities  to  see  all  stages  of  its  progress.  In  the  majority  of 
cases  the  inflammation  subsides  and  the  thin  fibrinous  lamina  gradually 
become  converted  into  connective  tissue,  which  unites  the  pericardial  leaves 
firmly  together.  In  other  instances  the  inflammation  progresses,  with  in- 
crease of  the  exudation,  and  the  condition  is  changed  from  a  "  dry  "  to  a 
"  moist  "  pericarditis,  or  the  pericarditis  with  effusion. 

In  a  few  instances — probably  always  tuberculous — the  simple  plastic 
pericarditis  becomes  chronic,  and  great  thickening  of  both  visceral  and 
parietal  layers  is  gradually  induced. 

Pericarditis  with  Effusion. — Though  commonly  a  direct  sequence  of 
the  dry  or  plastic  pericarditis,  of  which  it  is  sometimes  called  the  second 
stage,  this  form  presents  special  features  and  deserves  separate  considera- 
tion. It  is  found  most  frequently  in  association  with  acute  rheumatism, 
tuberculosis,  and  septicsemia,  and  sets  in  usually  with  the  symptoms  above 
described,  namely,  praecordial  pain,  with  slight  fever  or  a  distinct  chill. 

In  children  the  disease  may,  like  pleurisy,  come  on  without  local  symp- 
toms, and,  after  a  week  or  two  of  failing  health,  slight  fever,  shortness  of 
breath,  and  increasing  pallor,  the  physician  may  find,  to  his  astonishment, 
signs  of  most  extensive  pericardial  effusion.  These  latent  cases  are  often 
tuberculous.  W.  Ewart  has  called  special  attention  to  latent  and  ephemeral 
pericardial  effusions,  which  he  thinks  are  often  of  short  duration  and  of 
moderate  size,  with  an  absence  of  the  painful  features  of  pericarditis.  The 
effusion  may  be  sero-fibrinous,  hasmorrhagic,  or  purulent.  The  amount 
varies  from  200  or  300  cc.  to  2  litres.  In  the  cases  of  sero-fibrinous  exuda- 
tion the  pericardial  membranes  are  covered  with  thick,  creamy  fibrin,  which 


692  DISEASES  OP  THE  CIRCULATOflY  SYSTEM. 

may  be  in  ridges  or  honeyconibed,  or  may  present  long,  villous  extensions. 
The  parietal  layer  may  be  several  millimetres  in  thickness  and  may  form 
a  firm,  leathery  membrane.  The  hsemorrhagic  exudation  is  usually  associ- 
ated with  tuberculous,  or  with  cancerous  pericarditis,  or  with  the  disease 
in  the  aged.  The  lymph  is  less  abundant,  but  both  surfaces  are  injected 
and  often  show  numerous  haemorrhages.  Thick,  curdy  masses  of  lymph 
are  usually  found  in  the  dependent  part  of  the  sac.  In  the  purulent  effu- 
sion the  fluid  has  a  creamy  consistency,  particularly  in  tuberculosis.  In 
many  cases  the  effusion  is  really  sero-purulent,  a  thin,  turbid  exudation  con- 
taining flocculi  of  fibrin. 

The  pericardial  layers  are  greatly  thickened  and  covered  with  fibrin. 
When  the  fluid  is  pus,  they  present  a  grayish,  rough,  granular  surface. 
Sometimes  there  are  distinct  erosions  on  the  visceral  membrane.  The 
heart  muscle  in  these  cases  becomes  involved  to  a  greater  or  less  extent, 
and  on  section,  the  tissue,  for  a  depth  of  from  3  to  3  mm.,  is  pale  and 
turbid,  and  shows  evidence  of  fatty  and  granular  change.  Endocarditis 
coexists  frequently,  but  rarely  results  from  the  extension  of  the  inflamma- 
tion through  the  wall  of  the  heart. 

Symptoms. — Even  with  copious  effusion  the  onset  and  course  may 
be  so  insidious  that  no  suspicion  of  the  true  nature  of  the  disease  is  aroused. 

As  in  the  simple  pericarditis,  pain  may  be  present,  either  sharp  and 
stabbing  or  as  a  sense  of  distress  and  discomfort  in  the  cardiac  region.  It 
is  more  frequent  with  effusion  than  in  the  plastic  form.  Pressure  at  the 
lower  end  of  the  sternum  usually  aggravates  it.  Dyspnoea  is  a  common 
and  important  symptom,  one  which,  perhaps,  more  than  any  other,  excites 
suspicion  of  grave  disorder  and  leads  to  careful  examination  of  heart  and 
lungs.  The  patient  is  restless,  lies  upon  the  left  side  or,  as  the  effusion 
increases,  sits  up  in  bed.  Associated  with  the  dyspnoea  is  in  many  cases  a 
peculiarly  dusky,  anxious  countenance.  The  pulse  is  rapid,  small,  some- 
times irregular,  and  may  present  the  characters  known  as  pulsus  paradoxus, 
in  which  during  each  inspiration  the  pulse-beat  becomes  very  weak  or  is 
lost.  These  symptoms  are  due,  in  great  part,  to  the  direct  mechanical 
effect  of  the  fluid  within  the  pericardium  which  embarrasses  the  heart's 
action.  Other  pressure  effects  are  distention  of  the  veins  of  the  neck, 
dysphagia,  which  may  be  a  marked  symptom,  and  irritative  cough  from 
compression  of  the  trachea.  Aphonia  is  not  uncommon,  owing  to  compres- 
sion or  irritation  of  the  recurrent  laryngeal  as  it  winds  round  the  aorta. 
Another  important  pressure  effect  is  exercised  upon  the  left  lung.  In 
massive  effusion  the  pericardial  sac  occupies  such  a  large  portion  of  the 
antero-lateral  region  of  the  left  side  that  the  condition  has  frequently  been 
mistaken  for  pleurisy.  Even  in  moderate  grades  the  left  lung  is  somewhat 
compressed.  This  is  an  additional  element  in  the  production  of  the 
dyspnoea. 

Great  restlessness,  insomnia,  and  in  the  later  stages  low  delirium  and 
coma  are  symptoms  in  the  more  severe  cases.  Delirium  and  marked  cere- 
bral symptoms  are  associated  with  the  hyperpyrexia  of  rheumatic  cases, 
but  apart  from  the  ordinary  delirium  there  may  be  peculiar  mental  symp- 
toms.   The  patient  may  become  melancholic  and  show  suicidal  tendencies. 


PERICARDITIS.  693 

In  other  cases  the  condition  resembles  closely  delirium  tremens.  Sibson, 
who  has  specially  described  this  condition,  states  that  the  majority  of  such 
cases  recover.  Chorea  may  also  occur,  as  was  pointed  out  by  Bright.  Epi- 
lepsy is  a  rare  complication  which  has  occurred  during  paracentesis. 

Physical  Signs. — Inspection. — In  children  the  prsecordia  bulges  and 
with  copious  exudation  the  antero-lateral  region  of  the  left  chest  becomes 
enlarged.  The  intercostal  spaces  bulge  somewhat  and  there  may  be  marked 
cedema  of  the  wall.  The  epigastrium  may  be  more  prominent.  Perfora- 
tion externally  through  a  space  is  very  rare.  Owing  to  the  compression 
of  the  lung,  the  expansion  of  the  left  side  is  greatly  diminished.  The  dia- 
phragm and  left  lobe  of  the  liver  may  be  pushed  down  and  may  produce 
a  distinct  prominence  in  the  epigastric  region. 

Palpation. — A  gradual  diminution  and  final  obliteration  of  the  cardiac 
shock  is  a  striking  feature  in  progressive  eflEusion.  The  position  of  the 
apex  beat  is  not  constant.  In  large  effusions  it  is  usually  not  felt.  In  chil- 
dren as  the  fluid  collects  the  pulsation  may  be  best  seen  in  the  fourth  space, 
but  this  may  not  be  the  apex  itself.  Ewart  maintains  that  the  position  of 
the  apex  beat  is  unaltered,  or  even  depressed.  The  pericardial  friction  may 
lessen  with  the  effusion,  though  it  often  persists  at  the  base  when  no  longer 
palpable  over  the  right  ventricle,  or  may  be  felt  in  the  erect  and  not  in  the 
recumbent  postiire.    Fluctuation  can  rarely,  if  ever,  be  detected. 

Percussion  gives  most  important  indications.  The  gradual  distention 
of  the  pericardial  sac  pushes  aside  the  margins  of  the  lungs  so  that  a  large 
area  comes  in  contact  with  the  chest  wall  and  gives  a  greatly  increased 
percussion  dulness.  The  form  of  this  dulness  is  irregularly  pear-shaped; 
the  base  or  broad  surface  directed  downward  and  the  stem  or  apex  directed 
upward  toward  the  manubrium.  A  valuable  sign,  to  which  Rotch  called 
attention,  is  the  absence  of  resonance  in  the  right  fifth  intercostal  space — 
the  cardio-hepatic  angle.  In  the  left  infrascapular  area  there  may  be  a 
patch  of  diminished  resonance  or  even  flatness  (Ewart). 

Auscultation. — The  friction  sound  heard  in  the  early  stages  may  dis- 
appear when  the  effusion  is  copious,  but  often  persists  at  the  base  or  at 
the  limited  area  of  the  apex.  It  may  be  audible  in  the  erect  and  not  in 
the  recumbent  posture.  With  the  absorption  of  the  fluid  the  friction  re- 
turns. One  of  the  most  important  signs  is  the  gradual  weakening  of  the 
heart-sounds,  which  with  the  increase  in  the  effusion  may  become  so  muf- 
fled and  indistinct  as  to  be  scarcely  audible.  The  heart's  action  is  usually 
increased  and  the  rhythm  disturbed.  Occasionally  a  systolic  endocardial 
murmur  is  heard.  Early  and  persistent  accentuation  of  the  pulmonary 
second  sound  may  be  present  (Warthin). 

Important  accessory  signs  in  large  effusion  are  due  to  pressure  on  the 
left  lung.  The  antero-lateral  margin  of  the  lower  lobe  is  pushed  aside  and 
in  some  instances  compressed,  so  that  percussion  in  the  axillary  region, 
in  and  just  below  the  transverse  nipple  line,  gives  a  modified  percussion 
note,  usually  a  flat  tympany.  Variations  in  the  position  of  the  patient 
may  change  materially  this  modified  percussion  area,  over  which  on  auscul- 
tation there  is  either  feeble  or  tubular  breathing. 

Course. — Cases  vary  extremely  in  the  rapidity  with  which  the  effusion 


694  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

takes  place.  In  every  instance,  when  a  pericardial  friction  murnmr  has 
been  detected,  the  practitioner  should  first  outline  with  care — using  the 
anUine  pencil  or  nitrate  of  silver — the  upper  and  lateral  limits  of  cardiac 
dulness,  secondly  mark  the  position  of  the  apex  beat,  and  thirdly  note  the 
intensity  of  the  heart  sounds.  In  many  instances  the  exudation  is  slight 
in  amount,  reaches  a  maximum  within  forty-eight  hours,  and  then  grad- 
ually subsides.  In  other  instances  the  accumulation  is  more  gradual  and 
progressive,  increasing  for  several  weeks.  To  such  cases  the  term  chronic 
has  been  applied.  The  rapidity  with  which  a  sero-fibrinous  effusion  may 
be  absorbed  is  surprising.  The  possibility  of  the  absorption  of  a  purulent 
exudate  is  shown  by  the  cases  in  which  the  pericardium  contains  semi-solid 
grayish  masses  in  all  stages  of  calcification.  With  sero-fibrinous  effusion, 
if  moderate  in  amount,  recovery  is  the  rule,  with  inevitable  union,  however, 
of  the  pericardial  layers.  In  some  of  the  septic  cases  there  is  a  rapid  for- 
mation of  pus  and  a  fatal  result  may  follow  in  three  or  four  days.  More 
commonly,  when  death  occurs  with  large  effusion,  it  is  not  until  the  second 
or  third  week  and  takes  place  by  gradual  asthenia. 

Prognosis. — In  the  sero-fibrinous  effusions  the  outlook  is  good,  and 
a  large  majority  of  all  the  rheumatic  cases  recover.  The  purulent  effusions 
are,  of  course,  more  dangerous;  the  septic  cases  are  usually  fatal,  and  re- 
covery is  rare  in  the  slow,  insidious  tuberculous  forms. 

Diagnosis. — Probably  no  serious  disease  is  so  frequently  overlooked 
by  the  practitioner.  Post-mortem  experience  shows  how  often  pericarditis 
is  not  recognized,  or  goes  on  to  resolution  and  adhesion  without  attracting 
notice.  In  a  case  of  rheumatism,  watched  from  the  outset,  with  the  atten- 
tion directed  daily  to  the  heart,  it  is  one  of  the  simplest  of  diseases  to  diag- 
nose; but  when  one  is  called  to  a  case  for  the  first  time  and  finds  perhaps  an 
increased  area  of  prgecordial  dulness,  it  is  often  very  hard  to  determine  with 
certainty  whether  or  not  effusion  is  present. 

The  difficulty  usually  lies  in  distinguishing  between  dilatation  of  the 
heart  and  pericardial  effusion.  Although  the  differential  signs  are  simple 
enough  on  paper,  it  is  notoriously  difficult  in  certain  cases,  particularly  in 
stout  persons,  to  say  which  of  the  conditions  exists.  The  points  which 
deserve  attention  are: 

(a)  The  character  of  the  impulse,  which  in  dilatation,  particularly  in 
thin-chested  people,  is  commonly  visible  and  wavy. 

(h)  The  shock  of  the  cardiac  sounds  is  more  distinctly  palpable  in  dila- 
tation. 

(c)  The  area  of  dulness  in  dilatation  rarely  has  a  triangular  form; 
nor  does  it,  except  in  cases  of  mitral  stenosis,  reach  so  high  along  the  left 
sternal  margin  or  so  low  in  the  fifth  and  sixth  interspaces  ivithout  visible 
or  palpable  impulse.  An  upper  limit  of  dulness  shifting  with  change  of 
position  speaks  strongly  for  effusion. 

(d)  In  dilatation  the  heart-sounds  are  clearer,  often  sharp,  valvular, 
or  foetal  in  character;  gallop  rhythm  is  common,  whereas  in  effusion  the 
sounds  are  distant  and  muffled. 

(e)  Earely  in  dilatation  is  the  distention  sufficient  to  compress  the  lung 
and  produce  the  tympanitic  note  in  the  axillary  region. 


PERICARDITIS.  695 

The  number  of  excellent  observers  who  have  acknowledged  that  they 
have  failed  sometimes  to  discriminate  between  these  two  conditions,  and 
who  have  indeed  performed  paracentesis  cordis  instead  of  paracentesis  peri- 
cardii, is  perhaps  the  best  comment  on  the  difficulties. 

Massive  (1^  to  2  litre)  exudations  have  been  confounded  with  a  pleural 
effusion.  On  more  than  one  occasion  the  pericardium  has  been  tapped 
under  the  impression  that  the  exudate  was  pleuritic.  The  flat  tympany 
in  the  infrascapular  region,  the  absence  of  well-defined  movable  dulness, 
and  the  feeble,  muffled  sounds  are  indicative  points.  If  the  case  has  been 
followed  from  day  to  day  there  is  rarely  much  difficulty;  but  it  is  different 
when  a  case  presents  a  large  area  of  dulness  in  the  antero-lateral  region 
of  the  left  chest,  and  there  is  no  to-and-fro  pericardial  friction  murmur. 
Many  of  the  cases  have  been  regarded  as  encapsulated  pleural  effusions. 

The  nature  of  the  fluid  cannot  positively  be  determined  without  aspira- 
tion; but  a  fairly  accurate  opinion  can  be  formed  from  the  nature  of  the 
primary  disease  and  the  general  condition  of  the  patient.  In  rheumatic 
cases  the  exudation  is  usually  sero-fibrinous;  in  septic  and  tuberculous 
cases  it  is  often  purulent  from  the  outset;  in  senile,  nephritic,  and  tuber- 
culous cases  the  exudation  is  sometimes  hasmorrhagic. 

Treatment. — The  patient  should  have  absolute  quiet,  mentally  and 
bodily,  so  as  to  reduce  to  a  minimum  the  heart's  action.  Drugs  given  for 
this  purpose,  such  as  aconite  or  digitalis,  are  of  doubtful  utility.  Local 
bloodletting  by  cupping  or  leeches  is  certainly  advantageous  in  robust 
subjects,  particularly  in  the  cases  of  extension  in  pleuro-pneumonia.  The 
ice-bag  is  of  great  value.  It  may  be  applied  to  the  prsecordia  at  first  for  an 
hour  or  more  at  a  time,  and  then  continuously.  It  reduces  the  frequency 
of  the  heart's  action  and  seems  to  retard  the  progress  of  an  effusion.  Blis- 
ters are  not  indicated  in  the  early  stage. 

When  effusion  is  present,  the  following  measures  to  promote  absorption 
may  be  adopted:  Blisters  to  the  prgecordia,  a  practice  not  so  much  in  vogue 
now  as  formerly.  It  is  surprising,  however,  in  some  instances,  how  quickly 
an  effusion  will  subside  on  their  application.  If  the  patient's  strength  is 
good,  a  purge  every  other  morning  may  be  given.  The  diet  should  be  light, 
dry,  and  nutritious.  In  cases  in  which  the  pulse  is  strong  and  the  consti- 
tutional disturbance  not  great,  iodide  of  potassium  may  be  of  service,  and 
the  action  of  the  kidneys  may  be  promoted  by  the  infusion  of  digitahs  and 
potassium  acetate. 

When  the  effusion  is  large,  as  soon  as  signs  of  serious  impairment  of 
the  heart  occur,  as  indicated  by  dyspnoea,  small  rapid  pulse,  dusky,  anxious 
countenance,  surgical  measures  should  be  resorted  to,  and  paracentesis,  or 
incision  of  the  pericardium,  at  once  be  performed.  With  the  sero-fibrinous 
exudate,  such  as  commonly  occurs  after  rheumatism,  aspiration  is  suffi- 
cient; but  when  the  exudate  is  purulent,  the  pericardium  should  be  freely 
incised  and  freely  drained.  The  puncture  may  be  made  in  the  fourth  inter- 
space, either  at  the  left  sternal  margin  or  3.5  cm.  (an  inch)  from  it.  If 
made  in  the  fifth  interspace  it  is  well  to  puncture  an  inch  and  a  half  from 
the  left  sternal  margin.  In  large  effusions  the  pericardium  can  also  be 
readily  reached  without  danger  by  thrusting  the  needle  upward  and  back- 


696  DISEASES  OF  THE  CIKCULATORY  SYSTEM. 

ward  close  to  the  costal  margin  in  the  left  costo-xiphoid  angle.  The  re- 
sults of  paracentesis  of  the  pericardium  have  so  far  not  been  satisfactory. 
With  an  earlier  operation  in  many  instances  and  a  more  radical  one  in 
others — a  free-  incision  and  not  aspiration  when  the  fluid  is  purulent — the 
percentage  of  recoveries  will  be  greatly  increased.  Of  35  cases  of  suppura- 
tive pericarditis  treated  by  incision  15  recovered  and  20  died  (Eoberts,  Am. 
Jr.  Med.  Sciences,  Dec,  1897). 

Chronic  Adhesive  Pericarditis  {Adherent  Pericardium). — Two  groups 
of  cases  may  be  recognized: 

(a)  Simple  adhesion  of  the  peri-  and  epicardial  layers.  This  is  a  com- 
mon sequence  of  pericarditis,  and  is  frequently  met  with  post  mortem  as 
an  accidental  lesion.  It  is  not  necessarily  associated  with  disturbance  in 
the  function  of  the  heart,  and  in  a  large  proportion  of  the  cases  there  is 
neither  dilatation  nor  hypertrophy. 

(&)  Adherent  pericardium  with  chronic  mediastinitis  and  union  of  the 
outer  layer  of  the  pericardium  to  the  pleura  and  to  the  chest  walls.  This 
constitutes  one  of  the  most  serious  forms  of  cardiac  disease,  particularly  in 
early  life,  and  may  lead  to  an  extreme  grade  of  hypertrophy  and  dilatation 
of  the  heart.  Even  with  partial  adhesion  between  the  epicardium  and 
pericardium  there  may  be  enormous  hypertrophy  under  the  conditions  just 
mentioned.  The  symptoms  of  adherent  pericardium  are  uncertain  and  in- 
definite. In  the  second  group  the  features  are  those  of  hypertrophy  and 
dilatation  of  the  heart,  later  cardiac  insufficiency,  and  in  a  few  instances 
signs  of  extension  of  the  mediastinitis  to  the  peritongeum,  causing  chronic 
proliferative  peritonitis,  with  perihepatitis  and  perisplenitis.*  Sudden 
death  may  occur  after  an  unusual  exertion  or  during  parturition  (Eeynolds 
Wilson). 

The  following  are  important  points  in  the  diagnosis:  Inspection. — A 
majority  of  the  signs  of  value  come  under  this  heading,  (a)  The  preecordia 
is  prominent  and  there  may  be  marked  asymmetry,  owing  to  the  enormous 
enlargement  of  the  heart.  (&)  The  extent  of  the  cardiac  impulse  is  greatly 
increased,  and  may  sometimes  be  seen  from  the  third  to  the  sixth  inter- 
spaces, and  in  extreme  cases  from  the  right  parasternal  line  to  outside  the 
left  nipple,  (c)  The  character  of  the  cardiac  impulse.  It  is  undulatory, 
wavy,  and  in  the  apex  region  there  is  marked  systolic  retraction,  (d)  Dia- 
phragm phenomena.  J.  F.  H.  Broadbent  has  called  attention  to  a  very  valu- 
able sign  in  adherent  pericardium.  When  the  heart  is  adherent  over  a  large 
area  of  the  diaphragm  there  is  with  each  pulsation  a  systolic  tug,  which 
may  be  communicated  through  the  diaphragm  to  the  points  of  its  attach- 
ment on  the  wall,  causing  a  visible  systolic  tugging.  This  has  long  been 
recognized  in  the  region  of  the  seventh  or  eighth  ribs  in  the  left  parasternal 
line,  but  Dr.  Broadbent  called  attention  to  the  fact  that  it  was  frequently 
best  seen  on  the  left  side  behind,  between  the  eleventh  and  twelfth  ribs. 
With  each  systole  there  may  be  here  a  distinct,  visible  retraction  of  the  chest 
wall.  This  is  a  very  valuable  and  quite  common  sign.  Sir  William  Broad- 
bent calls  attention  also  to  the  fact  that  owing  to  the  attachment  of  the 

♦  For  illustrative  cases  see  Arch,  of  Pediatrics,  1896. 


OTHER  AFFECTIONS  OF  THE  PERICARDIUM.  697 

heart  to  the  central  tendon  of  the  diaphragm  this  part  does  not  descend 
with  inspiration,  during  which  act  there  is  not  the  visible  movement  in  the 
epigastrium,  (e)  Diastolic  collapse  of  the  cervical  veins,  the  so-called  Fried- 
reich's sign.    This  is  not  of  much  moment. 

Palpation. — The  apex  beat  is  fixed,  and  turning  the  patient  on  the  left 
side  does  not  alter  its  position.  This  I  have  found,  however,  somewhat  un- 
certain. On  placing  the  hand  over  the  heart  there  is  felt  a  diastolic  shock 
or  rebound,  which  some  have  regarded  as  the  most  reliable  of  all  signs  of  ad- 
herent pericardium. 

Percussion. — The  area  of  cardiac  dulness  is  usually  much  increased.  In 
a  majority  of  instances  there  are  adhesions  between  the  pleura  and  the  peri- 
cardium, and  the  limit  of  cardiac  dulness  above  and  to  the  left  may  be 
fixed  and  is  uninfluenced  by  deep  inspiration.  This,  too,  is  an  uncertain 
sign,  inasmuch  as  there  may  be  close  adhesions  between  the  pleura  and  the 
pericardium  and  between  the  pleura  and  the  chest  wall,  which  at  the  same 
time  allow  a  very  considerable  degree  of  mobility  to  the  edge  of  the  lung. 

Auscultation. — The  phenomena  are  variable  and  uncertain.  In  the 
cases  in  children  with  a  history  of  rheumatism,  endocarditis  has  usually 
.been  present.  Even  in  the  absence  of  chronic  endocarditis,  when  the  dila- 
tation reaches  a  certain  grade  there  are  murmurs  of  relative  insufficiency, 
which,  as  in  one  case  I  have  recorded,  may  be  present  not  only  at  the  mitral 
but  also  at  the  tricuspid  and  pulmonary  orifices.  Theodore  Fisher  has  called 
attention  to  the  fact  that  there  may  be  a  well-marked  presystolic  murmur 
in  connection  with  adherent  pericardium.  This  was  present  in  one  of  my 
cases. 

The  pulsus  paradoxus,  in  which  during  inspiration  the  pulse-wave  is 
small  and  feeble,  is  sometimes  present,  but  it  is  not  a  diagnostic  sign  of 
either  simple  pericardial  adhesion  or  of  the  cicatricial  mediastino-peri- 
carditis. 

In  children,  chronic  adhesive  pericarditis  and  mediastinitis  may  be  asso- 
ciated with  proliferative  peritonitis,  perihepatitis,  and  perisplenitis,  in 
which  condition  ascites  may  recur  for  months,  or  even  for  years. 


II.    OTHER    AFFECTIONS    OF   THE    PERICARDIUM. 

(1)  Hydropericardium. — Naturally  there  are  in  the  pericardial  sac  a  few 
cubic  centimetres  of  clear,  citron-colored  fluid,  which  probably  represents 
a  post-mortem  transudate.  In  certain  conditions  during  life  there  may  be 
a  large  secretion  of  serum  forming  what  is  known  as  dropsy  of  the  peri- 
cardium. It  occurs  usually  in  connection  with  general  dropsy,  due  to  Icid- 
ney  or  heart  disease;  more  commonly  the  former.  It  rarely  of  itself  proves 
fatal,  though  when  the  effusion  is  excessive  it  adds  to  the  embarrassment  of 
the  heart  and  the  lungs,  particularly  when  the  pleural  cavities  are  the  seat 
of  similar  exudation.  There  are  rare  instances  in  which  effusion  into  the 
pericardium  occurs  after  scarlet  fever  with  few,  if  any,  other  dropsical 
symptoms.  The  physical  signs  are  those  already  referred  to  in  connection 
with  pericarditis  with  effusion.     It  is  frequently  overlooked. 


g98  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

In  rare  cases  the  serum  has  a  milky  character — chylo-pericardium. 

(2)  Hsemo-pericardium. — This  condition,  by  no  means  uncommon,  is  met 
with  in  aneurism  of  the  first  part  of  the  aorta,  of  the  cardiac  wall,  or  of  the 
coronary  arteries,  and  in  rupture  and  wounds  of  the  heart.  Death  usually 
follows  before  there  is  time  for  the  production  of  symptoms  other  than 
those  of  rapid  heart-failure  due  to  compression.  Particularly  is  this  the 
case  in  aneurism.  In  rupture  of  the  heart  the  patient  may  live  for  many 
hours  or  even  days  with  symptoms  of  progressive  heart-failure,  dyspnoea, 
and  the  physical  signs  of  efEusion. 

As  already  mentioned,  the  inflammatory  exudate  of  tubercle  or  cancer 
is  often  blood-stained.  The  same  is  true  of  the  effusion  in  the  pericarditis 
of  Bright's  disease  and  of  old  people. 

(3)  Pneumo-pericardium. — Gas  is  rarely  found  in  the  pericardial  sac, 
and  is  due,  as  a  rule,  to  perforation  from  without,  as  in  the  case  of  stab 
wounds,  or  is  the  result  oi  perforation  from  the  lungs,  oesophagus,  or  stom- 
ach. Perforation  from  a  tuberculous  cavity  is  a  not  uncommon  cause.  In 
those  cases,  formerly  so  puzzling,  in  which  the  gas  is  present  shortly  after 
death  (a  few  hours),  the  gas  bacillus  {B.  aerogenes  capsulatus)  will  be  found. 
In  a  case  at  the  Eoyal  Victoria  Hospital,  in  which  the  gas  bacillus  was 
isolated,  the  diagnosis  was  made  during  life  (Mcholls).  As  a  result  of  per- 
foration, acute  pericarditis  is  always  excited,  and  the  effusion  rapidly  be- 
comes purulent.  The  fluid  and  gas  together  give  a  movable  area  of  per- 
cussion dulness  with  marked  tympany.  On  auscultation,  remarkable 
splashing,  churning,  metallic  phenomena  are  heard  with  friction  and  pos- 
sibly feeble,  distant  heart-sounds. 

(4)  Calcified  Pericardium.— This  remarkable  condition  may  follow  peri- 
carditis, particularly  the  suppurative  and  tuberculous  forms;  occasionally 
it  extends  from  the  calcified  valves.  It  may  be  partial  or  complete.  Of  59 
cases  collected  by  A.  E.  Jones,  in  38  there  were  no  cardiac  symptoms.  Ad- 
herent pericardium  was  diagnosed  in  one  case.  Jones's  careful  study  shows 
that  the  condition  is  usually  latent  and  unrecognized. 


II.    DISEASES   OF  THE  HEAET. 

I.    ENDOCARDITIS. 

Inflammation  of  the  lining  membrane  of  the  heart  is  usually  confined  to 
the  valves,  so  that  the  term  is  practically  synonymous  with  valvular  endo- 
carditis. It  occurs  in  two  forms — acute,  characterized  by  the  presence  of 
vegetations  with  loss  of  continuity  or  of  substance  in  the  valve  tissues; 
chronic,  a  slow  sclerotic  change,  resulting  in  thickening,  puckering,  and  de- 
formity. 

Acute  Endocarditis. 

This  occurs  in  rare  instances  as  a  primary,  independent  affection;  but 
in  the  great  majority  of  cases  it  is  an  accident  in  various  infective  processes, 
so  that  in  reality  the  disease  does  not  constitute  an  etiological  entity.  • 


ENDOCARDITIS.  699 

For  convenience  of  description  we  speak  of  a  simple  or  benign,  and  a 
malignant  or  ulcerative  endocarditis,  between  which,  however,  there  is  no 
essential  anatomical  difference,  as  all  gradations  can  be  traced,  and  they 
represent  bnt  different  degrees  of  intensity  of  the  same  process. 

Etiology. — Simple  endocarditis  does  not  constitute  a  disease  of  itself, 
but  is  invariably  found  with  some  other  affection.  The  general  experience 
of  the  profession  has  confirmed  the  original  observation  of  Bouillaud  as  to 
the  frequency  of  association  of  simple  endocarditis  with  acute  articular 
rheumatism.  Possibly  it  is  nothing  in  the  disease  itself,  but  simply  an 
altered  state  of  the  fluid  media — a  reduction  perhaps  of  the  lethal  influ- 
ences which  they  normally  exert — permitting  the  invasion  of  the  blood  by 
certain  micro-organisms.  Tonsillitis,  which  in  some  forms  is  regarded  as 
a  rheumatic  affection,  may  be  complicated  with  endocarditis.  Of  the  spe- 
cific diseases  of  childhood  it  is  not  uncommon  in  scarlet  fever,  while  it  is 
rare  in  measles  and  chicken-pox.  In  diphtheria  simple  endocarditis  is  rare. 
In  small-pox  it  is  not  common.  In  typhoid  fever  I  have  met  with  it  twice 
in  80  autopsies. 

In  pneumonia  both  simple  and  malignant  endocarditis  are  common. 
In  100  autopsies  in  this  disease  made  at  the  Montreal  General  Hospital  there 
were  5  instances  of  the  former.  Acute  endocarditis  is  by  no  means  rare  in 
phthisis.    I  have  met  with  it  in  12  cases  in  216  post  mortems. 

In  chorea  simple  warty  vegetations  are  found  on  the  valves  in  a  large 
majority  of  all  fatal  cases,  in  62  of  73  cases  collected  by  me.  There  is  no 
disease  in  which,  post  mortem,  acute  endocarditis  has  been  so  frequently 
found.  And,  lastly,  simple  endocarditis  is  met  with  in  diseases  associated 
with  loss  of  flesh  and  progressive  debility,  as  cancer,  and  such  disorders  as 
gout,  diabetes,  and  Bright's  disease. 

A  very  common  form  is  that  which  occurs  on  the  sclerotic  valves  in  old 
heart-disease — the  so-called  recurring  endocarditis. 

Malignant  endocarditis  is  met  with:  (a)  As  a  primary  disease  of  the 
lining  membrane  of  the  heart  or  of  its  valves. 

(h)  As  a  secondary  affection  in  acute  rheumatism,  pneumonia,  and  in 
various  specific  fevers;  or  as  an  associated  condition  in  septic  processes. 

It  is  also  known  by  the  names  of  ulcerative,  infectious,  or  diphtheritic 
endocarditis,  but  the  term  malignant  seems  most  appropriate  to  charac- 
terize the  essential  clinical  features  of  the  disease. 

The  existence  of  a  primary  endocarditis  has  been  doubted;  but  there 
are  instances  in  which  persons  previously  in  good  health,  without  any  his- 
tory of  affections  with  which  endocarditis  is  usually  associated,  have  been 
attacked  with  symptoms  resembling  severe  typhus  or  typhoid.  In  one  case 
which  I  saw,  death  occurred  on  the  sixth  day  and  no  lesions  were  found 
other  than  those  of  malignant  endocarditis. 

The  simple  endocarditis  of  rheumatism  rarely  develops  into  the  malig- 
nant form.  In  only  24  of  209  cases  the  symptoms  of  severe  endocarditis 
arose  in  the  progress  of  acute  or  subacute  rheumatism.  In  only  3  of  my 
Montreal  cases  was  there  a  history  of  rheumatiam  i^ither  before  or  during 
the  attacks- 
Malignant  endocarditis  is  extremely  rare  in  chorea.     Of  all  acute  dis- 


700  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

eases  complicated  with  severe  endocarditis  pneumonia  probably  heads  the 
list.  This  fact,  which  had  been  referred  to  by  several  of  the  older  writers, 
was  brought  out  in  a  striking  manner  by  the  figures  on  which  my  Goul- 
stonian  lectures  were  based.  In  11  of  the  23  Montreal  cases  the  disease  came 
on  with  lobar  pneumonia,  while  it  developed  with  this  disease  in  54  of  the 
209  cases  analyzed — indeed,  the  endocarditis  which  occurs  in  pneumonia 
seems  to  be  of  an  unusually  malignant  type,  as  in  16  cases  of  my  100  autop- 
sies in  this  disease  in  which  this  lesion  was  present,  11  were  of  this  form. 
This  has  been  confirmed  by  Netter,  Kanthack,  and  others.  Meningitis  was 
associated  with  endocarditis  in  25  of  the  209  cases,  and  in  15  there  was  also 
pneumonia. 

The  affection  may  complicate  erysipelas,  septicaemia  (from  whatever 
cause)  and  puerperal  fever  and  gonorrhoea.  Malignant  endocarditis  is  very 
rare  in  tuberculosis,  typhoid  fever,  and  diphtheria. 

It  has  been  stated  by  many  writers  that  endocarditis  occurs  in  ague. 
With  the  unusual  facilities  for  the  study  of  this  disease  which  I  have  had 
in  the  past  twelve  years  I  have  not  yet  met  with  an  instance.  Unquestion- 
ably, in  the  majority  of  these  cases,  the  intermittent  pyrexia,  which  has 
been  regarded  as  characteristic  of  the  ague,  has  depended  upon  the  endo- 
carditis. In  dysentery  cases  have  been  described.  In  small-pox  and  scarlet 
fever,  with  which  simple  endocarditis  is  not  infrequently  complicated,  the 
malignant  form  is  extremely  rare. 

Morbid  Anatomy  of  Simple  and  Malignant  Endocarditis. — Simple  endo- 
carditis is  characterized  by  the  presence  on  the  valves  or  on  the  lining  mem- 
brane of  the  chambers  of  minute  vegetations,  ranging  from  1  to  4  mm. 
in  diameter,  with  an  irregular  and  fissured  surface,  giving  to  them  a  warty 
or  verrucose  appearance.  Often  these  little  cauliflower-like  excrescences  are 
attached  by  very  narrow  pedicles.  They  are  more  common  on  the  left  side 
of  the  heart  than  the  right,  and  occur  on  the  mitral  valves  more  often  than 
on  the  aortic.  The  vegetations  are  usually  above  the  line  of  closure  of  the 
valves.  It  is  rare  to  see  any  swelling  or  macroscopic  evidence  of  infiltration 
of  the  endocardium  in  the  neighborhood  of  even  the  smallest  of  the  granu- 
lations, and  redness,  indicative  of  distention  of  the  vessels,  is  uncommon, 
even  when  they  occur  upon  valves  already  the  seat  of  sclerotic  changes,  in 
which  capillary  vessels  extend  to  the  edges.  With  time  the  vegetations  may 
increase  greatly  in  size,  but  in  what  may  be  called  simple  endocarditis  the 
size  rarely  exceeds  that  mentioned  above. 

The  earliest  vegetations  consist  of  elements  derived  from  the  blood,  and 
are  composed  of  blood  platelets,  leucocytes,  and  fibrin  in  varying  propor- 
tions. At  a  later  stage  they  appear  as  small  outgrowths  of  connective  tissue. 
The  transition  of  one  form  into  the  other  can  often  be  followed.  The 
process  consists  of  a  proliferation  of  the  endothelial  cells  and  the  cells  of 
the  subendothelial  layer  which  gradually  invade  the  fresh  vegetation,  and 
ultimately  entirely  replace  it.  The  blood-cells  and  fibrin  undergo  disinte- 
gration and  gradually  they  are  removed.  The  whole  process  has  received 
the  name  of  "  organization."  Even  when  the  vegetation  has  been  entirely 
converted  into  granulations  or  connective  tissue  it  is  often  found  at  autopsy 
to  be  capped  with  a  thin  layer  of  fibrin  and  leucocytes. 


ENDOCARDITIS.  701 

Micro-organisms  are  generally,  even  if  not  invariably,  found  associated 
with  the  vegetations.  They  tend  to  be  entangled  in  the  granular  and 
fibrillated  fibrin  or  in  the  older  ones  to  cap  the  apices. 

In  both  man  and  animals  there  is  a  form  of  chronic  vegetative  endo- 
carditis in  which,  without  much  or  any  loss  of  substance,  the  valves  and 
chords  tendineae  are  covered  with  large,  firm  outgrowths.  In  several  cases 
of  this  kind  the  clinical  history  has  been  characterized  by  a  protracted  fever 
of  a  marked  remittent  or  even  intermittent  type. 

Subsequent  Changes. — (1)  The  vegetations  may  become  organized  and 
the  valve  restored  to  a  normal  state  (?).  (2)  The  process  may  extend,  and  a 
simple  may  become  an  ulcerative  endocarditis.  (3)  The  vegetations  may  be 
broken  off  and  carried  in  the  circulation  to  distant  parts.  (4)  The  vegeta- 
tions become  organized  and  disappear,  but  they  initiate  a  nutritive  change 
in  the  valve  tissue  which  ultimately  leads  to  sclerosis,  thickening,  and  de- 
formity. The  danger  in  any  case  of  simple  endocarditis  is  not  immediate, 
but  remote,  and  consists  in  this  perversion  of  the  normal  processes  of  nutri- 
tion which  results  in  sclerosis  of  the  valves. 

A  gradual  transition  from  the  simple  to  a  more  severe  affection,  to  which 
the  name  malignant  or  ulcerative  endocarditis  has  been  given,  may  be  traced. 
Practically  every  case  of  ulcerative  endocarditis  is  attended  by  vegetations. 
In  this  form  the  loss  of  substance  in  the  valve  is  more  pronounced,  the  dep- 
osition— thrombus  formation — from  the  blood  is  more  extensive,  and  the 
micro-organisms  are  present  in  greater  number  and  often  show  increased 
virulence.  Ulcerative  endocarditis  is  often  found  in  connection  with  heart 
valves  already  the  seat  of  chronic  proliferative  and  sclerotic  changes. 

In  malignant  endocarditis  there  is  distinct  loss  of  substance  in  the  heart 
valve.  This  loss  may  be  superficial  and  limited  to  the  endocardium,  or, 
what  is  more  common,  it  involves  deeper  structures,  and  not  very  infre- 
quently leads  to  perforation  of  a  valve,  a  septum,  or  even  of  the  heart  itself. 

Upon  microscopical  examination  the  affected  valve  shows  necrosis,  with 
more  or  less  loss  of  substance;  the  necrotic  tissue  is  devoid  of  preserved 
nuclei  and  presents  a  coagulated  appearance.  Upon  it  a  mixture  of  blood 
platelets,  fibrin — granular  or  fibrillated — and  leucocytes  enclosing  masses 
of  micro-organisms  are  met  with.  The  subjacent  tissue  often  shows  scle- 
rotic thickening  and  always  infiltration  with  exuded  granulation  tissue-cells. 

Parts  affected. — The  following  figures,  taken  from  my  Goulstonian  lec- 
tures at  the  Eoyal  College  of  Physicians,  give  an  approximate  estimate  of 
the  frequency  with  which  in  209  cases  different  parts  of  the  heart  were 
affected  in  malignant  endocarditis:  Aortic  and  mitral  valves  together,  in 
41;  aortic  valves  alone,  in  53;  mitral  valves  alone,  in  77;  tricuspid  in  19; 
the  pulmonary  valves  in  15;  and  the  heart  walls  in  33.  In  9  instances  the 
right  heart  alone  was  involved,  in  most  cases  the  auriculo-ventricular  valves. 

Mural  endocarditis  is  seen  most  often  at  the  upper  part  of  the  septum 
of  the  left  ventricle.  Next  in  order  is  the  endocarditis  of  the  left  auricle 
on  the  postero-external  wall.  The  vegetations  may  extend,  as  in  a  recent 
case  in  my  wards,  along  tlic  intima  of  the  pulmonary  artery  into  the  hilum 
of  the  lung.  The  ulcerative  changes  may  lead  to  perforation  of  a  valve  seg- 
ment, erosion  of  the  chordae  tendineae,  perforation  of  the  septum,  or  even 


702  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

of  the  heart  itself.  A  common  result  of  the  ulceration  is  the  production  of 
valvular  aneurism.  In  three  fourths  of  the  eases  the  affected  valves  present 
old  sclerotic  changes.  The  process  may  extend  to  the  aorta,  producing,  as 
in  one  of  my  cases,  extensive  endarteritis  with  multiple  acute  aneurisms. 

Associated  Lesions. — The  associated  pathological  changes  are  partly 
those  of  the  primary  disease  to  which  the  endocarditis  is  secondary  and 
partly  those  due  to  embolism.  In  the  endocarditis  of  septic  processes  there 
is  the  local  lesion — an  acute  necrosis,  a  suppurative  wound,  or  puerperal  dis- 
ease. In  many 'cases  the  lesions  are  those  of  pneumonia,  rheumatism,  or 
other  febrile  processes.  The  changes  due  to  embolism  constitute  the  most 
striking  features,  but  it  is  remarkable  that  in  some  instances,  even  with 
endocarditis  of  a  markedly  ulcerative  character,  there  may  be  no  trace  of 
embolic  processes. 

The  infarcts  may  be  few  in  number — only  one  or  two,  perhaps,  in  the 
spleen  or  kidney — or  they  may  exist  in  hundreds  throughout  the  various 
parts  of  the  body.  They  may  present  the  ordinary  appearance  of  red  or 
white  infarcts  of  a  suppurative  character.  They  are  most  common  in  the 
spleen  and  kidneys,  though  they  may  be  numerous  in  the  brain,  and  in 
many  cases  are  very  abundant  in  the  intestines.  In  right-sided  endocar- 
ditis there  may  be  infarcts  in  the  lungs.  In  many  of  the  cases  there  are 
innumerable  miliary  abscesses.  Acute  suppurative  meningitis  was  met 
with  in  5  of  23  of  the  Montreal  cases,  and  in  over  10  per  cent  of  the  309 
cases  analyzed  in  the  literature.  Acute  suppurative  parotitis  also  may 
occur. 

Bacteriology. — No  distinction  in  the  micro-organisms  found  in  the  two 
forms  of  endocarditis  can  be  made.  In  both  the  pyogenic  cocci — strepto- 
cocci, staphylococci,  pneumococci,  and  gonococci — are  the  most  frequent 
bacteria  met  with.  More  rarely,  especially  in  the  simple  vegetative  endo- 
carditis, the  bacilli  of  tuberculosis,  typhoid  fever,  and  anthrax  have  been 
encountered.  The  bacillus  coli  communis  has  also  been  found,  and  Howard 
has  described  a  case  of  malignant  endocarditis  due  to  an  attenuated  form 
of  the  diphtheria  bacillus.  Flexner  *  has  analyzed  34  cases  of  acute  endo- 
carditis associated  with  chronic  renal  and  cardiac  disease, -and  found  the 
micrococcus  lanceolatus  and  the  streptococcus  pyogenes  present  each  twelve 
times,  the  staphylococcus  three  times.  Other  bacteria  encountered  were 
bacillus  pyocyaneus,  coli,  and  influenzse,  and  the  gonoeoccus. 

Symptoms. — Neither  the  clinical  course  nor  the  physical  signs  of 
simple  endocarditis  are  in  any  respect  characteristic.  The  great  majority 
of  the  cases  are  latent  and  there  is  no  indication  whatever  of  cardiac  mis- 
chief. Experience  has  taught  us  that  endocarditis  is  frequently  found  post 
mortem  in  persons  in  whom  it  was  not  suspected  during,  life.  There  are 
certain  features,  however,  by  which  its  presence  is  indicated  with  a  degree 
of  probability.  The  patient,  as  a  rule,  does  not  complain  of  any  pain  or 
cardiac  distress.  In  a  case  of  acute  rheumatism,  for  example,  the  symptoms 
to  excite  suspicion  would  be  increased  rapidity  of  the  heart's  action,  per- 
haps slight  irregularity,  and  an  increase  in  the  fever  without  aggravation 

*  Journal  of  Experimental  Medicine,  1896,  i,  p.  559. 


ENDOCAEDITIS.  703 

of  the  joint  trouble.  Eows  of  tiny  vegetations  on  the  mitral  or  on  the  aortic 
segments  seem  a  trifling  matter  to  excite  fever,  and  it  is  dif&cult  in  the 
endocarditis  of  febrile  processes  to  say  definitely  in  every  instance  that  an 
increase  in  the  fever  depends  upon  the  endocardial  complication.  But  a 
study  of  the  recurring  endocarditis — which  is  of  the  warty  variety,  con- 
sisting of  minute  beads  on  old  sclerotic  valves — shows  that  this  process  may 
be  associated,  for  days  or  weeks  at  a  time,  with  slight  fever  ranging  from 
100°  to  102^°.  Palpitation  may  be  a  marked  feature  and  is  a  symptom  upon 
which  certain  authors  lay  great  stress. 

The  diagnosis  of  the  condition  rests  upon  physical  signs  which  are 
notoriously  uncertain.  The  presence  of  a  murmur  at  one  or  other  of  the 
cardiac  areas  in  a  case  of  fever  is  often  regarded  as  indicative  of  the  exist- 
ence of  endocarditis.  This  extremely  common  mistake  has  arisen  from  the 
fact  that  the  bruit  de  souffle  or  bellows  murmur  is  common  to  endocarditis 
and  a  number  of  other  conditions  which  have  nothing  to  do  with  it.  At 
first  there  may  be  only  a  slight  roughening  of  the  first  sound,  which  may 
gradually  develop  into  a  distinct  murmur.  Reduplication  and  accentua- 
tion of  the  pulmonic  second  sound  are  frequently  present. 

It  is  difficult  to  give  a  satisfactory  clinical  picture  of  malignant  endo- 
carditis because  the  modes  of  onset  are  so  varied  and  the  symptoms  so 
diverse.  Arising  in  the  course  of  some  other  disease,  there  may  be  simply 
an  intensification  of  the  fever  or  a  change  in  its  character.  In  a  majority 
of  the  cases  there  are  present  certain  general  features,  such  as  irregular 
pyrexia,  sweating,  delirium,  and  gradual  failure  of  strength. 

Embolic  processes  may  give  special  characters,  such  as  delirium,  coma 
or  paralysis  from  involvement  of  the  brain  or  its  membranes,  pain  in  the 
side  and  local  peritonitis  from  infarction  of  the  spleen,  bloody  urine  from 
implication  of  the  kidneys,  impaired  vision  from  retinal  haemorrhage,  and 
suppuration,  and  even  gangrene,  in  various  parts  from  the  distribution  of 
the  emboli. 

Two  special  types  of  the  disease  have  been  recognized — the  septic  or 
pyaemic  and  the  typhoid.  Other  cases  closely  resemble  true  intermittent 
fever.  In  some  the  cardiac  symptoms  are  most  prominent,  while  in  others 
again  the  main  symptoms  may  be  those  of  an  acute  affection  of  the  cerebro- 
spinal sy,stem. 

The  septic  type  is  met  with  usually  in  connection  with  an  external 
wound,  the  puerperal  process,  or  an  acute  necrosis.  There  are  rigors,  sweats, 
irregular  fevers,  and  all  of  the  signs  of  septic  infection.  The  heart  symp- 
toms may  be  completely  masked  by  the  general  condition,  and  attention 
called  to  them  only  on  the  occurrence  of  embolism.  In  a  most  remarkable 
sub-group  of  this  type  the  disease  may  simulate  a  quotidian  or  a  tertian 
ague.  The  symptoms  may  develop  in  persons  with  chronic  heart-disease 
without  any  external  lesions.  These  cases  may  be  much  prolonged — -for 
three  or  four  months,  or  even  longer,  as  in  one  of  Bristowe's.  The  ex- 
istence in  some  of  these  instances  of  a  previous  genuine  malaria  has  been 
a  very  puzzling  circumstance. 

The  typhnkl  type  is  by  far  the  most  common  and  is  characterized  by  a 
less  irregular  temperature,  early  prostration,  delirium,  somnolence,  and  coma, 
44 


704  DISEASES  OF  THE  CIECULATORY  SYSTEM. 

relaxed  bowels,  sweating,  which  may  be  of  a  most  drenching  character, 
petechial  and  other  rashes,  and  occasionally  parotitis.  The  heart  symptoms 
may  be  completely  overlooked,  and  in  some  instances  the  most  careful 
examination  has  failed  to  discover  a  murmur. 

Under  the  cardiac  group,  as  suggested  by  Bramwell,  may  be  consid- 
ered those  cases  in  which  patients  with  chronic  valve  disease  are  attacked 
with  marked  fever  and  evidence  of  recent  endocarditis.  Many  such  cases 
present  symptoms  of  the  pyemic  and  typhoid  character  and  may  run  a 
most  acute  course.  In  others  the  course  is  chronic,  lasting  for  weeks  or 
months.  I  have  reported  two  cases  of  this  chronic  vegetative  endocarditis, 
with  intermittent  fever,  one  of  more  than  a  year's  duration.  The  autopsies 
showed  extensive  vegetative  and  ulcerative  disease  of  the  mitral  valves. 

-There  are  cases  in  which  it  is  often  difficult  to  decide  whether  malig- 
nant endocarditis  is  present  or  not.  Thus,  a  patient  with  aortic  valve  dis- 
ease is  under  treatment  for  failing  compensation  and  begins  to  have  irregu- 
lar fever  with  restlessness  and  cardiac  distress;  embolic  phenomena  may 
develop — sudden  hemiplegia,  pain  in  the  region  of  the  spleen,  or  bloody 
urine,  or  perhaps  peripheral  embolism.  There  may  be  a  low  delirium  and 
the  case  may  run  a  tolerably  acute  course;  but  in  other  instances  the  fever 
subsides  and  recovery  occurs. 

In  what  may  be  termed  the  cerebral  group  of  cases  the  clinical  picture 
may  simulate  a  meningitis,  either  basilar  or  cerebro-spinal.  There  may 
be  acute  delirium  or,  as  in  three  of  the  Montreal  cases,  the  patient  may  be 
brought  into  the  hospital  unconscious.  Heineman  reports  an  instance,  with 
autopsy,  in  which  the  clinical  picture  was  that  of  an  acute  cerebro-spinal 
meningitis. 

Certain  special  symptoms  may  be  mentioned.  The  fever  is  not  always 
of  a  remittent  type,  but  may  be  high  and  continuous.  Petechial  rashes 
are  very  common  and  render  the  similarity  very  strong  to  certain  cases  of 
typhoid  and  cerebro-spinal  fever.  In  one  case  the  disease  was  thought 
to  be  hsemorrhagic  small-pox.  Erythematous  rashes  are  not  uncommon. 
The  sweating  may  be  most  profuse,  even  exceeding  that  which  occurs  in 
phthisis  and  ague.  Diarrhoea  is  not  necessarily  associated  with  embolic 
lesions  in  the  intestines.  Jaundice  has  been  observed  and  cases  are  on 
r-ecord  which  were  mistaken  for  acute  yellow  atrophy. 

The  heart  symptoms  may  be  entirely  latent  and  are  not  found  unless  a 
careful  search  be  made.  Even  on  examination  there  may  be  no  murmur 
present.  Instances  are  recorded  by  careful  observers,  in  which  the  examina- 
tion of  the  heart  has  been  negative.  Cases  with  chronic  valve  disease  usu- 
ally present  no  difficulty  in  diagnosis. 

The  course  of  the  disease  is  varied,  depending  largely  upon  the  nature 
of  the  primary  trouble.  Except  in  the  disease  grafted  upon  chronic  valvu- 
litis the  course  is  rarely  extended  beyond  five  or  six  weeks.  As  already 
mentioned,  there  are  instances  in  which  the  disease  is  prolonged  for  months. 
The  most  rapidly  fatal  case  on  record  is  described  by  Eberth,  the  duration 
of  which  was  scarcely  two  days. 

Diagnosis.' — In  many  cases  the  detection  of  the  disease  is  very  diffi- 
cult; in  others,  with  marked  embolic  symptoms,  it  is  easy.     From  simple 


ENDOCARDITIS.  Y05 

endocarditis  it  is  readily  distinguished,  though  confusion  occasionally 
occurs  in  the  transitional  stage,  when  a  simple  is  developing  into  a  malig- 
nant form.  The  constitutional  symptoms  are  of  a  graver  type,  the  fever 
is  higher,  rigors  are  common,  and  septic  and  typhoid  symptoms  develop. 
Perhaps  a  majority  of  the  cases  not  associated  with  puerperal  processes  or 
bone-disease  are  confounded  with  typhoid  fever.  A  differential  diagnosis 
may  even  be  impossible,  particularly  when  we  consider  that  in  typhoid 
fever  infarctions  and  parotitis  Blay  occur.  The  diarrhoea  and  abdominal 
tenderness  may  also  be  present,  which  with  the  stupor  and  progressive 
asthenia  make  a  picture  not  to  be  distinguished  from  this  disease.  Points 
which  may  guide  us  are:  The  more  abrupt  onset  in  endocarditis,  the  ab- 
sence of  any  regularity  of  the  pyrexia  in  the  early  stage  of  the  disease,  and 
the  cardiac  pain.  Oppression  and  shortness  of  breath  may  be  early  symp- 
toms in  malignant  endocarditis.  Eigors,  too,  are  not  uncommon.  There 
is  a  marked  leucocytosis  in  infective  endocarditis.  Between  pyaemia  and 
malignant  endocarditis  there  are  practically  no  differential  features,  for 
the  disease  really  constitutes  an  arterial  pycemia  (Wilks).  In  the  acute  cases 
resembling  malignant  fevers,  the  diagnosis  is  usually  made  of  typhus, 
typhoid,  cerebro-spinal  fever,  or  even  of  hsemorrhagic  small-pox.  The  in- 
termittent pyrexia,  occurring  for  weeks  or  months,  has  led  in  some  cases 
to  the  diagnosis  of  malaria,  but  this  disease  could  now  be  positively  excluded 
by  the  blood  examination.    Blood  cultures  may  aid  greatly  in  the  diagnosis. 

The  cases  usually  terminate  fatally.  The  instances  of  recovery  are  those 
more  subacute  forms,  the  so-called  recurring  endocarditis  developing  on 
old  sclerotic  valves  in  cases  of  chronic  heart-disease. 

Treatment. — We  know  no  measures  by  which  in  rheumatism,  chorea, 
or  the  eruptive  fevers  the  onset  of  endocarditis  can  be  prevented.  As  it  is 
probable  that  many  cases  develop,  particularly  in  children,  in  mild  forms 
of  these  diseases,  it  is  well  to  guard  the  patients  against  taking  cold  and 
insist  upon  rest  and  quiet,  and  to  bear  in  mind  that  of  all  complications 
an  acute  endocarditis,  though  in  its  immediate  effects  harmless,  is  per- 
haps the  most  serious.  This  statement  is  enforced  by  the  observations  of 
Sibson  that  on  a  system  of  absolute  rest  the  proportion  of  cases  of  rheu- 
matism attacked  by  endocarditis  was  less  than  of  those  who  were  not  so 
treated. 

It  is  doubtful  whether  the  salicylates  in  rheumatism  have  an  influence 
in  reducing  the  liability  to  endocarditis.  When  the  endocarditis  is  present 
we  know  no  remedies  which  will  definitely  influence  the  valvular  lesions. 
If  there  is  much  vascular  excitement  aconite  may  be  given  and  an  ice-bag 
placed  over  the  heart. 

The  salicylates  are  strongly  advised  by  some  writers  and  the  sulpho- 
carbolates  have  been  recommended  by  Sansom.  In  the  severer  cases  of 
malignant  endocarditis  the  treatment  is  practically  that  of  septicaemia. 

Cheonic  Endocarditis. 

This  condition,  which  is  a  sclerosis  of  the  valve,  may  be  primary,  but  is 
oftener  secondary  to  acute  endocarditis,  particularly  the  rheumatic  form. 


706  DISEASES  OF  THE  CIRCULATOEY  SYSTEM. 

It  is  essentially  a  slow,  insidious  process  which  leads  to  deformity  of  the 
valve  segment  and  is  the  foundation  of  chronic  valvular  disease. 

Certain  poisons  appear  capable  of  initiating  the  change,  such  as  alco- 
hol, syphilis,  and  gout,  though  we  are  at  present  ignorant  of  the  way  in 
which  they  act.  A  very  important  factor,  particularly  in  the  case  of  the 
aortic  valves,  is  the  strain  of  prolonged  and  heavy  muscular  exertion.  In 
no  other  way  can  be  explained  the  occurrence  of  so  many  cases  of  sclerosis 
of  the  aortic  valves  in  young  and  middle-aged  men  whose  occupations  neces- 
sitate the  overuse  of  the  muscles. 

Morbid  Anatomy. — Vegetations  in  the  form  in  which  they  occur 
in  acute  endocarditis  are  not  present.  In  the  early  stage,  which  we  have 
frequent  opportunities  of  seeing,  the  edge  of  the  valve  is  a  little  thickened 
and  perhaps  presents  a  few  small  nodular  prominences,  which  in  some 
cases  may  represent  the  healed  vegetations  of  the  acute  process.  In  the 
aortic  valves  the  tissue  about  the  corpora  Arantii  is  first  affected,  producing 
a  slight  thickening  with  an  increase  in  the  size  of  the  nodules.  The  sub- 
stance of  the  valve  may  lose  its  translucency,  and  the  only  change  noticeable 
be  a  grayish  opacity  and  a  slight  loss  of  its  delicate  tenuity.  In  the  auriculo- 
ventrieular  valves  these  early  changes  are  seen  just  within  the  margin 
and  here  it  is  not  uncommon  to  find  swellings  of  a  grayish-red,  somewhat 
infiltrated  appearance,  almost  identical  with  the  similar  structures  on  the 
intima  of  the  aorta  in  arterio-sclerosis.  Even  early  there  may  be  seen  yel- 
low or  opaque-white  subintimal  fatty  degenerated  areas.  As  the  sclerotic 
changes  increase,  the  fibrous  tissue  contracts  and  produces  thickening  and 
deformity  of  the  segment,  the  edges  of  which  become  round,  curled,  and 
incapable  of  that  delicate  apposition  necessary  for  perfect  closure.  A  sig- 
moid valve,  for  instance,  may  be  narrowed  one  fourth  or  even  one  third 
across  its  face,  the  most  extreme  grade  of  insufficiency  being  induced  with- 
out any  special  deformity  and  without  any  definite  narrowing  of  the  arterial 
orifice.  In  the  auriculo-ventricular  segments  a  simple  process  of  thicken- 
ing and  curling  of  the  edges  of  the  valves,  inducing  a  failure  to  close  with- 
out forming  any  obstruction  to  the  normal  course  of  the  blood-flow,  is  less 
common.  Still,  we  meet  with  instances  at  the  mitral  orifice,  particularly 
in  children,  in  which  the  edges  of  the  valves  are  curled  and  thickened, 
so  that  there  is  extreme  insufficiency  without  any  material  narrowing  of  the 
orifice.  More  frequently,  as  the  disease  advances,  the  chordae  tendinese 
become  thickened,  first  at  the  valvular  ends  and  then  along  their  course. 
The  edges  of  the  valves  at  their  angles  are  gradually  drawn  together  and 
there  is  a  definite  narrowing  of  the  orifice,  leading  in  the  aorta  to  more 
or  less  stenosis  and  in  the  left  auriculo-ventricular  orifice — the  two  sites 
most  frequently  involved — to  constriction.  Finally,  in  the  sclerotic  and 
necrotic  tissues  lime  salts  are  deposited  and  may  even  reach  the  deeper 
structures  of  the  fibrous  rings,  so  that  the  entire  valve  becomes  a  dense  cal- 
careous mass  with  scarcely  a  remnant  of  normal  tissue.  The  chordae  ten- 
dineae  may  gradually  become  shortened,  greatly  thickened,  and  in  extreme 
cases  the  papillary  muscles  are  implanted  directly  upon  the  sclerotic  and 
deformed  valve.  The  apices  of  the  papillary  muscles  usually  show  marked 
fibroid  change. 

/ 


CHRONIC  VALVUIiAR  DISEASE.  707 

In  all  stages  of  the  process  the  vegetations  of  simple  endocarditis  may 
be  present,  and  upon  sclerotic  valves  we  find  the  severer,  ulcerative  form  of 
the  disease. 

Chronic  mural  endocarditis  produces  cicatricial-like  patches  of  a  gray- 
ish-white appearance  which  are  sometimes  seen  on  the  muscular  trabeculse 
of  the  ventricle  or  in  the  auricles.  It  often  occurs  in  association  with  myo- 
carditis. 

The  frequency  with  which  chronic  endocarditis  is  met  with  may  be 
gathered  from  the  following  figures:  In  the  statistics,  amounting  to  from 
12,000  to  14,000  autopsies,  reported  from  Dresden,  Wiirzburg,  and  Prague 
the  percentage  ranged  from  four  to  nine.  The  relative  frequency  of  involve- 
ment of  the  various  valves  is  thus  given  in  the  collected  statistics  of  Parrot: 
The  mitral  orifice  was  involved  in  621,  the  aortic  in  380,  the  tricuspid  in 
46,  and  the  pulmonary  in  11.  This  gives  57  instances  in  the  right  to  1,001 
in  the  left  heart. 

The  endocarditis  of  the  foetus  is  usually  of  the  sclerotic  form  and  in- 
volves the  valves  of  the  right  more  frequently  than  those  of  the  left  side. 


II.    CHRONIC  VALVULAR    DISEASE. 

1.  General  Inteoduction.  ^ 

The  incidence  of  valvular  lesions  may  be  gathered  from  the  following 
figures  compiled  by  Gillespie  from  the  records  of  the  Eoyal  Infirmary,  Edin- 
burgh: Of  2,368  cases  with  cardiac  lesions,  valvular  disease  occurred  in  80.8 
per  cent;  endocarditis  and  pericarditis  in  5.3;  myocardial  lesions  in  11.9 
per  cent;  66.2  per  cent  of  the  cases  were  in  males. 

Effects  of  Valve  Lesions. — The  general  influence  on  the  work  of  the 
heart  may  be  briefly  stated  as  follows:  The  sclerosis  induces  insufficiency 
or  stenosis,  which  may  exist  separately  or  in  combination.  The  narrowing 
retards  in  a  measure  the  normal  outflow  and  the  insufficiency  permits  the 
blood  current  to  take  an  abnormal  course.  In  both  instances  the  effect  is 
dilatation  of  a  chamber.  The  result  in  the  former  case  is  an  increase  in 
the  difficulty  which  the  chamber  has  in  expelling  its  contents  through  the 
narrow  orifice;  in  the  other,  the  overfilling  of  a  chamber  by  blood  flowing 
into  it  from  an  improper  source,  as,  for  instance,  in  mitral  insufficiency, 
when  the  left  auricle  receives  blood  both  from  the  pulmonary  veins  and 
from  the  left  ventricle. 

The  cardiac  mechanism  is  fully  prepared  to  meet  ordinary  grades  of 
dilatation  which  constantly  occur  during  sudden  exertion.  A  man,  for  in- 
stance, at  the  end  of  a  hundred-yard  race  has  his  right  chambers  greatly 
dilated  and  his  reserve  cardiac  power  worked  to  its  full  capacity.  The  slow 
progress  of  the  sclerotic  changes  brings  about  a  gradual,  not  an  abrupt,  in- 
sufficiency, and  the  moderate  dilatation  which  follows  is  at  first  overcome 
by  the  exercise  of  the  ordinary  reserve  strength  of  the  heart  muscle.  Grad- 
ually a  new  factor  is  introduced.  The  reserve  power  which  is  capable  of 
meeting  sudden  emergencies  in  such  a  remarkable  manner  is  unable  to  cope 


708 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


long  with,  a  permanent  and  perhaps  increasing  dilatation.  ^lore  "^ork  has 
to  be  done  and,  in  accordance  with  definite  physiological  laws,  more  power 
is  given  by  increase  of  the  muscles.  The  heart  hypertrophies  and  the  effect 
of  the  valve  lesion  becomes,  as  we  say,  compensated.  The  equilibrium  of 
the  circulation  is  in  this  way  maintained. 

The  nature  of  the  process  with  which  we  have  to  deal  is  graphically 
illustrated  in  the  accompanying  diagrams,  which  we  owe  to  Martins,  of 
Eostock.  The  perpendicular  lines  in  the  figures  represent  the  power  of 
work  of  the  heart.  While  the  muscle  in  the  healthy  heart  (Diagram  I)  has 
at  its  disposal  the  maximal  force,  a  c,  it  carries  on  its  work  under  ordinary 
circumstances  (when  the  body  is  at  rest)  with  the  force  a  h.  The  force  h  c 
is  reserve  force,  by  means  of  which  the  heart  accommodates  itself  to  greater 
exertion. 

If  now  there  be  a  gross  valvular  lesion,  the  force  required  to  do  the  ordi- 
nary work  of  the  heart  (at  rest)  becomes  very  much  increased  (Diagram  II). 
But  in  spite  of  this  enormous  call  for  force,  insufficiency  of  the  heart  muscle 
does  not  necessarily  result,  for  the  working  force  required  is  still  within  the 


Reserve-force  =     , 
Accommodation-  \ 
capacity 


Reserve-force= 
AccommodatiDn- 

capacity' 


^b 


Power  of  work 
(body  at  rest) 


lb. 


Power  of  worV 
(body  at  rest) 


Total  power  of  heart 
less  than  amounttieeded 
when  the  body  is  at  rest. 
Insufficiency  ef-the  head 


I.  Normal  heart 


II.  Heart  in  valvular  disease  In 
stage  of  compensation 

Chart  XVI. 


m.  Heart  in  uncompensated 
Valvular  disease 


limits  of  the  maximal  power  of  the  heart,  a^  &i,  being  less  than  a^  c^.  The 
muscle  accommodates  itself  to  the  new  conditions  by  making  its  reserve 
force  mobile  (experiment  of  Eosenbach).  If  nothing  further  occurred, 
however,  this  condition  could  not  be  permanently  maintained,  for  there 
would  be  left  over  for  emergencies  only  the  small  reserve  force,  h^  y.  Even 
when  at  rest  the  heart  would  be  using  continuously  almost  its  entire  maxi- 
mal force.  Any  slight  exertion  requiring  more  extra  force  than  that  repre- 
sented by  the  small  value  &i  y  (say  the  effort  required  on  walking  or  on 


CHRONIC  VALVULAR  DISEASE.  709 

going  upstairs)  would  bring  the  heart  to  the  limit  of  its  working  power, 
and  palpitation  and  dyspncea  would  appear.  Such  a  condition  does  not 
last  long.  The  working  power  of  the  heart  gradually  increases.  More  and 
more  exertion  can  be  borne  without  causing  dyspnoea,  for  the  heart  hyper- 
trophies. Finally,  a  new,  more  or  less  permanent  condition  is  attained,  in 
that  the  hypertrophied  heart  possesses  the  maximal  force,  a^,  c^.  Owing  to 
the  increase  in  volume  of  the  heart  muscle,  the  total  force  of  the  heart  is 
greater  absolutely  than  that  of  the  normal  heart  by  the  amount  y,  c^.  It  is, 
however,  relatively  less  efficient,  for  its  reserve  force  is  much  less  than  that 
of  the  healthy  heart.  Its  capacity  for  accommodating  itself  to  unusual  calls 
upon  it  is  accordingly  permanently  diminished. 

Turning  now  to  the  disturbances  of  compensation,  it  is  to  be  distinctly 
borne  in  mind  that  any  heart,  normal  or  diseased,  can  become  insufficient 
whenever  a  call  upon  it  exceeds  its  maximal  working  capacity.  The  liability 
to  such  disturbance  will  depend,  above  all,  upon  the  accommodation  limits 
of  the  heart — ^the  less  the  width  of  the  latter,  the  easier  will  it  be  to  go 
beyond  the  heart's  efficiency.  A  comparison  of  Diagrams  I  and  II  will  im- 
mediately make  it  clear  that  the  heart  in  valvular  disease  will  much  earlier 
become  insufficient  than  the  heart  of  a  healthy  individual.  If  the  heart 
muscle  is  compelled  to  do  maximal  or  nearly  maximal  work  for  a  long  time, 
it  becomes  exhausted.  It  is  obvious  that  the  heart  in  valvular  disease  has 
on  account  of  its  small  amount  of  reserve  force  to  do  maximal  or  nearly 
maximal  work  far  more  frequently  than  does  the  normal  heart.  The  power 
of  the  heart  may  become  decreased  to  the  amount  necessary  simply  to  carry 
on  the  work  of  the  heart  when  the  body  is  at  rest,  or  it  may  cease  to  be 
sufficient  even  for  this.  The  reserve  force  gained  through  the  compensa- 
tory process  may  be  entirely  lost  (Diagram  III).  If  the  loss  be  only  tem- 
porary, the  exhausted  heart  muscle  quickly  recovering,  the  condition  is 
spoken  of  as  a  "  disturbance  of  compensation."  The  term  "  loss  of  com- 
pensation "  is  reserved  for  the  condition  in  which  the  disturbance  is  con- 
tinuous. - 

2.  Aortic  Izstcompetency. 

Incompetency  of  the  aortic  valves  arises  either  from  inability  of  the 
valve  segments  to  close  an  abnormally  large  orifice  or  more  commonly  from 
disease  of  the  segments  themselves.  This  best-defined  and  most  easily 
recognized  of  valvular  lesions  was  first  carefully  studied  by  Corrigan,  whose 
name  it  sometimes  bears. 

Etiology  and  Morbid  Anatomy. — It  is  more  frequent  in  males 
than  in  females,  affecting  chiefly  able-bodied,  vigorous  men  at  the  middle 
period  of  life.  The  ratio  which  it  bears  to  other  valve  diseases  has  been 
variously  given  as  from  30  to  50  per  cent. 

There  are  four  groups  of  cases:  I.  Those  due  to  congenital  malformation, 
particularly  fusion  of  two  of  the  cusps — most  commonly  those  behind  which 
the  coronary  arteries  are  given  off.  It  is  probable  that  an  aortic  orifice 
may  be  competent  with  this  bicuspid  state  of  the  valves,  but  a  great  dan- 
ger is  the  liability  of  these  malformed  segments  to  sclerotic  endocarditis. 
Of  17  cases  which  I  have  reported  all  presented  sclerotic  changes,  and  the 


YIO  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

majority  of  them  had,  during  life,  the  clinical  features  of  chronic  heart- 
disease. 

II.  The  endocarditic  group.  Endocarditis  may  produce  an  acute  insuffi- 
ciency by  ulceration  and  destruction  of  the  valves;  such  cases  are  usually 
rapidly  fatal.  The  valvulitis  of  rheumatism  and  of  the  fevers,  while  more 
rarely  aortic,  is  common  enough  in  children,  and  the  insufficiency  is  caused 
by  nodular  excrescences  at  the  margins  or  in  the  valves,  which  may  ulti- 
mately become  calcified;  more  often  it  induces  a  slow  sclerosis  of  the  valves 
with  adhesions,  causing  also  some  degree  of  narrowing. 

III.  The  arteriosclerotic  group.  By  far  the  most  frequent  cause  of  in- 
sufficiency is  a  slow,  progressive  sclerosis  of  the  segments,  resulting  in  a 
curling  of  the  edges,  which  lessens  the  working  surface  of  the  valve.  This 
form  is  most  often  met  with  in  strong,  able-bodied  men  among  the  work- 
ing classes.  There  are  three  main  factors  in  its  production:  First,  strain — 
not  a  sudden,  forcible  strain,  but  a  persistent  increase  of  the  normal  tension 
to  which  the  segments  are  subject  during  the  diastole  of  the  ventricle.  Of 
circumstances  increasing  this  tension,  repeated  and  excessive  use  of  the 
muscles  is  perhaps  the  most  important.  So  often  is  this  form  of  heart- 
disease  found  in  persons  devoted  to  athletics  that  it  is  sometimes  called 
the  "  athlete's  heart."  Secondly,  alcohol,  which  not  only  raises  the  tension 
in  the  arterial  system,  but  directly  promotes  arterio-sclerosis.  A  com- 
bination of  these  two  causes  is  extremely  common.  Thirdly,  syphilis, 
which  may  be  only  one  of  several  elements  in  inducing  early  arterial  change, 
an  added  factor  to  the  wear  and  tear  of  the  tubing.  There  is  a  small  group, 
usually  in  young  men,  in  which  syphilis  causes  a  localized  arterio-sclerosis 
at  the  root  of  the  aorta,  either  involving  the  valves  themselves  or  more 
frequently  causing  dilatation  of  the  aortic  ring  with  relative  insufficiency. 
The  endarteritis  may  be  singularly  localized,  even  annular,  sometimes 
patchy.  It  may  be  difficult  or  impossible  from  the  lesion  itself  to  determine 
the  syphilitic  nature;  the  youth  of  the  patient,  the  peculiar  localization,  the 
history  of  syphilis,  and  the  existence  of  syphilitic  lesions  elsewhere,  may 
render  the  diagnosis  tolerably  certain.  I  am  in  the  habit  of  enforcing 
upon  my  students  the  etiological  lesson  of  this  type  of  aortic  insufficiency 
by  a  reference  to  Bacchus  and  Vulcan,  at  whose  shrines  a  majority  of 
patients  with  aortic  insufficiency  have  worshipped,  and  not  a  few  at  those 
of  Mars  and  Venus. 

The  condition  of  the  valves  is  such  as  has  already  been  described  in 
chronic  endocarditis.  It  may  be  noted,  however,  how  slight  a  grade  of 
curling  may  produce  serious  incompetency.  Associated  with  the  valve  dis- 
ease is,  in  a  majority  of  cases,  a  more  or  less  advanced  arterio-sclerosis 
of  the  arch  of  the  aorta,  one  serious  defect  of  which  may  be  a  narrowing 
of  the  orifices  of  the  coronary  arteries.  The  sclerotic  changes  are  often 
combined  with  atheroma,  either  in  the  fatty  or  calcareous  stage.  This  may 
exist  at  the  attached  margin  of  the  valves  without  inducing  insufficiency. 
In  other  instances  insufficiency  may  result  from  a  calcified  spike  projecting 
from  the  aortic  attachment  into  the  body  of  the  valve,  and  so  preventing 
its  proper  closure.  Some  writers  (Peter)  have  laid  great  stress  upon  the 
extension  of  the  endarteritis  to  the  valve,  and  would  separate  the  instances 


CHRONIC  VALVULAR  DISEASE.  711 

of  this  kind  from  those  of  simple  valvular  endocarditis.  Anatomically  one 
can  usually  recognize  the  arterio-sclerotic  variety  by  the  smooth  surface, 
the  rounded  edges,  and  the  absence  of  excrescences. 

IV.  Insufficiency  may  be  induced  by  rupture  of  a  segment — a  very  rare 
event  in  healthy  valves,  but  not  uncommon  in  disease,  either  from  excessive 
effort  during  heavy  lifting  or  from  the  ordinary  endarterial  strain  on  a 
valve  eroded  and  weakened  by  ulcerative  endocarditis. 

Relative  insufficiency  of  the  sigmoid  valves,  due  to  dilatation  of  the 
aortic  ring,  is  not  very  infrequent.  It  occurs  in  extensive  arterial  sclerosis 
of  the  ascending  portion  of  the  arch  with  great  dilatation  just  above  the 
valves.  The  valve  segments  are  usually  involved  with  the  arterial  coats, 
but  the  changes  in  them  may  be  very  slight.  In  aneurism  just  above  the 
aortic  ring,  relative  insufficiency  of  the  valve  may  be  present. 

It  would  appear  from  the  careful  measurements  of  Beneke  that  the 
aortic  orifice,  which  at  birth  is  20  mm.,  increases  gradually  with  the  growth 
of  the  heart  until  at  one-and-twenty  it  is  about  60  mm.  At  this  it  remains 
until  the  age  of  forty,  beyond  which  date  there  is  a  gradual  increase  in  the 
size  up  to  the  age  of  eighty,  when  it  may  reach  from  68  to  70  mm.  There 
is  thus  at  the  very  period  of  life  in  which  sclerosis  of  the  valve  is  most 
common  a  physiological  tendency  toward  the  production  of  a  state  of  rela- 
tive insufficiency. 

The  insufficiency  may  be  combined  with  various  grades  of  narrowing, 
particularly  in  the  endocarditic  group.  In  a  majority  of  the  cases  of  the 
arterio-sclerotic  form  there  are  no  signs  of  stenosis.  On  the  other  hand, 
aortic  stenosis  almost  without  exception  is  associated  with  some  grade,  how- 
ever slight,  of  regurgitation. 

Effects. — The  direct  effect  of  aortic  insufficiency  is  the  regurgitation 
of  blood  from  the  artery  into  the  ventricle,  causing  an  overdistention  of 
the  cavity  and  a  reduction  of  the  blood  column;  that  is,  a  relative  anaemia 
in  the  arterial  tree.  As  an  immediate  effect  of  the  double  blood-flow  into 
the  left  ventricle  dilatation  of  the  chamber  occurs,  and  finally  hypertrophy. 
In  this  way  the  valve  defect  is  compensated,  and  as  with  each  ventricular 
systole  a  larger  amount  of  blood  is  propelled  into  the  arterial  system,  the 
regurgitation  of  a  certain  amount  during  diastole  does  not,  for  a  time  at 
least,  seriously  impair  the  nutrition  of  the  peripheral  parts.  In  this  valve 
lesion  dilatation  and  hypertrophy  reach  their  most  extreme  limit.  The 
heaviest  hearts  on  record  are  described  in  connection  with  this  affection. 
The  so-called  bovine  heart,  cor  hovinum,  may  weigh  35  or  40  ounces,  or 
even,  as  in  a  case  of  Dulles's,  48  ounces.  The  dilatation  is  usually  extreme, 
and  is  in  marked  contrast  to  the  condition  of  the  chamber  in  cases  of  pure 
aortic  stenosis.  The  papillary  muscles  may  be  greatly  flattened.  The 
mitral  valves  are  usually  not  seriously  affected,  though  the  edges  may  pre- 
sent slight  sclerosis,  and  there  is  often  relative  incompetency,  owing  to 
distention  of  the  mitral  ring.  Dilatation  and  hypertrophy  of -the  left 
auricle  are  common,  and  secondary  enlargement  of  the  right  heart  occurs 
in  all  cases  of  long  standing.  In  the  arterio-sclerotic  group  there  is  an 
ever  present  possibility  of  narrowing  of  the  orifices  of  the  coronary  arteries 
or  an  extension  of  the  sclerosis  to  their  branches,  leading  to  fibroid  myo- 


712  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

carditis.  In  the  endoearditic  cases,  particularly  those  following  rheuma- 
tism, the  intima  is  perfectly  smooth,  and  the  arch  with  its  main  branches 
not  dilated.  A  normal  aorta  may  be  found  post  mortem  even  when  during 
life  there  have  been  the  most  characteristic  signs  of  enlargement  of  the 
arch  and  of  dilatation  of  the  innominate  and  right  carotid.  I  have  even 
known  the  condition  of  aneurism  to  be  diagnosed  when  post  mortem  no 
trace  of  dilatation  or  sclerosis  was  found,  only  an  extreme  grade  of  insuffi- 
ciency with  enormous  cardiac  dilatation  and  hypertrophy.  The  so-called 
dynamic  dilatation  of  the  arch  is  best  seen  in  certain  of  these  cases.  Al- 
though the  coronary  arteries,  as  shown  by  Martin  and  Sedgwick,  are  filled 
during  the  ventricular  systole,  the  circulation  in  them  must  be  embarrassed 
in  aortic  incompetency.  They  must  miss  the  effect  of  the  blood-pressure 
in  the  sinuses  of  Valsalva  during  the  elastic  recoil  of  the  arteries,  which 
surely  aids  in  keeping  the  coronary  vessels  full.  The  arteries  of  the  body 
usually  present  more  or  less  sclerosis  consequent  upon  the  strain  which 
they  undergo  during  the  forcible  ventricular  systole. 

Symptoms. — The  condition  is  often  discovered  accidentally  in  per- 
sons who  have  not  presented  any  features  of  cardiac  disease. 

Headache,  dizziness,  flashes  of  light,  and  a  feeling  of  faintness  on  ris- 
ing quickly  are  among  the  earliest  symptoms.  Palpitation  and  cardiac 
distress  on  slight  exertion  are  common.  Long  before  any  signs  of  failing 
compensation  pain  may  become  a  marked  and  troublesome  feature.  It  is 
extremely  variable  in  its  manifestations.  It  may  be  of  a  dull,  aching  char- 
acter confined  to  the  prsecordia.  More  frequently,  however,  it  is  sharp 
and  radiating,  and  is  transmitted  up  the  neck  and  down  the  arms,  particu- 
larly the  left.  Attacks  of  true  angina  pectoris  are  more  frequent  in  this 
than  in  any  other  valvular  disease.  Ansemia  is  also  common,  much  more 
so  than  in  aortic  stenosis  or  in  mitral  affections. 

More  serious  symptoms,  as  compensation  fails,  are  shortness  of  breath 
and  oedema  of  the  feet.  The  attacks  of  dyspnoea  are  liable  to  come  on  at 
night,  and  the  patient  has  to  sleep  with  the  head  high  or  even  in  a  chair. 
Cyanosis  is  rare.  It  is  most  commonly  due  to  complicating  valve  disease, 
or  it  is  stated  that  it  may  result  from  bulging  of  the  septum  ventriculorum 
and  encroachment  upon  the  right  ventricle.  Of  respiratory  symptoms  cough 
is  common,  due  to  the  congestion  of  the  lungs  or  oedema.  Hsemoptysis  is 
less  frequent  than  in  mitral  disease.  I  have  reported  a  case  in  which  it 
was  profuse  and  believed  to  be  due  to  tuberculosis  of  the  lungs,  inasmuch 
as  the  patient  was  admitted  in  a  state  of  emaciation  and  profound  ex- 
haustion. General  dropsy  is  not  common,  but  oedema  of  the  feet  may  occur 
early  and  is  sometimes  due  to  the  anaemia,  at  others  to  the  venous  stasis, 
at  times  to  both.  Unless  there  is  coexisting  disease  of  the  mitral  valve, 
it  is  rare  in  aortic  incompetency  for  the  patient  to  die  with  general  ana- 
sarca. Sudden  death  is  frequent;  more  so  in  this  than  in  other  valvular 
diseases.-  As  compensation  fails  the  patient  takes  to  bed  and  slight  irregu- 
lar fever,  associated  usually  with  a  recurring  endocarditis,  is  not  uncom- 
mon toward  the  close.  Embolic  symptoms  are  not  infrequent — pain  in  the 
splenic  region  with  enlargement  of  the  organ,  hgematuria,  and  in  some 
cases  paralysis.  Distressing  dreams  and  disturbed  sleep  are  more  common 
in  this  than  in  other  forms  of  valvular  disease. 


CHRONIC   VALVULAR  DISEASE.  713 

Here  may  appropriately  be  mentioned  the  connection  between  mental 
symptoms  and'  cardiac  disease,  as  they  are  oftenest  seen  with  this  lesion. 
An  admirable  account  of  the  relations  between  insanity  and  disease  of  the 
heart  is  to  be  found  in  Mickle's  Goulstonian  lectures  for  1888.  In  general 
medical  practice  we  seldom  find  marked  mental  symptoms,  except  toward 
the  close  of  the  disease,  when  there  may  be  delirium,  hallucinations,  and 
morbid  impulses.  It  is  to  be  remembered  that  in  many  heart  cases  this 
terminal  delirium  is  uraemic.  The  irritability  and  peevishness  sometimes 
found  in  persons  the  subject  of  organic  heart-disease  can  not,  I  think,  be 
associated  with  it  in  any  special  manner.  We  do  meet  insanity,  breaking 
out  in  patients  with  aortic  and  mitral  disease,  in  the  stage  of  compensation, 
which  appears  to  be  related  definitely  to  the  cardiac  lesion.  It  is  important 
to  bear  this  in  mind,  for  patients  occasionally  display  suicidal  tendencies. 
I  have  twice  had  patients  throw  themselves  from  a  window  of  the  ward. 

Physical  Signs. — Inspection  shows  a  wide  and  forcible  area  of  cardiac 
impulse  with  the  apex  beat  in  the  sixth  or  seventh  interspace,  and  perhaps 
as  far  out  as  the  anterior  axillary  line.  In  young  subjects  the  prsecordia 
may  bulge.  On  palpation  a  thrill,  diastolic  in  time,  is  occasionally  felt, 
but  is  not  common.  The  impulse  is  usually  strong  and  heaving,  unless 
in  conditions  of  extreme  dilatation,  when  it  is  wavy  and  indefinite.  Occa- 
sionally two  or  three  interspaces  between  the  nipple  line  and  sternum  will 
be  depressed  with  the  systole  as  a  result  of  atmospheric  pressure.  Percus- 
sion shows  a  greater  increase  in  the  area  of  heart  dulness  than  is  found  in 
any  other  valvular  lesion.    It  extends  chiefly  downward  and  to  the  left. 

Auscultation. — A  murmur  is  heard  during  the  diastole  of  the  ventricles 
at  the  base  of  the  heart  and  propagated  down  the  sternum.  It  may  be 
feeble  or  inaudible  at  the  aortic  cartilage,  and  is  usually  heard  best  at 
midsternum  opposite  the  third  costal  cartilage  or  along  the  right  border 
of  the  sternum  as  low  as  the  ensiform  cartilage.  It  is  usually  soft,  blowing 
in  quality,  and  is  prolonged,  or  "  long  drawn,"  as  the  phrase  is.  It  is  pro- 
duced by  the  reflux  of  blood  into  the  ventricle.  The  second  sound  may 
be  well  heard  or  it  may  be  replaced  by  the  murmur.  When  the  arch  is 
dilated  the  second  sound  may  have  a  ringing  metallic  or  booming  quality. 

The  first  sound  may  be  clear  at  the  base;  more  commonly  there  is  a 
soft,  short  systolic  murmur.  In  the  arterio-sclerotic  group  the  systolic 
bruit  is,  as  a  rule,  short  and  soft,  while  in  the  endocarditic  group,  in  which 
the  valve  segments  are  united  and  often  covered  Math  calcified  vegetations 
and  excrescences,  the  systolic  murmur  is  rough  and  may  be  accompanied 
by  a  thrill. 

At  the  apex,  or  toward  it,  the  diastolic  murmur  may  be  faintly  heard 
propagated  from  the  base.  With  full  compensation  the  first  sound  is  usually 
clear  at  tbe  apex;  with  dilatation  there  is  a  loud  systolic  murmur  of  relative 
mitral  insufficiency,  which  may  disappear  under  observation  as  the  dilata- 
tion lessens. 

A  second  murmur  at  the  apex,  probably  produced  at  the  mitral  orifice, 
is  not  uncommon.  Attention  was  called  to  this  by  the  late  Austin  Flint, 
and  the  murmur  usually  goes  by  his  name.  It  is  of  a  rumbling,  echoing 
character,  occurring  in  the  middle  or  latter  part  of  diastole,  usually  pre- 


714  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

systolic  in  time,  and  limited  to  the  apex  region.  It  is  similar  to,  though 
less  intense  than,  the  louder  presystolic  murmurs  of  mitral  stenosis,  and  is 
often  associated  with  a  palpable  thrill.  It  is-  probably  caused  by  the  im- 
pinging of  the  regurgitant  current  from  the  aortic  orifice  on  the  large, 
anterior  flap  of  the  mitral  valve,  so  as  to  cause  interference  with  the  en- 
trance of  blood  at  the  time  of  auricular  contraction.  The  condition  is 
thus  essentially  the  same  as  in  a  moderate  mitral  stenosis.  This  late  dias- 
tolic echoing  or  rumbling  murmur  is  present  in  about  half  of  the  cases 
of  uncomplicated  aortic  insufficiency.  It  is  very  variable,  disappearing  and 
reappearing  again  without  apparent  cause.  The  sharp,  valvular  first  sound 
and  abrupt  systolic  shock,  so  common  in  true  mitral  stenosis,  are  rarely 
present,  whUe  the  pulse  is  characteristic  of  uncomplicated  aortic  insuffi- 
ciency. 

Arteries. — The  examination  of  the  arteries  in  aortic  insufficiency  is  of 
great  value.  Visible  pulsation  is  more  commonly  seen  in  the  peripheral 
vessels  in  this  than  in  any  other  condition.  The  carotids  may  be  seen  to 
throb  forcibly,  the  temporals  to  dilate,  and  the  brachials  and  radials  to 
expand  with  each  heart-beat.  With  the  ophthalmoscope  the  retinal  arteries 
are  seen  to  pulsate.  Not  only  is  the  pulsation  evident,  but  the  character- 
istic jerking  quality  is  apparent.  In  the  throat  the  throbbing  carotids  may 
lead  to  the  diagnosis  of  aneurism.  In  many  cases  the  pulsation  can -be  seen 
in  the  suprasternal  notch,  and  prominent,  forcibly-throbbing  vessels  be- 
neath the  right  sterno-mastoid  muscle.  The  abdominal  aorta  may  lift  the 
epigastrium  with  each  systole.  To  be  mentioned  with  this  is  the  capillary 
pulse,  met  very  often  in  aortic  insufficiency,  and  best  seen  in  the  finger-nails 
or  by  drawing  a  line  upon  the  forehead,  when  the  margin  of  hypersemia  on 
either  side  alternately  blushes  and  pales.  In  extreme  grades  the  face  or 
the  hand  may  blush  visibly  at  each  systole.  It  is  met  with  also  in  profound 
anaemia,  occasionally  in  neurasthenia,  and  in  health  in  conditions  of  great 
relaxation  of  the  peripheral  arteries.  Pulsation  may  also  be  present  in  the 
peripheral  veins.  On  palpation  the  characteristic  water-hammer  or  Corri- 
gan  pulse  is  felt.  In  the  majority  of  instances  the  pulse  wave  strikes  the 
finger  forcibly  with  a  quick  jerking  impulse,  and  immediately  recedes  or 
collapses.  The  characters  of  this  are.  sometimes  best  appreciated  by  grasp- 
ing the  arm  above  the  wrist  and  holding  it  up.  Moreover,  the  pulse  of 
aortic  regurgitation  is  usually  retarded  or  delayed — i.  e.,  there  is  an  appre- 
ciable interval  between  the  beat  of  the  heart  and  the  pulsation  in  the  radial 
artery,  which  varies  according  to  the  extent  of  the  incompetence.  On  aus- 
cultation a  double  murmur  may  be  heard  in  the  carotids  and  subclavians 
when  it  is  present  at  the  aortic  orifice.  Occasionally  in  the  carotid  the 
second  sound  is  distinctly  audible  when  absent  at  the  aortic  cartdage. 
Indeed,  according  to  Broadbent,  it  is  at  the  carotid  that  we  must  listen 
for  the  second  aortic  sound,  for  when  heard  it  indicates  that  the  regurgi- 
tation is  small  in  amount,  and  is  consequently  a  very  favorable  prognostic 
element.  In  the  femoral  artery  a  double  murmur  also  may  be  heard  some- 
times, as  pointed  out  by  Duroziez. 

Aortic  insufficiency  may  for  years  be  fully  compensated.  Persons  do 
not  necessarily  suffer  any  inconvenience,  and  the  condition  is  often  found 


CHEONIC  VALVULAR  DISEASE.  Y15 

accidentally.  So  long  as  the  hypertrophy  Just  equalizes  the  valvular  de- 
fect there  may  be  no  symptoms  and  the  individual  may  even  take  moder- 
ately heavy  exercise  without  experiencing  sensations  of  distress  about  the 
heart.  The  cases  which  last  the  longest  are  those  in  which  the  insufficiency 
follows  endocarditis  and  is  not  a  part  of  a  general  arterio-sclerosis.  The 
age  of  the  patient  too,  at  the  time  of  onset,  is  a  most  important  considera- 
tion, as  in  youth  the  lesion  is  not  often  from  sclerosis,  and  the  coronary 
arteries  are  unaffected.  Coexistent  lesions  of  the  mitral  valves  tend  early  to 
disturb  the  compensation.  Pure  aortic  insufficiency  is  consistent  with  years 
of  average  health  and  with  a  tolerably  active  life.  I  know  several  physi- 
cians with  aortic  insufficiency  who  have  been  able  to  carry  on  for  years  large 
and  somewhat  onerous  practices.  One  of  them  since  the  establishment 
of  insufficiency  has  passed  successfully  through  two  attacks  of  acute  rheu- 
matism. 

With  the  onset  of  myocardial  changes,  with  increasing  degeneration  of 
the  arteries,  particularly  with  a  progressive  sclerosis  of  the  arch  and  in- 
volvement of  the  orifices  of  the  coronary  arteries,  the  compensation  becomes 
disturbed.  In  advanced  cases  the  changes  about  the  aortic  ring  may  be 
associated  with  alterations  in  the  cardiac  nerves  and  ganglia,  and  so  intro- 
duce an  important  factor. 

3.  AoETic  Stenosis. 

Narrowing  or  stricture  of  the  aortic  orifice  is  not  nearly  so  common  as 
insufficiency.  The  two  conditions,  as  already  stated,  may  occur  together, 
however,  and  probably  in  almost  every  case  of  stenosis  there  is  some  leakage. 

Etiology  and  Morbid  Anatomy. — In  the  milder  grades  there  is 
adhesion  between  the  segments,  which  are  so  stiffened  that  during  systole 
they  cannot  be  pressed  back  against  the  aortic  wall.  The  process  of  cohe- 
sion between  the  segments  may  go  on  without  great  thickening,  and  pro- 
duce a  condition  in  which  the  orifice  is  guarded  by  a  comparatively  thin 
membrane,  on  the  aortic  face  of  which  may  be  seen  the  primitive  raphes 
separating  the  sinuses  of  Valsalva.  In  some  instances  this  membrane  is 
so  thin  and  presents  so  few  traces  of  atheromatous  or  sclerotic  changes  that 
the  condition  looks  as  if  it  had  originated  during  foetal  life.  More  com- 
monly the  valve  segments  are  thickened  and  rigid,  and  have  a  cartilaginous 
hardness.  In  advanced  cases  they  may  be  represented  by  stiff,  calcified 
masses  obstructing  the  orifice,  through  which  a  circular  or  slit-like  passage 
can  be  seen.  The  older  the  patient  the  more  likely  it  is  that  the  valves 
will  be  rigid  and  calcified. 

We  may  speak  of  a  relative  stenosis  of  the  aortic  orifice  when  with  nor- 
mal valves  and  ring  the  aorta  immediately  beyond  is  greatly  dilated.  A 
stenosis  due  to  involvement  of  the  aortic  ring  in  sclerotic  and  calcareous 
changes  without  lesion  of  the  valves  is  referred  to  by  some  authors.  I  have 
never  met  with  an  instance  of  this  kind.  A  subvalvular  stenosis,  the  result 
of  endocarditis  in  the  mitro-sigmoidean  sinus,  usually  occurs  as  the  result  of 
foetal  endocarditis.  In  comparison  with  aortic  insufficiency,  stenosis  is  a 
rare  disease.     It  is  usually  met  with  at  a  more  advanced  period  of  life  than 


'^16  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

insufficiency,  and  the  most  typical  cases  of  it  are  found  associated  with 
extensive  calcareous  changes  in  the  arterial  system  in  old  men. 

When  gradually  produced  and  when  there  is  not  much  insufficiency 
the  dilatation  of  the  left  ventricle  may  be  slight,  though  I  think  that  in 
all  cases  it  does  occur.  The  walls  of  the  ventricles  become  hypertrophied, 
and  we  see  in  this  condition  the  most  typical  instances  of  what  is  called 
concentric  hypertrophy,  in  which,  without  much,  if  any,  enlargement  of 
the  cavity,  the  walls  are  greatly  thickened,  in  contradistinction  to  the  so- 
called  eccentric  hypertrophy,  in  which,  with  the  increase  in  the  thickness 
of  the  walls,  the  chamber  itself  is  greatly  dilated.  There  may  be  no  changes 
in  the  other  cardiac  cavities  if  compensation  is  well  maintained;  but  with 
its  failure  come  dilatation,  impeded  auricular  discharge,  pulmonary  con- 
gestion, and  increased  work  for  the  right  heart.  The  arterial  changes  are, 
as  a  rule,  not  so  marked  as  in  aortic  insufficiency,  for  the  walls  have  not 
to  withstand  the  impulse  of  a  greatly  increased  blood-wave  with  each  sys- 
tole. On  the  contrary,  the  amount  of  blood  propelled  through  the  narrow 
orifice  may  be  smaller  than  normal,  though  when  compensation  is  fully 
established  the  pulse-wave  may  be  of  medium  volume. 

Symptoms. — Physical  Signs. — Inspection  may  fail  to  reveal  any  area 
of  cardiac  impulse.  Particularly  is  this  the  case  in  old  men  with  rigid 
chest  walls  and  large  emphysematous  lungs.  Under  these  circumstances 
there  may  be  a  high  grade  of  hypertrophy  without  any  visible  impulse. 
Even  when  the  apex  beat  is  visible,  it  may  be,  as  Traube  pointed  out,  feeble 
and  indefinite.  In  many  cases  the  apex  is  seen  displaced  downward  and 
outward,  and  the  impulse  looks  strong  and  forcible. 

Palpation  reveals  in  many  cases  a  thrill  at  the  base  of  the  heart  of 
maximum  force  in  the  aortic  region.  With  no  other  condition  do  we  meet 
with  thrills  of  greater  intensity.  The  apex  beat  may  not  be  palpable  under 
the  conditions  above  mentioned,  or  there  may  be  a  slow,  heaving,  forcible 
impulse. 

Percussion  never  gives  the  same  wide  area  of  dulness  as  in  aortic  in- 
sufficiency. The  extent  of  it  depends  largely  on  the  state  of  the  lungs, 
whether  emphysematous  or  not. 

Auscultation. — A  rough  systolic  murmur,  of  maximum  intensity  at  the 
aortic  cartilage,  and  propagated  into  the  great  vessels,  is  the  most  constant 
physical  sign  in  aortic  stenosis.  One  of  the  last  lessons  learned  by  the  stu- 
dent of  physical  diagnosis  is  to  recognize  the  fact  that  a  systolic  murmur  at 
the  aortic  area  is  only  in  comparatively  rare  cases  produced  by  decided  nar- 
rowing of  the  aortic  orifice.  Roughening  of  the  valves,  or  of  the  intima  of 
the  aorta,  and  hsemic  states  are  much  more  frequent  causes.  In  aortic  steno- 
sis the  murmur  often  has  a  much  harsher  quality,  is  louder,  and  is  more  fre- 
quently musical  than  in  the  conditions  just  mentioned.  When  compensation 
fails  and  the  ventricle  is  dilated  and  feeble,  the  murmur  may  be  soft  and  dis- 
tant. The  second  sound  is  rarely  heard  at  the  aortic  cartilage,  owing  to  the 
thickening  and  stiffness  of  the  valve.  A  diastolic  murmur  is  not  uncommon, 
but  in  many  cases  it  can  not  be  heard.  Occasionally,  as  noted  by  W.  H. 
Dickinson,  there  is  a  musical  murmur  of  greatest  intensity  in  the  region  of 
the  apex,  due  probably  to  a  slight  regurgitation  at  high  pressure  through 


CHRONIC  VALVULAR  DISEASE.  717 

the  mitral  valves.  The  pulse  in  pure  aortic  stenosis  is  small,  usually  of 
good  tension,  well  sustained,  regular,  and  perhaps  slower  than  normal. 

The  condition  may  be  latent  for  an  indefinite  period,  as  long  as  the 
hypertrophy  is  maintained.  Early  symptoms  are  those  due  to  defective 
blood-supply  to  the  brain,  dizziness,  and  fainting.  Palpitation,  pain  about 
the  heart,  and  anginal  symptoms  are  not  so  marked  as  in  insufficiency. 
With  degeneration  of  the  heart-muscle  and  dilatation  relative  insufficiency 
of  the  mitral  valve  is  established,  and  the  patient  may  present  all  the  fea- 
tures of  engorgement  in  the  lesser  and  systemic  circulations,  with  dyspnoea, 
cough,  rusty  expectoration,  and  the  signs  of  anasarca  in  the  lower  part  of 
the  body.  Many  of  the  cases  in  old  people,  without  presenting  any  dropsy, 
have  symptoms  -pointing  rather  to  general  arterial  disease.  Cheyne-Stokes 
breathing  is  not  uncommon  with  or  without  signs  of  uraemia. 

Diagnosis.' — With  an  extremely  rough  or  musical  murmur  of  maxi- 
mum intensity  at  the  aortic  region  and  signs  of  hypertrophy  of  the  left 
ventricle,  a  thrill,  and  especially  a  hard,  slow  pulse  of  moderate  volume  and 
fairly  good  tension,  which  in  a  sphygmographic  tracing  gives  a  curve  of  slow 
rise,  a  broad,  well-sustained  summit  and  slow  decline,  a  diagnosis  of  aortic 
stenosis  can  be  made  with  some  degree  of  probability,  particularly  if  the 
subject  is  an  old  man.  Mistakes  are  common,  however,  and  a  roughened 
or  calcified  valve  segment,  or,  in  some  instances,  a  very  roughened  and 
prominent  calcified  plate  in  the  aorta,  and  hypertrophy  associated  with 
renal  disease,  may  produce  similar  S5nTLptoms. 

Let  me  repeat  that  a  murmur  of  maximum  intensity  at  the  aortic  car- 
tilage is  of  no  importance  in  itself  as  a  diagnostic  sign  of  stenosis.  Eough- 
ening  of  the  valve,  sclerosis  of  the  intima  of  the  arch,  and  anasmia  are  con- 
ditions more  frequently  associated  with  a  systolic  murmur  in  this  region. 
Seldom  is  there  difficulty  in  distinguishing  the  murmur  due  to  ansemia, 
since  it  is  rarely  so  intense  and  is  not  associated  with  thrill  or  with  marked 
hypertrophy  of  the  left  ventricle.  In  aortic  insufficiency  a  systolic  mur- 
mur is  usually  present,  but  has  neither  the  intensity  nor  the  musical  qual- 
ity, nor  is  it  accompanied  with  a  thrill.  With  roughening  and  dilatation 
of  the  ascending  aorta  the  murmur  may  be  very  harsh  or  musical;  but  the 
existence  of  a  second  sound,  accentuated  and  ringing  in  quality,  is  usually 
sufficient  to  differentiate  this  condition. 

4.  Mitral  Incompetency. 

Etiology. — Insufficiency  of  the  mitral  valve  ensues:  (a)  From 
changes  in  the  segments  whereby  they  are  contracted  and  shortened,  usu- 
ally combined  with  changes  in  the  chordas  tendinese,  or  with  more  or  less 
narrowing  of  the  orifice,  (b)  As  a  result  of  changes  in  the  inuscular  walls 
of  the  ventricle,  either  dilatation,  so  that  the  valve  segments  fail  to  close 
an  enlarged  orifice,  or  changes  in  the  muscular  substance,  so  that  the  seg- 
ments are  imperfectly  coapted  during  the  systoles-muscular  incompetency. 
The  common  lesions  producing  insufficiency  result  from  endocarditis,  which 
causes  a  gradual  thickening  at  the  edges  of  the  valves,  contraction  of  the 
chordae  tendineaj,  and  union  of  the  edges  of  the  segments,  so  that  in  a 


fjlS  DISEASES  OP  THE  CIRCrLATORY  SYSTEM. 

majority  of  the  instances  there  is  not  only  insufficiency,  but  some  grade  of 
narrowing  as  well.  Except  in  children,  we  rarely  see  the  mitral  leaflets 
curled  and  puckered  without  narrowing  of  the  orifice.  Calcareous  plates 
at  the  base  of  the  valve  may  prevent  perfect  closure  of  one  of  the  segments. 
In  long-standing  cases  the  entire  mitral  structures  are  converted  into  a  firm 
calcareous  ring.  From  this  valvular  insufficiency  the  other  condition  of 
muscular  incompetency  must  be  carefully  distinguished.  It  iS  met  with 
in  all  conditions  of  extreme  dilatation  of  the  left  ventricle,  and  also  in 
weakening  of  the  muscles  in  prolonged  fevers  and  in  ansemia. 

Morbid  Anatomy. — The  effects  of  incompetency  of  the  mitral  seg- 
ment upon  the  heart  and  circulation  are  as  follows:  (a)  The  imperfect 
closure  allows  a  certain  amount  of  blood  to  regurgitate  from  the  ventricle 
into  the  auricle,  so  that  at  the  end  of  auricular  diastole  this  chamber  con- 
tains not  only  the  blood  which  it  has  received  from  the  lungs,  but  also  that 
which  has  regurgitated  from  the  left  ventricle.  This  necessitates  dilata- 
tion, and,  as  increased  work  is  thrown  upon  it  in  expelling  the  augmented 
contents,  hypertrophy  as  well. 

(h)  With  each  systole  of  the  left  auricle  a  larger  volume  of  blood  is 
forced  into  the  left  ventricle,  which  also  dilates  and  subsequently  becomes 
hypertrophied. 

(c)  During  the  diastole  of  the  left  auricle,  as  blood  is  regurgitated  into 
it  from  the  left  ventricle,  the  pulmonary  veins  are  less  readily  emptied. 
In  consequence  the  right  ventricle  expels  its  contents  less  freely,  and  in 
turn  becomes  dilated  and  hypertrophied. 

(d)  Finally,  the  right  auricle  also  is  involved,  its  chamber  is  enlarged, 
and  its  walls  are  increased  in  thickness. 

(e)  The  effect  upon  the  pulmonary  vessels  is  to  produce  dilatation  both 
of  the  arteries  and  veins — often  in  long-standing  cases,  atheromatous 
changes;  the  capillaries  are  distended,  and  ultimately  the  condition  of 
brown  induration  is  produced.  Perfect  compensation  may  be  effected, 
chiefly  through  the  hypertrophy  of  both  ventricles,  and  the  effect  upon 
the  peripheral  circulation  may  not  be  manifested  for  years,  as  a  normal 
volume  of  blood  is  discharged  from  the  left  heart  at  each  systole.  The 
time  comes,  however,  when,  owing  either  to  increase  in  the  grade  of  the 
incompetency  or  to  failure  of  the  compensation,  the  left  ventricle  is  unable 
to  send  out  its  normal  volume  into  the  aorta.  Then  there  is  overfilling  of 
the  left  auricle,  engorgement  in  the  lesser  circulation,  embarrassed  action 
of  the  right  heart,  and  congestion  in  the  systemic  veins.  For  years  this 
somewhat  congested  condition  may  be  limited  to  the  lesser  circulation,  but 
finally  the  right  auricle  becomes  dilated,  the  tricuspid  valves  incompetent, 
and  the  systemic  veins  are  engorged.  This  gradually  leads  to  the  condi- 
tion of  cyanotic  induration  in  the  viscera  and,  when  extreme,  to  dropsical 
effusion. 

Muscular  incompetency,  due  to  impaired  nutrition  of  the  mitral  and 
papillary  muscles,  is  rarely  followed  by  such  perfect  compensation.  There 
may  be  in  acute  destruction  of  the  aortic  segments  an  acute  dilatation  of 
the  left  ventricle  with  relative  incompetency  of  the  mitral  segments,  great 
dilatation  of  the  left  auricle,  and  intense  engorgement  of  the  lungs,  under 


CHRONIC  VALVULAH  DISEASE.  Yl9 

which  circumstances  profuse  haemorrhage  may  result.  In  these  cases  there 
is  little  chance  for  the  establishment  of  compensation.  In  cases  of  hyper- 
trophy and  dilatation  of  the  heart,  without  valvular  lesions,  but  associated 
with  heavy  work  and  alcohol,  the  insufficiency,  of  the  mitral  valve  may  be 
extreme  and  lead  to  great  pulmonary  congestion,  engorgement  of  the  sys- 
temic veins,  and  a  condition  of  cardiac  dropsy,  which  cannot  be  distin- 
guished by  any  feature  from  that  of  mitral  incompetency  due  to  lesion  of 
the  valve  itself.  In  chronic  Bright's  disease  the  hypertrophy  of  the  left 
ventricle  may  gradually  fail,  leading,  in  the  later  stages,  to  relative  in- 
sufficiency of  the  mitral  valve,  and  the  production  of  a  condition  of  pul- 
monary and  systemic  congestion,  similar  to  that  induced  by  the  most  ex- 
treme grade  of  lesion  of  the  valve  itself.  Adherent  pericardium,  especially 
in  children,  may  lead  to  like  results. 

Symptoms. — During  the  development  of  the  lesion,  unless  the  in- 
competency com«s  on  acutely  in  consequence  of  rupture  of  the  valve  seg- 
ment or  of  ulceration,  the  compensatory  changes  go  hand  in  hand  with  the 
defect,  and  there  are  no  subjective  symptoms.  So,  also,  in  the  stage  of 
perfect  compensation,  there  may  be  the  most  extreme  grade  of  mitral 
insufficiency  with  enormous  hypertrophy  of  the  heart,  yet  the  patient  may 
not  be  aware  of  the  existence  of  heart  trouble,  and  may  suffer  no  incouT 
venience  except  perhaps  a  little  shortness  of  breath  on  exertion  or  on  going 
upstairs.  It  is  only  when  from  any  cause  the  compensation  has  not  been 
perfectly  effected,  or,  having  been  so,  is  broken  abruptly  or  gradually,  that 
the  patients  begin  to  be  troubled.  The  symptoms  may  be  divided  into  two 
groups: 

(a)  The  minor  manifestations  while  compensation  is  still  good.  Pa- 
tients with  extreme  incompetency  often  have  a  congested  appearance  of 
the  face,  the  lips  and  ears  have  a  bluish  tint,  and  the  venules  on  the  cheeks 
may  be  enlarged — signs  in  many  cases  very  suggestive.  In  long-standing 
cases,  particularly  in  children,  the  fingers  may  be  clubbed,  and  there  is 
shortness  of  breath  on  exertion.  This  is  one  of  the  most  constant  features 
in  mitral  insufficiency,  and  may  exist  for  years,  even  when  the  compensa- 
tion is  perfect.  Owing  to  the  somewhat  congested  condition  of  the  lungs 
these  patients  have  a  tendency  to  attacks  of  bronchitis  or  haemoptysis. 
There  may  also  be  palpitation  of  the  heart.  As  a  rule,  however,  in  well- 
balanced  lesions  in  adults,  this  period  of  full  compensation  or  latent  stage 
is  not  associated  with  symptoms  which  call  the  attention  to  an  affection 
of  the  heart,  and  with  care  the  patient  may  reach  old  age  in  comparative 
comfort  without  being  compelled  to  curtail  seriously  his  pleasures  or  his 
work. 

{h)  Sooner  or  later  comes  a  period  of  disturbed  or  broken  compensa- 
tion, in  which  the  most  intense  symptoms  are  those  of  venous  engorgement. 
There  are  palpitation,  weak,  irregular  action  of  the  heart,  and  signs  of 
dilatation.  Dyspnoea  is  an  especial  feature,  and  there  may  be  cough.  A 
distressing  symptom  is  the  cardiac  "  sleep-start,"  in  which,  just  as  the  pa- 
tient falls  asleep,  he  wakes'  gasping  and  feeling  as  if  the  heart  was  stopping. 
There  is  usually  a  slight  cyanosis,  and  even  a  jaundiced  tint  to  the  skin. 
The  most  marked  symptoms,  however,  are  those  of  venous  stasis.  The 
45 


720  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

overfilling  of  the  pulmonary  vessels  accounts  in  part  for  the  dyspnoea. 
There  is  cough,  often  with  bloody  or  watery  expectoration,  and  the  alveolar 
epithelium  containing  brown  pigment-grains  is  abundant.  Dropsical  effu- 
sion usually  sets  in,  beginning  in  the  feet  and  extending  to  the  body  and 
the  serous  sacs.  Eight-sided  hydrothorax  may  recur  and  require  repeated 
tapping.  The  liver  is  enlarged,  and  there  are  signs  of  portal  congestion. 
The  urine  is  usually  scanty  and  albuminous,  and  contains  tube-casts  and 
sometimes  blood-corpuscles.  With  judicious  treatment  the  compensation 
may  be  restored  and  all  the  serious  symptoms  may  pass  away.  Patients 
usually  have  recurring  attacks  of  this  kind,  and  die  of  a  general  dropsy; 
or  there  is  progressive  dilatation  of  the  heart,  and  death  from  asystole. 
Sudden  death  in  these  cases  is  rare. 

Physical  Signs. — Inspection. — In  children  the  prsecordia  may  bulge  and 
there  may  be  a  large  area  of  visible  pulsation.  The  apex  beat  is  to  the  left 
of  the  nipple,  in  some  cases  in  the  sixth  interspace,  in  the  anterior  axillary 
line.  There  may  be  a  wavy  impulse  in  the  cervical  veins  which  are  often 
full,  particularly  when  the  patient  is  recumbent. 

Palpation. — A  thrill  is  rare;  when  present  it  is  felt  at  the  apex,  often 
in  a  limited  area.  The  force  of  the  impulse  may  depend  largely  upon  the 
stage  in  which  the  case  is  examined.  In  full  compensation  it  is  forcible 
and  heaving;  when  the  compensation  is  disturbed,  usually  wavy  and  feeble. 

Percussion. — The  dulness  is  increased,  particularly  in  a  lateral  direction. 
There  is  no  disease -of  the  valves  which  produces,  in  long-standing  cases, 
a  more  extensive  transverse  area  of  heart  dulness.  It  does  not  extend  so 
much  upward  along  the  left  margin  of  the  sternum  as  beyond  the  right 
margin  and  to  the  left  of  the  nipple  line. 

Auscultation. — At  the  apex  there  is  a  systolic  murmur  which  wholly 
or  partly  obliterates  the  first  sound.  It  is  loudest  here,  and  has  a  blowing, 
sometimes  musical  character,  particularly  toward  the  latter  part.  The 
murmur  is  transmitted  to  the  axilla  and  may  be  heard  at  the  back,  in  some 
instances  over  the  entire  chest.  There  are  cases  in  which,  as  pointed  out 
by  Naunyn,  the  murmur  is  heard  best  along  the  left  border  of  the  sternum. 
Usually  in  diastole  at  the  apex  the  loudly  transmitted  second  sound  may 
be  heard.  Occasionally  there  is  also  a  soft,  sometimes  a  rough  or  rumbling 
presystolic  murmur.  As  a  rule,  in  cases  of  extreme  mitral  insufficiency 
from  valvular  lesion  with  great  hypertrophy  of  both  ventricles,  there  is 
heard  only  a  loud  blowing  murmur  during  systole.  A  murmur  of  mitral 
insuificiency  may  vary  a  great  deal  according  to  the  position  of  the  patient. 
It  may  be  present  in  the  recumbent  and  absent  in  the  erect  posture.  In 
cases  of  dilatation,  particularly  when  dropsy  is  present,  there  may  be  heard 
at  the  ensiform  cartilage  and  in  the  lower  sternal  region  a  soft  systolic 
murmur  due  to  tricuspid  regurgitation.  An  important  sign  on  ausculta- 
tion is  the  accentuated  pulmonary  second  sound.  This  is  heard  to  the  left 
of  the  sternum  in  the  second  interspace,  or  over  the  third  left  costal  car- 
tilage. 

The  pulse  in  mitral  insufficiency,  during  the  period  of  full  compensa- 
tion, may  be  full  and  regular,  often  of  low  tension.  Usually  with  the  first 
onset  of  the  symptoms  the  pulse  becomes  irregular,  a  feature  which  then 


CHRONIC  VALVULAR  DISEASE.  721 

dominates  the  case  throughout.  There  may  be  no  two  beats  of  equal  force 
or  volume.  Often  after  the  disappearance  of  the  symptoms  of  failure  of 
compensation  the  irregularity  of  the  pulse  persists. 

The  three  important  physical  signs  then  of  mitral  regurgitation  are: 
(a)  Systolic  murmur  of  maximum  intensity  at  the  apex,  which  is  propa- 
gated to  the  axilla  and  heard  at  the  angle  of  the  scapula;  (b)  accentuation 
of  the  pulmonary  second  sound;  (c)  evidence  of  enlargement  of  the  heart, 
particularly  the  increase  in  the  transverse  diameter,  due  to  hypertrophy 
of  both  right  and  left  ventricles. 

Diagnosis.  ^ — There  is  rarely  any  difficulty  in  the  diagnosis  of  mitral 
insufficiency.  The  physical  signs  Just  referred  to  are  quite  characteristic 
and  distinctive.  Two  points  are  to  be  borne  in  mind.  First,  a  murmur, 
systolic  in  character,  and  of  maximum  intensity  at  the  apex,  and  propa- 
gated even  to  the  axilla,  does  not  necessarily  indicate  incompetency  of  the 
mitral  valve.  There  is  heard  in  this  region  a  large  group  of  what  are 
termed  accidental  murmurs,  the  precise  nature  of  which  is  still  doubtful. 
They  are  probably  formed,  however,  in  the  ventricle,  and  are  not  associated 
with  hypertrophy,  or  accentuation  of  pulmonary  second  sound. 

Second,  it  is  not  always  possible  to  say  whether  the  insufficiency  is  due 
to  lesion  of  the  valve  segment  or  to  dilatation  of  the  mitral  ring  and  rela- 
tive incompetency.  Here  neither  the  character  of  the  murmur,  the  propa- 
gation, the  accentuation  of  the  pulmonary  second  sound,  nor  the  hyper- 
trophy assists  in  the  differentiation.  The  history  is  sometimes  of  greater 
value  in  this  matter  than  the  physical  examination.  The  cases  most  likely 
to  lead  to  error  are  those  of  the  so-called  idiopathic  dilatation  and  hyper- 
trophy of  the  heart  (in  which  the  systolic  murmur  may  be  of  the  greatest 
intensity),  and  the  instances  of  arterio-sclerosis  with  dilated  heart.  Balfour 
and  others,  however,  maintain  that  organic  disease  of  the  mitral  leaflets 
sufficient  to  produce  incompetency  is  always  accompanied  with  a  certain 
degree  of  narrowing  of  the  orifice,  so  that  the  only  unequivocal  proof  of  the 
actual  disease  of  the  mitral  valve  is  the  presence  of  a  presystolic  murmur. 

5.  MiTKAL  Stenosis. 

Etiology. — ISTarrowing  of  the  mitral  orifice  is  usually  the  result  of 
valvular  endocarditis  occurring  in  the  earlier  years  of  life;  very  rarely  it 
is  congenital.  It  is  very  much  more  common  in  women  than  in  men — in 
63  of  80  cases  noted  by  Duckworth,  while  in  4,791  autopsies  at  Guy's  Hos- 
pital during  ten  years  there  were  196  cases,  of  which  107  were  females  and 
89  males  (Samways).  This  is  not  easy  to  explain,  but  there  are  at  least  two 
factors  to  be  considered.  Eheumatism  prevails  more  in  girls  than  in  boys 
and,  as  is  well  known,  endocarditis  of  the  mitral  valve  is  more  common 
in  rheumatism.  Chorea,  also,  as  suggested  by  Barlow,  has  an  important 
influence,  occurring  more  frequently  in  girls  and  being  often  associated 
with  endocarditis.  Of  140  cases  of  chorea  which  I  examined  at  a  period 
more  than  two  years  subsequent  to  the  attack,  72  had  signs  of  organic 
heart-disease,  among  which  were  24  instances  with  the  physical  signs  of 
mitral  stenosis.    Anaemia  and  chlorosis,  which  are  prevalent  in  girls,  have 


722  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

been  regarded  as  possible  factors.  In  a  surprising  number  of  cases  no  recog- 
nizable etiological  factor  can  be  discovered.  This  has  been  regarded  by 
some  writers  as  favoring  the  view  that  many  cases  are  of  congenital  origin; 
but  it  is  not  improbable  that  with  any  of  the  febrile  affections  of  childhood 
endocarditis  may  be  associated.  Whooping-cough,  too,  with  its  terrible 
strain  on  the  heart-valves,  may  be  accountable  for  certain  cases.  Con- 
genital affections  of  the  mitral  valve  are  notoriously  rare.  While  met  with 
at  all  ages,  stenosis  is  certainly  more  frequent  in  young  persons. 

Morbid  Anatomy. — In  a  majority  of  instances  with  the  stenosis 
there  is  some  incompetency;  indeed,  Balfour  maintains  that  we  never  find 
mitral  stenosis  without  some  degree  of  regurgitation.  The  narrowing  re- 
sults from  thickening  and  contraction  of  the  tissues  of  the  ring,  of  the  valve 
segments,  and  of  the  chordae  tendinese.  The  condition  varies  a  good  deal 
according  to  the  amount  of  atheromatous  change.  In  many  cases  the  cur- 
tains are  so  welded  together  and  the  whole  valvular  region  so  thickened  that 
the  orifice  is  reduced  to  a  mere  chink — Corrigan's  button-hole  contraction. 
In  other  cases  the  curtains  are  not  much  thickened,  but  narrowing  has 
resulted  from  gradual  adhesion  at  the  edges,  and  thickening  of  the  chordae 
tendineas,  so  that  from  the  auricle  it  looks  cone-like — the  so-called  funnel- 
shaped  variety  of  stenosis.  The  instances  in  which  the  valve  segments  are 
very  slightly  deformed,  but  in  which  the  orifice  is  considerably  narrowed, 
are  regarded  by  some  as  possibly  of  congenital  origin.  Occasionally  the 
curtains  are  in  great  part  free  from  disease,  but  the  narrowing  results  from 
large  calcareous  masses,  which  project  into  them  from  the  ring.  The  in- 
volvement of  the  chords  tendineae  is  usually  extreme,  and  the  papillary 
muscles  may  be  inserted  directly  upon  the  valve.  In  moderate  grades  of 
constriction  the  orifice  will  admit  the  tip  of  the  index-finger;  in  more 
extreme  forms,  the  tip  of  the  little  finger;  and  occasionally  one  meets  with 
a  specimen  in  which  the  orifice  seems  almost  obliterated,  as  in  a  case  which 
came  under  my  notice,  which  only  admitted  a  medium-sized  Bowman's 
probe. 

The  heart  in  mitral  stenosis  is  not  greatly  enlarged,  rarely  weighing 
more  than  14  or  15  ounces.  Occasionally,  in  an  elderly  person,  it  may 
seem  only  slightly,  if  at  all,  enlarged,  and  again  there  are  instances  in  which 
the  weight  may  reach  as  much  as  20  ounces.  The  left  ventricle  is  usually 
small,  and  may  look  very  small  in  comparison  with  the  right  ventricle, 
which  forms  the  greater  portion  of  the  apex.  In  cases  in  which  with  the 
narrowing  there  is  very  considerable  incompetency  the  left  ventricle  may 
be  moderately  dilated  and  hypertrophied. 

These  changes  gradually  induced  are  associated  with  secondary  altera- 
tions of  great  importance  in  the  heart.  The  left  auricle  discharges  its  blood 
with  greater  difficulty  and  in  consequence  dilates,  and  its  walls  reach  three 
or  four  times  their  normal  thickness.  Although  the  auricle  is  by  structure 
unfitted  to  compensate  an  extreme  lesion,  the  probability  is  that  for  some 
time  during  the  gradual  production  of  stenosis,  the  increasing  muscular 
power  of  the  walls  is  sufficient  to  counterbalance  the  defect.  Samways 
found  in  36  cases  of  well-marked  stenosis  the  auricle  hypertrophied  in  26, 
dilatation  coexisting  in  14.    Eventually  the  tension  is  increased  in  the  pul- 


CHRONIC  VALVULAR  DISEASE.  Y23 

monary  circulation,  owing  to  impeded  outflow  from  the  veins.  To  overcome 
this  the  right  ventricle  undergoes  dilatation  and  hypertrophy,  and  upon  this 
chamber  falls  the  work  of  equalizing  the  circulation.  Eelative  incompetency 
of  the  tricuspid  and  congestion  of  the  systemic  veins  at  last  supervene. 

It  is  not  uncommon  at  the  examination  to  find  white  thrombi  in  the 
appendix  of  the  left  auricle.  Occasionally  a  large  part  of  the  auricle  is 
occupied  by  an  ante-mortem  thrombus.  Still  more  rarely  the  remarkable 
ball  thrombus  is  found,  in  which  a  globular  concretion,  varying  in  size  from 
a  walnut  to  a  small  egg,  lies  free  in  the  auricle,  two  examples  of  which  have 
come  under  my  observation  (see  W.  H.  Welch,  art.  Thrombosis,  Allbutt's 
System). 

Symptoms. — Physical  Signs. — Inspection. — In  children  the  lower 
sternum  and  the  fifth  and  sixth  left  costal  cartilages  are  often  prominent, 
owing  to  hypertrophy  of  the  right  ventricle.  The  apex  beat  may  be  ill- 
defined.  Usually,  it  is  not  dislocated  far  beyond  the  nipple  line,  and  the 
chief  impulse  is  over  the  lower  sternum  and  adjacent  costal  cartilages. 
Often  in  thin-chested  persons  there  is  pulsation  in  the  third  and  fourth 
left  interspaces  close  to  the  sternum.  "When  compensation  fails,  the  prse- 
cordial  impulse  is  much  feebler,  and  in  the  veins  of  the  neck  there  may  be 
marked  systolic  regurgitation. 

Palpation  reveals  in  a  majority  of  the  cases  a  characteristic,  well-defined 
fremitus  or  thrill,  which  is  best  felt,  as  a  rule,  in  the  fourth  or  fifth  inter- 
space within  the  nipple  line.  It  is  of  a  rough,  grating  quality,  often  pecul- 
iarly limited  in  area,  most  marked  during  expiration,  and  can  be  felt  to 
terminate  in  a  sharp,  sudden  shock,  synchronous  with  the  impulse.  This 
most  characteristic  of  physical  signs  is  pathognomonic  of  narrowing  of  the 
mitral  orifice,  and  is  perhaps  the  only  instance  in  which  the  diagnosis  of 
a  valvular  lesion  can  be  made  by  palpation  alone.  The  cardiac  impulse  is 
felt  most  forcibly  in  the  lower  sternum  and  in  the  fourth  and  fifth  left  in- 
terspaces. The  impulse  is  felt  very  high  in  the  third  and  fourth  interspaces, 
or  in  rare  cases  even  in  the  second,  and  it  has  been  thought  that  in  the 
latter  interspace  the  impulse  is  due  to  pulsation  of  the  auricle.  It  is  always 
the  impulse  of  the  conus  arteriosus  of  the  right  ventricle;  even  in  the  most 
extreme  grades  of  mitral  stenosis,  there  is  never  such  tilting  forward  of  the 
auricle  or  its  appendix  as  would  enable  it  to  produce  an  impression  on  the 
chest  wall. 

Percussion  gives  an  increase  in  the  cardiac  dulness  to  the  right  of  the 
sternum  and  along  the  left  margin;  not  usually  a  great  increase  beyond 
the  nipple  line,  except  in  extreme  cases,  when  the  transverse  dulness  may 
reach  from  5  cm.  beyond  the  right  margin  of  the  sternum  to  10  cm.  beyond 
the  nipple  line. 

Auscultation. — In  the  mitral  area,  usually  to  the  inner  side  of  the  apex 
beat  and  often  in  a  very  limited  region,  is  heard  a  rough,  vibratory  or  purr- 
ing murmur,  which  terminates  abruptly  in  the  first  sound.  By  combining 
palpation  and  auscultation  the  purring  murmur  is  found  to  be  synchro- 
nous with  the  thrill  and  the  loud  shock  with  the  first  sound.  This  is  the 
presystolic  murmiir,  about  the  time  and  mode  of  production  of  which  so 
much  discussion  has  occurred.    I  hold  with  those  who  regard  it  as  occur- 


Y24  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ring  during  the  auricular  systole.  In  whatever  way  produced,  it  remains 
one  of  the  most  distinctive  and  characteristic  of  murmurs  and  its  presence 
is  positively  indicative  of  narrowing  of  the  mitral  orifice.  The  sole  excep- 
tion to  this  statement  is  the  Flint  murmur  already  referred  to  in  aortic 
incompetency.  Once,  in  a  case  of  enormous  enlargement  of  the  spleen, 
with  dropsy,  in  which  the  heart  was  greatly  pushed  up,  I  heard  a  presystolic 
murmur  of  rough  quality,  and  the  mitral  valves  were  found  post  mortem 
to  be  normal.  The  presystolic  murmur  may  occupy  the  entire  period  of  the 
diastole,  or  the  middle  or  only  the  latter  half,  corresponding  to  the  auricu- 
lar systole.  The  difference  may  sometimes  be  noted  between  the  first  and 
second  portions  of  the  murmur,  when  it  occupies  the  entire  time.  Often 
there  is  a  peculiar  rumbling  or  echoing  quality,  which  in  some  instances 
is  very  limited  and  may  be  heard  only  over  a  single  bell-space  of  the  stetho- 
scope. A  systolic  murmur  may  be  heard  at  the  apex  or  along  the  left  sternal 
border,  often  of  extreme  softness  and  audible  only  when  the  breath  is  held. 
Sometimes  the  systolic  murmur  is  loud  and  distinct  and  is  transmitted  to 
the  axilla.  The  second  sound  in  the  second  left  interspace  is  loudly  accentu- 
ated, sometimes  reduplicated.  It  may  be  transmitted  far  to  the  left  and 
be  heard  with  great  clearness  beyond  the  apex.  In  uncomplicated  cases 
of  mitral  stenosis  there  are  usually  no  murmurs  audible  at  the  aortic  region, 
at  which  spot  the  second  sound  is  less  intense  than  at  the  pulmonary  area. 
In  the  lower  sternum  and  to  the  right  a  tricuspid  murmur  is  sometimes 
heard  in  advanced  cases.  Other  points  to  be  noted  are  the  following:  The 
unusually  sharp,  clear  first  sound  which  follows  the  presystolic  murmur, 
the  cause  of  which  is  by  no  means  easy  to  explain.  It  can  scarcely  be  a 
valvular  sound  produced  chiefly  at  the  mitral  orifice,  since  it  may  be  heard 
with  great  intensity  in  cases  in  which  the  valves  are  rigid  and  calcified. 
It  has  been  suggested  by  A.  E.  Sansom  and  others  that  it  is  a  loud 
"  snap  "  of  the  tricuspid  valves  caused  by  the  powerful  contraction  of  the 
greatly  hypertrophied  right  ventricle.  Broadbent's  explanation  is  as  fol- 
lows: "  Owing  to  the  narrowing  of  the  mitral  orifice  there  is  not  time  in 
the  diastolic  interval  for  a  sufficient  amount  of  blood  to  flow  into  the  left 
ventricle  to  completely  fill  it.  At  the  commencement  of  systole,  therefore, 
the  ventricular  cavity  is  not  fully  distended  with  blood,  so  that  the  mus- 
cular walls  at  the  first  moment  of  their  contraction  meet  with  no  resist- 
ance; then  closing  down  rapidly,  they  are  suddenly  brought  up  and  made 
tense  as  they  encounter  the  contained  blood.  This  sudden  tension  and 
abbreviated  systole  may  thus  account  for  the  short  first  sound."  The 
valvular  sound  may  be  audible  at  a  distance,  as  one  sits  at  the  bedside  of 
the  patient  (Graves). 

These  physical  signs,  it  is  to  be  borne  in  mind,  are  characteristic  only 
of  the  stage  in  which  compensation  is  maintained.  Finally  there  comes  a 
period  in  which,  with  rupture  of  compensation,  the  presystolic  murmur 
disappears  and  there  is  heard  in  the  apex  region  a  sharp  first  sound,  or 
sometimes  a  gallop  rhythm.  The  marked  systolic  shock  may  be  present 
after  the  disappearance  of  the  thrill  and  the  characteristic  murmur.  Under 
treatment,  with  gradual  recovery  of  compensation,  probably  with  increas- 
ing vigor  of  contraction  of  the  right  ventricle  and  left  auricle,  the  pre- 


CHRONIC   VALVULAR  DISEASE.  725 

0 

systolic  murmur  reappears.  In  cases  seen  at  this  stage  of  the  disease  the 
nature  of  the  valve  lesion  may  be  entirely  overlooked. 

Stenosis  of  the  mitral  valve  may  for  years  be  efficiently  compensated 
by  the  hypertrophy  of  the  right  ventricle.  Many  persons  with  the  char- 
acteristic physical  signs  of  this  lesion  present  no  sj^mptoms.  They  may 
for  years  perhaps  be  short  of  breath  on  going  upstairs,  but  are  able  to  pass 
through  the  ordinary  duties  of  life  without  discomfort.  The  pulse  is 
smaller  in  volume  than  normal,  and  very  often  irregular.  A  special 
danger  of  this  stage  is  the  recurring  endocarditis.  Vegetations  may  be 
whipped  off  into  the  circulation  and,  blocking  a  cerebral  vessel,  may  cause 
hemiplegia  or  aphasia,  or  both.  This,  unfortunately,  is  not  an  uncommon 
sequence  in  women.  Patients  with  mitral  stenosis  may  survive  this  acci- 
dent for  an  indefinite  period.  A  woman,  above  seventy  years  of  age,  died 
in  one  of  my  wards  at  the  Philadelphia  Hospital,  who  had  been  in  the 
almshouse,  hemiplegic,  for  more  than  thirty  years.  The  heart  presented 
an  extreme  grade  of  mitral  stenosis  which  had  probably  existed  at  the  time 
of  the  hemiplegic  attack. 

Pressure  of  the  enlarged  auricle  on  the  left  recurrent  laryngeal  nerve, 
causing  paralysis  of  the  vocal  cord  on  the  corresponding  side,  has  been 
described  by  Ortner  and  by  Herrick.  I  have  met  with  two  instances.  It 
is  a  point  to  be  borne  in  mind,  as  the  diagnosis  of  aneurism  of  the  arch  of 
the  aorta  may  be  made. 

Failure  of  compensation  brings  in  its  train  the  group  of  symptoms 
which  have  been  discussed  under  mitral  insufficiency.  Briefly  enumerated 
they  are:  Eapid  and  irregular  action  of  the  heart,  shortness  of  breath, 
cough,  signs  of  pulmonary  engorgement,  and  very  frequently  hsemoptysis. 
Attacks  of  this  kind  may  recur  for  years.  Bronchitis  or  a  febrile  attack 
may  cause  shortness  of  breath  or  slight  blueness.  Inflammatory  affections 
of  the  lungs  or  pleura  seriously  disturb  the  right  heart,  and  these  patients 
stand  pneumonia  very  badly.  Many,  perhaps  a  majority  of  cases  of  mitral 
stenosis,  do  not  have  dropsy.  The  liver  may  be  greatly  enlarged,  and  in 
the  late  stages  ascites  is  not  uncommon,  particularly  in  children.  General 
anasarca  is  most  frequently  met  with  in  those  cases  in  which  there  is  sec- 
ondary narrowing  of  the  tricuspid  orifice  (Broadbent). 

6.  Tricuspid  Valve  Disease. 

(a)  Tricuspid  Regurgitation. — Occasionally  this  results  from  acute  or 
chronic  endocarditis  with  puckering;  more  commonly  the  condition  is  one 
of  relative  insufficiency,  and  is  secondary  to  lesions  of  the  valves  on  the  left 
side,  particularly  of  the  mitral.  It  is  met  with  also  in  all  conditions  of  the 
lungs  which  cause  obstruction  to  the  circulation,  such  as  cirrhosis  and 
emphysema,  particularly  in  combination  with  chronic  bronchitis.  The 
symptoms  are  those  of  obstruction  in  the  lesser  circulation  with  venous 
congestion  in  the  systemic  veins,  such  as  has  already  been  described  in  con- 
nection with  mitral  insufficiency.     The  signs  of  this  condition  are: 

(1)  Systolic  regurgitation  of  the  Iflood  into  the  riglit  auricle  and  the 
transmission  of  the  pulse-wave  into  the  veins  of  the  neck.    If  the  regurgi- 


726  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

• 
tation  is  slight  or  the  contraction  of  the  ventricle  is  feeble  there  may  be 
no  venous  throbbing,  but  in  other  cases  there  is  marked  systolic  pulsation 
in  the  cervical  veins.  That  in  the  right  jugular  is  more  forcible  than  that 
in  the  left.  It  may  be  seen  both  in  the  internal  and  the  external  vein, 
particularly  in  the  latter.  Marked  pulsation  in  these  veins  occurs  only 
when  the  valves  guarding  them  become  incompetent.  Slight  oscillations 
are  by  no  means  uncommon,  even  when  "the  valves  are  intact.  The  dis- 
tention is  sometimes  enormous,  particularly  in  the  act  of  coughing,  when 
the  right  Jugular  at  the  root  of  the  neck  may  stand  out,  forming 
an  extraordinary  prominent  ovoid  mass.  Occasionally  the  regurgitant 
pulse-wave  may  be  widely  transmitted  and  be  seen  in  the  subclavian  and 
axillary  veins,  and  even  in  the  subcutaneous  veins  over  the  shoulder, 
or,  as  in  a  case  recently  under  observation,  in  the  superficial  mammary 
veins. 

Eegurgitant  pulsation  through  the  tricuspid  orifice  may  be  transmitted 
to  the  inferior  cava,  and  so  to  the  hepatic  veins,  causing  a  systolic  disten- 
tion of  the  liver.  This  is  best  appreciated  by  bimanual  palpation,  placing 
one  hand  over  the  fifth  and  sixth  costal  cartilages  and  the  other  in  the 
lateral  region  of  the  liver  in  the  mid-axillary  line.  The  rhythmical  ex- 
pansile pulsation  may  be  readily  distinguished,  as  a  rule,  from  the  systolic 
depression  of  the  liver  due  to  communicated  pulsation  from  the  left  ven- 
tricle. 

(2)  The  second  important  sign  of  tricuspid  regurgitation  is  the  occur- 
rence of  a  systolic  murmur  of  maximum  intensity  in  the  lower  sternum. 
It  is  usually  a  soft,  low  murmur,  often  to  be  distinguished  from  a  coexist- 
ing mitral  murmur  by  diiferences  in  quality  and  pitch,  and  may  be  heard 
to  the  right  as  far  as  the  axilla.  Sometimes  it  is  very  limited  in  its  distri- 
bution. 

Together  these  two  signs  positively  indicate  tricuspid  regurgitation. 
In  addition,  the  percussion  usually  shows  increase  in  the  area  of  dulness 
to  the  right  of  the  sternum,  and  the  impulse  in  the  lower  sternal  region  is 
forcible.  In  the  great  majority  of  cases  the  symptoms  are  those  of  the 
associated  lesions.  In  cirrhosis  of  the  lung  and  in  chronic  emphysema  the 
failure  of  compensation  of  the  right  ventricle  with  insufficiency  of  the  tri- 
cuspid not  infrequently  leads  either  to  acute 'asystole  or  to  gradual  failure 
with  cardiac  dropsy. 

(i)  Tricuspid  Stenosis. — This  interesting  condition  may  be  either  con- 
genital or  acquired.  The  congenital  cases  are  not  uncommon,  and  are 
associated  usually  with  other  valvular  defects  which  cause  early  death.  The 
acquired  form  is  not  very  infrequent.  Bedford  Fenwick  collected  46  ob- 
servations, of  which  41  were  in  women.  Leudet  *  has  analyzed  117  cases. 
Of  101  of  these  in  which  the  ages  were  mentioned,  80  were  in  women  and 
21  in  men.  A  great  majority  of  the  cases  were  in  adults,  only  8  being 
between  the  ages  of  ten  and  twenty.  Its  rarity  as  an  isolated  condition 
may  be  gathered  from  the  fact  that  of  114  autopsies,  in  11  only  was  the 
lesion  confined  to  this  valve.    In  21  the  tricuspid,  mitral,  and  aortic  seg- 

*  Paris  Thesis, 


CHRONIC   VALVULAR  DISEASE.  727 

ments  were  involved,  and  in  78  the  tricuspid  and  mitral.     Practically  the 
condition  is  almost  always  secondary  to  lesions  of  the  left  heart. 

The  physical  signs  are  sometimes  characteristic.  For  instance,  a  pre- 
systolic thrill  has  been  noted  by  several  observers.  The  percussion  shows 
dulness  to  be  increased,  particularly  to  the  right  of  the  sternum.  On  aus- 
cultation a  presystolic  murmur  has  been  determined  in  certain  cases,  and 
is  heard  best  at  the  root  of  the  ensiform  cartilage,  or  a  little  to  the  right 
of  it.  Of  general  symptoms,  cyanosis  of  the  face  and  lips  is  very  common, 
and  in  the  late  stages,  when  dropsy  supervenes,  it  is  apt  to  be  intense.  The 
lesion  is  interesting  chiefly  because  it  forms  one  of  the  most  serious  com- 
plications of  mitral  stenosis. 

7.    PULMONAET   VaLVE    DISEASE. 

Murmurs  in  the  region  of  the  pulmonary  valves  are  extremely  common; 
lesions  of  the  valves  are  exceedingly  rare.  Balfour  has  well  called  the  pul- 
monic area  the  region  of  romance.  A  systolic  murmur  is  heard  here  under 
many  conditions — (1)  very  often  in  health,  in  thin-chested  persons,  par- 
ticularly in  children,  during  expiration  and  in  the  recumbent  posture;  (2) 
when  the  heart  is  acting  rapidly,  as  in  fever  and  after  exertion;  (3)  it  is  a 
favorite  situation  of  the  cardio-respiratory  murmur;  (4)  in  anaemic  states; 
and  (5)  as  mentioned  previously,  the  systolic  murmur  of  mitral  insufficiency 
may  be  transmitted  along  the  left  sternal  margin.  Actual  lesions  of  the 
valves  of  the  pulmonary  artery  are  rare. 

(a)  Stenosis  is  almost  invariably  a  congenital  anomaly.  It  constitutes 
one  of  the  most  important  of  the  congenital  cardiac  affections.  The  valve 
segments  are  usually  united,  leaving  a  small,  narrow  orifice.  In  the  adult 
cases  occasionally  occur.  In  Case  608  of  my  post-mortem  records  there 
was  extreme  stenosis  in  a  girl  of  eighteen,  owing  to  great  thickening  and 
adhesion  of  the  segments,  and  there  were  also  numerous  vegetations.  The 
orifice  was  only  2  mm.  in  diameter.  The  congenital  lesion  is  commonly  asso- 
ciated with  patency  of  the  ductus  Botalii  and  imperfection  of  the  ventricu- 
lar septum.    There  may  also  be  tricuspid  stenosis. 

The  physical  signs  are  extremely  uncertain.  There  may  be  a  systolic 
murmur  with  a  thrill  heard  best  to  the  left  of  the  sternum  in  the  second 
intercostal  space.  This  murmur  may  be  very  like  a  murmur  of  aortic 
stenosis,  but  is  not  transmitted  into  the  vessels.  Naturally  the  pulmonary 
second  sound  is  weak  or  obliterated,  or  may  be  replaced  by  a  diastolic  mur- 
mur.   Usually  there  is  hypertrophy  of  the  right  heart. 

(h)  Pulmonary  Insujficiency. — This  rare  affection  is  occasionally  due  to 
congenital  malformation,  particularly  fusion  of  two  of  the  segments.  It  is 
sometimes  present,  as  Bramwell  has  shown,  in  cases  of  malignant  endocar- 
ditis.   Barie  has  collected  58  cases. 

The  physical  signs  are  those  of  regurgitation  into  ^he  right  ventricle, 
but,  as  a  rule,  it  is  difficult  to  differentiate  the  murmur^from  that  of  aortic 
insufficiency,  though  the  maximum  intensity  may  be  in  the  pulmonary 
area.  The  absence  of  the  vascular  features  of  aortic  insufficiency  is  sug- 
gestive.   Both  Gibson  and  Graham  Steell  have  called  attention  to  the  pos- 


728  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

sibility  of  leakage  through  these  valves  in  cases  of  great  increase  of  pressure 
in  the  pulmonary  artery,  and  to  a  soft  diastolic  murmur  heard  under  these 
circumstances,  which  Steell  calls  "  the  murmur  of  high  pressure  in  the 
pulmonary  artery," 

8.  Combined  Yalvulae  Lesions. 

These  are  extremely  common.  The  mitral  and  aortic  segments  may  be 
affected  together;  next  in  frequency  comes  the  combination  of  mitral  and 
tricuspid  lesions;  and  then  of  aortic,  mitral,  and  tricuspid.  Aortic  insuf- 
ficiency or  aortic  stenosis  is  more  frequently  combined  with  mitral  incom- 
petency than  aortic  stenosis  with  mitral  stenosis,  or  mitral  stenosis  with 
aortic  insufficiency.  In  children  the  most  common  combination  is  aortic 
and  mitral  insufficiency.  In  adults,  mitral  insufficiency  with  thickening 
of  the  aortic  valves  and  slight  narrowing  is  perhaps  the  most  common. 

The  diagnosis  rests  upon  the  character  of  the  murmurs  and  the  state 
of  the  chambers  as  regards  hypertrophy  and  dilatation. 

Prognosis  in  Valvular  Disease. — The  question  is  entirely  one 
of  efficient  compensation.  So  long  as  this  is  maintained  the  patient  may 
suffer  no  inconvenience,  and  even  with  the  most  serious  forms  of  valve 
lesion  the  function  of  the  heart  may  be  little,  if  at  all,  disturbed. 

Practitioners  who  are  not  adepts  in  auscultation  and  feel  unable  to  esti- 
mate the  value  of  the  various  heart  murmurs  should  remember  that  the 
best  judgment  of  the  conditions  may  be  gathered  from  inspection  and  pal- 
pation. With  an  apex  beat  in  the  normal  situation  and  regular  in  rhythm 
the  auscultatory  phenomena  may  be  practically  disregarded. 

As  Sir  Andrew  Clark  states,  a  murmur  per  se  is  of  little  or  no  moment 
in  determining  the  prognosis  in  any  given  case.  There  is  a  large  group 
of  patients  who  present  no  other  symptoms  than  a  systolic  murmur  heard 
over  the  body  of  the  heart,  or  over  the  apex,  in  whom  the  left  ventricle  is 
not  hypertrophied,  the  heart  rhythm  is  normal,  and  Avho  may  not  have 
had  rheumatism.  Indeed,  the  condition  is  accidentally  discovered,  often 
during  examination  for  life  insurance.  I  know  cases  of  this  kind  which 
have  persisted  unchanged  for  more  than  fifteen  years.  Among  the  condi- 
tions influencing  prognosis  are: 

(a)  Age. — Children  under  ten  are  bad  subjects.  Compensation  is  well 
effected,  and  they  are  free  from  many  of  the  influences  which  disturb  com- 
pensation in  adults.  The  coronary  arteries  are  healthy,  and  nutrition  of 
the  heart-muscle  can  be  readily  maintained.  Yet,  in  spite  of  this,  the  out- 
look in  cardiac  lesions  developing  in  very  young  children  is  usually  bad. 
One  reason  is  that  the  valve  lesion  itself  is  apt  to  be  rapidly  progressive, 
and  the  limit  of  cardiac  reserve  force  is  in  such  cases  early  reached.  There 
seems  to  be  proportionately  a  greater  degree  of  hypertrophy  and  dilatation. 
Among  other  causes  of  the  risks  of  this  period  are  to  be  mentioned  insuf- 
ficient food  in  the  poorer  classes,  the  recurrence  of  rheumatic  attacks,  and 
the  existence  of  pericardial  adhesions.  The  outlook  in  a  child  who  can  be 
carefully  supervised  and  prevented  from  damaging  himself  by  overexertion 
is  naturally  better  than  in  one  who  is  constantly  overtasking  his  muscles, 


CHRONIC   VALVULAR  DISEASE.  Y29 

The  valvular  lesions  which  develop  at,  or  subsequent  to,  the  period  of 
puberty  are  more  likely  to  be  permanently  and  efficiently  compensated. 
Sudden  death  from  heart-disease  is  very  rare  in  children. 

(b)  Sex. — Women  bear  valve  lesions,  as  a  rule,  better  than  men,  owing 
partly  to  the  fact  that  they  live  quieter  lives,  partly  to  the  less  common 
involvement  of  the  coronary  arteries,  and  to  the  greater  frequency  of  mitral 
lesions.  Pregnancy  and  parturition  are  disturbing  factors,  but  are,  I  think, 
less  serious  than  some  writers  would  have  us  believe. 

(c)  Valve  affected. — The  relative  prognosis  of  the  different  valve  lesions 
is  very  difficult  to  estimate.  Each  case  must,  therefore,  be  judged  on  its 
own  merits.  Aortic  insufficiency  is  unquestionably  the  most  serious;  yet 
for  years  it  may  be  perfectly  compensated.  Favorable  circumstances  in 
any  case  are  the  moderate  grade  of  hypertrophy  and  dilatation,  the  absence 
of  all  symptoms  of  cardiac  distress,  and  the  absence  of  extensive  arterio- 
sclerosis and  of  angina.  The  prognosis  rests  in  reality  with  the  condition 
of  the  coronary  arteries.  Eheumatic  lesions  of  the  valves,  inducing  insuf- 
ficiency, are  less  apt  to  be  associated  with  endarteritis  at  the  root  of  the 
aorta;  and  in  such  cases  the  coronary  arteries  may  escape  for  years.  I 
know  a  physician,  now  about  forty-three  years  of  age,  who,  when  sixteen, 
had  his  first  attack  of  rheumatism,  which  involved  the  aortic  segments. 
He  has  had  two  subsequent  attacks  of  rheumatism,  but  Avith  care  has  been 
able  to  live  a  comfortable  and  fairly  active  life.  On  the  other  hand,  when 
the  aortic  insufficiency  is  only  a  part  of  an  extensive  arterio-sclerosis  at  the 
root  of  the  aorta,  the  coronary  arteries  are  almost  invariably  involved,  and 
the  outlook  in  such  cases  is  much  more  serious.  Sudden  death  is  not  un- 
common, either  from  acute  dilatation  during  some  exertion,  or,  more  fre- 
quently, from  blocking  of  one  of  the  branches  of  the  coronary  arteries. 
The  liability  of  this  form  to  be  associated  with  angina  pectoris  also  adds 
to  its  severity.  Aortic  stenosis  is  a  comparatively  rare  lesion,  most  com- 
monly met  with  in  middle-aged  or  elderly  men,  and  is,  as  a  rule,  well  com- 
pensated. In  Broadbent's  series  of  cases,  in  which  autopsy  showed  definite 
aortic  narrowing,  forty  years  was  the  average  age  at  death,  and  the  oldest 
was  but  fifty-three. 

In  mitral  lesions  the  outlook  on  the  whole  is  much  more  favorable  than 
in  aortic  insufficiency.  Mitral  insufficiency,  when  well  compensated,  car- 
ries with  it  a  better  prognosis  than  mitral  stenosis.  Except  aortic  stenosis, 
it  is  the  only  lesion  commonly  met  with  in  patients  over  threescore  years. 
It  must  be  borne  in  mind  that  the  cases  which  last  the  longest  are  those  in 
which  the  valve  orifice  is  more  or  less  narrowed,  as  well  as  incompetent. 
There  is,  in  reality,  no  valve  lesion  so  poorly  compensated  and  so  rapidly 
fatal  as  that  in  which  the  mitral  segments  are  gradually  curled  and  puckered 
until  they  form  a  narrow  strip  around  a  wide  mitral  ring — a  condition 
specially  seen  in  children.  There  are  many  cases  of  mitral  insufficiency 
in  which  the  defect  is  thoroughly  balanced  for  thirty  or  even  forty  years, 
without  distress  or  inconvenience.  Even  with  great  hypertrophy  and  the 
apex  beat  almost  in  the  mid-axillary  line,  there  may  be  little  or  no  distress, 
and  the  compensation  may  be  most  effective.  Women  may  pass  safely 
through  repeated  pregnancies,  though  here  they  arc  liable  to  accidents  asso- 


Y30  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

ciated  with,  the  seyere  strain.  I  haye  had  under  observation  for  many  3'ears 
a  patient  who  had  her  first  attack  of  rheumatism  at  the  age  of  fifteen,  when 
she  already  had  a  well-marked  mitral  murmur.  She  first  came  under  my 
observation,  twenty-seven  years  ago,  with  signs  of  hypertrophy  of  the  left 
ventricle  and  a  loud  systolic  murmur.  She  has  had  no  cardiac  disturbance 
whatever,  though  she  has  lived  a  very  active  life,  has  been  unusually  vigor- 
ous, has  borne  eleven  children,  and  has  passed  through  three  subsequent 
attacks  of  rheumatism. 

In  mitral  stenosis  the  prognosis  is  usually  regarded  as  less  favorable. 
My  own  experience  has  led  me,  however,  to  place  this  lesion  almost  on  a 
level,  particularly  in  women,  with  the  mitral  insufiiciency.  It  is  found 
very  often  in  persons  in  perfect  health,  who  have  had  neither  palpitation 
nor  signs  of  heart-failure,  and  who  have  lived  laborious  lives.  The  figures 
given,  too,  by  Broadbent  indicate  that  the  date  of  death  in  mitral  stenosis 
is  comparatively  advanced.  Of  53  cases  abstracted  from  the  post-mortem 
records  of  St.  Mary's  Hospital,  thirty-three  was  the  age  for  males,  and 
thirty-seven  or  thirty-eight  for  females.  These  women,  too,  pass  through 
repeated  pregnancies  with  safety.  There  are  of  course  those  too  common 
accidents,  the  result  of  cerebral  embolism,  which  are  more  likely  to  occur 
in  this  than  in  other  forms. 

Hard  and  fast  lines  cannot  be  drawn  in  the  question  of  prognosis  in 
valvular  disease.  Every  case  must  be  judged  separately,  and  all  the  cir- 
cumstances carefully  balanced.  There  is  no  question  which  requires  greater 
experience  and  more  mature  judgment,  and  even  the  most  experienced  are 
sometimes  at  fault. 

The  following  brief  summary  of  the  conditions  which  justify  a  favor- 
able prognosis  embodies  the  large  and  varied  clinical  experience  of  Sir 
Andrew  Clark:  Good  general  health;  just  habits  of  living;  no  exceptional 
liability  to  rheumatic  or  catarrhal  affections;  origin  of  the  valvular  lesion 
independently  of  degeneration;  existence  of  the  valvular  lesion  without 
change  for  over  three  years;  sound  ventricles,  of  moderate  frequency  and 
general  regularity  of  action;  sound  arteries,  with  a  normal  amount  of  blood 
and  tension  in  the  smaller  vessels;  free  course  of  blood  through  the  cer- 
vical veins;  and,  lastly,  freedom  from  pulmonary,  hepatic,  and  renal  con- 
gestion. 

Treatment  of  Valvular  Lesions.— For  this  purpose  the  valvular 
lesion  may  be  divided  into  the  period  of  progressive  development,  with  es- 
tablishment and  maintenance  of  hypertrophy,  and  the  period  of  disturbed 
compensation. 

(a)  Stage  of  Compensation.— ^Medicinal  treatment  at  this  period  is  not 
necessary  and  is  often  hurtful.  A  very  common  error  is  to  administer 
cardiac  drugs,  such  as  digitalis,  on  the  discovery  of  a  murmur  or  of  hyper- 
trophy. If  the  lesion  has  been  found  accidentally,  it  may  be  best  not  to 
tell  the  patient,  but  rather  an  intimate  friend.  Often  it  is  necessary,  how- 
ever, to  be  perfectly  frank  in  order  that  the  patient  may  take  certain  pre- 
ventive measures.  He  should  lead  a  quiet,  regulated,  orderly  life,  free  from 
excitement  and  worry,  and  the  risk  of  sudden  death  makes  it  imperative 
that  the  patient  suffering  from  aortic  disease  should  be  specially  warned 


CHRONIC   VALVULAR  DISEASE.  731 

against  overexertion  and  hurry.  An  ordinary  wholesome  diet  in  moderate 
quantities  should  be  taken,  tobacco  should  be  interdicted,  and  stimulants 
not  allowed.  Exercise  should  be  regulated  entirely  by  the  feelings  of  the 
patient.  So  long  as  no  cardiac  distress  or  palpitation  follows,  moderate  ex- 
ercise will  prove  very  beneficial.  The  skin  should  be  kept  active  by  a  daily 
bath.  Hot  baths  should  be  avoided  and  the  Turkish  bath  should  be  inter- 
dicted. In  the  case  of  full-blooded,  somewhat  corpulent  individuals,  an 
occasional  saline  purge  should  be  taken.  Patients  with  valvular  lesions 
should  not  go  into  very  high  altitudes.  The  act  of  coition  has  serious  risks, 
particularly  in  aortic  insufficiency.  Knowing  that  the  causes  which  most 
surely  and  powerfully  disturb  the  compensation  are  overexertion,  mental 
worry,  and  malnutrition,  the  physician  should  give  suitable  instructions  in 
each  case.  As  it  is  always  better  to  have  the  co-operation  of  an  intelli>gent 
patient,  he  should,  as  a  rule,  be  told  of  the  condition,  but  in  this  matter 
the  physician  must  be  guided  by  circumstances,  and  there  are  cases  in 
which  reticence  is  the  wiser  policy. 

(5)  Stage  of  Broken  Compensation.— The  break  may  be  immediate  and 
final,  as  when  sudden  death  results  from  acute  dilatation  or  from  blocking 
of  a  branch  of  the  coronary  artery,  or  it  may  be  gradual.  Among  the  first 
indications  are  shortness  of  breath  on  exertion  or  attacks  of  nocturnal  dysp- 
noea. These  are  often  associated  with  impaired  nutrition,  particularly 
with  anaemia,  and  a  course  of  iron  or  change  of  air  may  suffice  to  relieve  the 
symptoms. 

Irregularity  of  the  action  of  the  heart  cannot  always  be  termed  an  in- 
dication of  failing  compensation,  particularly  in  instances  of  mitral  disease. 
It  has  greater  significance  in  aortic  lesions.  Serious  failure  of  compensa- 
tion is  indicated  by  signs  of  dilatation  of  the  heart,  marked  cyanosis,  the 
gallop  rhythm,  or  various  forms  of  arrhythmia,  with  or  without  the  ex- 
istence of  dropsy.  Under  these  circumstances  the  following  measures  are 
to  be  carried  out: 

(1)  Rest. — Disturbed  compensation  may  be  completely  restored  by  rest 
of  the  body.  Both  in  Montreal  and  in  Philadelphia  it  was  a  favorite  dem- 
onstration in  practical  therapeutics  to  show  the  benign  infiuence  of  com- 
plete rest  and  quiet  on  the  cardiac  dilatation.  In  many  cases  with  oedema 
of  the  ankles,  moderate  dilatation  of  the  heart,  and  irregularity  of  the  pulse, 
the  rest  in  bed,  a  few  doses  of  the  compound  tincture  of  cardamoms,  and  a 
saline  purge  suffice,  within  a  week  or  ten  days,  to  restore  the  compensation. 
One  patient,  in  Ward  11  of  the  Montreal  General  Hospital,  with  aortic 
insufficiency  recovered  from  four  successive  attacks  of  failing  compensation 
with  these  measures  alone. 

(2)  The  relief  of  the  embarrassed  circulation. 

(a)  By  Venesection. — In  cases  of  dilatation,  from  whatever  cause,  whether 
in  mitral  or  aortic  lesions  or  distention  of  the  right  ventricle  in  emphysema, 
when  signs  of  venous  engorgement  are  marked  and  when  there  is  orthopnoea 
with  cyanosis,  the  abstraction  of  from  20  to  30  ounces  of  blood  is  indi- 
cated. This  is  the  occasion  in  which  timely  venesection  may  save  the 
patient's  life.  It  is  a  condition  in  which  I  have  had  most  satisfactory  re- 
sults from  blood-letting.     It  is  done  much  better  early  than  late.     I  have 


Y32  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

on  several  occasions  regretted  its  postponement,  particularly  in  instances 
of  acute  dilatation  and  cyanosis  in  connection  with  emphysema.* 

(&)  By  Depletion  through  the  Bowels. — This  is  particularly  valuable  when 
dropsy  is  present.  Of  the  various  purges  the  salines  are  to  be  preferred, 
and  may  be  given  by  Matthew  Hay's  method.  Half  an  hour  to  an  hour 
before  breakfast  from  half  an  ounce  to  an  ounce  and  a  half  of  Epsom  salts 
may  be  given  in  a  concentrated  form.  This  usually  produces  from  three  to 
five  liquid  evacuations.  The  compound  jalap  powder  in  half-drachm  doses, 
or  elaterium,  may  be  employed  for  the  same  purpose.  Even  when  the  pulse 
is  very  feeble  these  hydragogue  cathartics  are  well  borne,  and  they  deplete 
the  portal  system  rapidly  and  efficiently. 

(c)  The  Use  of  Remedies  which  stimulate  the  Heart's  Action. — Of  these, 
by  far  the  most  important  is  digitalis,  which  was  introduced  into  practice 
by  "Withering.  The  indication  for  its  use  is  dilatation;  the  contra-indica- 
tion  is  a  perfectly  balanced  compensatory  hypertrophy,  such  as  we  see  in  all 
forms  of  valvular  disease.  Broken  compensation,  no  matter  what  the 
valve  lesion  may  be,  is  the  signal  for  its  use.  It  acts  upon  the  heart,  slow- 
ing and  at  the  same  time  increasing  the  force  of  the  contractions.  It  acts 
on  the  peripheral  arteries,  raising  their  tension,  so  that  a  steady  and  equable 
flow  of  blood  is  maintained  in  the  capillaries,  which,  after  all,  is  the  prime 
aim  and  object  of  the  circulation.  The  beneficial  effects  are  best  seen  in 
cases  of  mitral  disease  with  small,  irregular  pulse  and  cardiac  dropsy..  Its 
effects  are  not  less  striking  in  the  dilatation  of  the  left  ventricle,  in  the 
failing  compensation  of  aortic  insufficiency  or  of  arterio-sclerosis.  On  theo- 
retical grounds  it  has  been  urged  that  its  use  is  not  so  advantageous  in 
aortic  insufficiency,-  since  it  prolongs  the  diastole  and  leads  to  greater  dis- 
tention. This  need  not  be  considered,  and  digitalis  is  just  as  serviceable 
in  this  as  in  any  other  condition  associated  with  progressive  dilatation; 
larger  doses  are  often  required.  It  may  be  given  as  the  tincture  or  the  in- 
fusion. In  cases  of  cardiac  dropsy,  from  whatever  cause,  15  minims  of  the 
tincture  or  half  an  ounce  of  the  infusion  may,  be  given  every  three  hours 
for  two  days,  after  which  the  dose  may  be  reduced.  Some  prefer  the  tinc- 
ture, others  the  infusion;  it  is  a  matter  of  indifference  if  the  drug  is  good. 
The  urine  of  a  patient  taking  digitalis  should  be  carefully  estimated  each 
day.  As  a  rule,  when  its  action  is  beneficial,  there  is  within  twenty-four 
hours  an  increase  in  the  amount;  often  the  flow  is  very  great.  Under  its 
use  the  dyspnoea  is  relieved,  the  dropsy  gradually  disappears,  the  pulse  be- 
comes firmer,  fuller  in  volume,  and  sometimes,  if  it  has  been  very  inter- 
mittent, regular. 

Ill  effects  sometimes  follow  digitalis.  There  is  no  such  thing  as  a 
cumulative  action  of  the  drug  manifested  by  sudden  symptoms.  Toxic 
effects  are  seen  in  the  production  of  nausea  and  vomiting.  The  pulse  be- 
comes irregular  and  small,  and  there  may  be  two  beats  of  the  heart  to  one 
of  the  pulse,  which,  as  pointed  out  by  Broadbent,  is  found  particularly  in 
cases  of  mitral  stenosis  when  they  are  under  the  influence  of  this  drug. 

*  For  ilhistrative  cases  from  my  wards  see  paper  by  H.  A.  Lafleur,  Medical  News, 
July,  1891. 


CHRONIC   VALVULAR  DISEASE.  733 

The  urine  is  reduced  in  amount.  These  symptoms  subside  on  the  with- 
drawal of  the  digitalis,  and  are  rarely  serious.  There  are  patients  who  take 
digitalis  uninterruptedly  for  years,  and  feel  palpitation  and  distress  if  the 
drug  is  omitted.  In  mitral  disease,  even  when  it  does  good  it  does  not  al- 
ways steady  the  pulse.  There  are  many  cases  in  which  the  irregularity  is 
not  affected  by  the  digitalis.  When  the  compensation  has  been  re-estab- 
lished the  drug  may  be  omitted.  When  there  is  dyspncea  on  exertion  and 
cardiac  distress,  from  5  to  10  minims  three  times  a  day  may  be  advan- 
tageously given  for  prolonged  periods,  but  the  effects  should  be  carefully 
watched.  In  cardiac  dropsy  digitalis  should  be  used  at  the  outset  with  a 
free  hand.  Small  doses  should  not  be  given,  but  from  the  first  half-ounce 
doses  of  the  infusion  every  three  hours,  or  from  15  to  20  minims  of  the 
tincture.  Digitalin,  hypodermically  (gr.  ^V)  every  three  or  four  hours, 
may  be  substituted. 

Of  other  remedies  strophanthus  alone  is  of  service.  Given  in  doses  of 
from  5  to  8  minims  of  the  tincture,  it  acts  like  digitalis.  It  certainly  will 
sometimes  steady  the  intermittent  heart  of  mitral  valve  disease  when  digi- 
talis fails  to  do  so,  but  it  is  not  to  be  compared  with  this  drug  when  dropsy 
is  present.  Convallaria,  citrate  of  caffeine,  and  adonis  vernalis  and  spar- 
teine are  warmly  recommended  as  substitutes  for  digitalis,  but  their  infe- 
riority is  so  manifest  that  their  use  is  rarely  indicated. 

There  are  two  valuable  adjuncts  in  the  treatment  of  valvular  disease — 
iron  and  strychnia.  When  angemia  is  a  marked  feature  iron  should  be 
given  in  full  doses.  In  some  instances  of  failing  compensation  this  is  the 
only  medicine  needed  to  restore  the  balance.  Arsenic  is  occasionally  an 
excellent  substitute,  and  one  or  other  of  them  should  be  administered  in 
all  instances  of  heart-trouble  when  pallor  is  present.  Strychnia  is  a  heart 
tonic  of  very  great  value.  It  may  be  given  alone  or  in  combination  with  the 
digitalis  in  1  or  2  drop  doses  of  the  1-per-cent  solution.  Alcoholic  stimu- 
lants in  moderation  are  occasionally  useful,  especially  in  tiding  over  a  period 
of  acute  cardiac  weakness. 

Treatment  of  Special  Symptoms,  (a)  Dropsy. — The  increased 
arterial  tension  and  activity  of  the  capillary  circulation  under  the  influence 
of  digitalis  hastens  the  interstitial  lymph  flow  and  favors  resorption  of  tlie 
fluid.  The  hydragogue  cathartics,  by  rapidly  depleting  the  blood,  promote, 
too,  the  absorption  of  the  fluid  from  the  lymph  spaces  and  the  lymph  sacs. 
These  two  measures  usually  suffice  to  rid  the  patient  of  the  dropsy.  In 
some  cases,  however,  it  cannot  be  relieved,  and  then  Southey's  tubes  may 
be  used  or  the  legs  punctured.  If  done  with  care,  after  a  thorough  wash- 
ing of  the  parts,  and  if  antiseptic  precautions  are  taken,  scarification  is  a 
very  serviceable  measure,  and  should  be  resorted  to  more  frequently  than  it 
is.     Canton  flannel  bandages  may  be  applied  on  the  oedematous  legs. 

(h)  Dyspncea. — The  patients  are  usually  unable  to  lie  down.  A  com- 
fortable bed-rest  should  therefore  be  provided — if  possible,  one  with  lateral 
projections,  so  that  in  sleeping  the  head  can  be  supported  as  it  falls  over. 
The  shortness  of  breath  is  associated  with  dilatation,  chronic  bronchitis, 
or  hydrothorax.  The  chest  should  be  carefully  examined  in  all  these  cases, 
as  hydrothorax  of  one  side  or  of  both  is  a  common  cause  of  shortness  of 
breath.     There  are  cases  of  mitral  regurgitation  with  recurring  hydrothorax 


734  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

usually  on  the  right  side,  which  is  relieved,  week  by  week  or  month  by 
month,  by  tapping.  For  the  nocturnal  dyspnoea,  particularly  when  com- 
bined with  restlessness,  morphia  is  invaluable  and  may  be  given  without 
hesitation.  The  value  of  the  calming  influence  of  opium  in  all  conditions 
of  cardiac  insufScieney  is  not  enough  recognized.  There  are  instances  of 
cardiac  dyspnoea  unassociated  with  dropsy,  particularly  in  mitral  valve  dis- 
ease, in  which  nitroglycerin  is  of  great  service,  if  given  in  the  1-per-cent 
solution  in  increasing  doses.  It  is  especially  serviceable  in  the  cases  in 
which  the  pulse  tension  is  high. 

(c)  Palpitation  and  Cardiac  Distress. — In  instances  of  great  hypertrophy 
and  in  the  throbbing  which  is  so  distressing  in  some  cases  of  aortic  in- 
sufficiency, aconite  is  of  service  in  doses  of  from  1  to  3  minims  every  two 
or  three  hours.  An  ice-bag  over  the  heart  or  Leiter's  coil  is  also  of  service 
in  allaying  the  rapid  action  and  the  throbbing.  For  the  pains,  which  are 
often  so  marked  in  aortic  lesions,  iodide  of  potassium  in  10-grain  doses, 
three  times  a  day,  or  the  nitroglycerin  may  be  tried.  Small  blisters  are 
sometimes  advantageous.  It  must  be  remembered  that  an  important  cause 
of  palpitation  and  cardiac  distress  is  flatulent  distention  of  the  stomach 
or  colon,  against  which  suitable  measures  must  be  directed. 

(d)  Gastric  Symptoms. — The  cases  of  cardiac  insufficiency  which  do 
badly  and  fail  to  respond  to  digitalis  are  most  often  those  in  which  nausea 
and  vomiting  are  prominent  features.  The  liver  is  often  greatly  enlarged 
in  these  eases;  there  is  more  or  less  stasis  in  the  hepatic  vessels,  and  but 
little  can  be  expected  of  drugs  imtil  the  venous  engorgement  is  relieved. 
If  the  vomiting  persists,  it  is  best  to  stop  the  food  and  give  small  bits  of 
jce,  small  quantities  of  milk  and  lime  water,  and  effervescing  drinks,  such 
as  Apollinaris  water  and  champagne.  Creasote,  hydrocyanic  acid,  and  the 
oxalate  of  cerium  are  sometimes  useful;  but,  as  a  rule,  the  condition  is  ob- 
stinate and  always  serious. 

(e)  Cough  and  Hcemoptysis. — The  former  is  almost  a  necessary  concomi- 
tant of  cardiac  insufficiency,  owing  to  engorgement  of  the  pulmonary  ves- 
sels and  more  or  less  bronchitis.  It  is  allayed  by  measures  directed  rather 
to  the  heart  than  to  the  lungs.  Haemoptysis  in  chronic  valvular  disease 
is  sometimes  a  salutary  symptom.  An  army  surgeon,  who  was  invalided 
during  the  late  civil  war  on  account  of  haemoptysis,  supposed  to  be  due 
to  tuberculosis,  had  for  many  years,  in  association  with  mitral  insuffi- 
ciency and  enlarged  heart,  many  attacks  of  haemoptysis.  He  assured  me 
that  his  condition  was  invariably  better  after  the  attack.  It  is  rarely  fatal, 
except  in  some  cases  of  acute  dilatation,  and  seldom  calls  for  special  treat- 
ment. 

(/)  Sleeplessness. — One  of  the  most  distressing  features  of  valvular  le- 
sions, even  in  the  stage  of  compensation,  is  disturbed  sleep.  Patients  may 
wake  suddenly  with  throbbing  of  the  heart,  often  in  an  attack  of  night- 
mare. Subsequently,  when  the  compensation  has  failed,  it  is  also  a  worry- 
ing symptom.  The  sleep  is  broken,  restless,  and  frequently  disturbed  by 
frightful  dreams.  Sometimes  a  dose  of  the  spirits  of  chloroform  or  of  ether, 
with  half  a  drachm  of  spirits  of  camphor,  given  in  a  little  hot  whisky,  will 
give  a  quiet  night.    The  compound  spirits  of  ether,  Hoffmann's  anodyne, 


HYPERTROPHY  AND  DILATATION.  735 

though  very  unpleasant  to  take,  is  frequently  a  great  boon  in  the  inter- 
mediate period  when  compensation  has  partially  failed  and  the  patients 
suffer  from  restless  and  sleepless  nights.  Paraldehyde  and  amylene  hydrate 
are  sometimes  serviceable.  Urethan,  sulphonal,  and  chloralamide  are  rarely 
efficacious,  and  it  is  best,  after  a  few  trials,  particularly  if  the  paraldehyde 
does  not  answer,  to  resort  to  morphia.  It  may  be  given  in  combination  with 
atropine. 

(g)  Renal  Symptoms. — With  ruptured  compensation  and  lowering  of 
the  tension  in  the  aorta,  the  urinary  secretion  is  greatly  diminished,  and 
the  amount  may  sink  to  5  or  6  ounces  in  the  day.  Digitalis,  and  strophan- 
thus  when  efficient,  usually  increase  the  flow.  A  brisk  purge  may  be  fol- 
lowed by  augmented  secretion.  The  combination  in  pill  form  of  digitalis, 
squill,  and  the  black  oxide  of  mercury,  will  sometimes  prove  effective  when 
the  infusion  or  tincture  of  digitalis  alone  has  failed.  Calomel  acts  well  in 
some  cases,  given  in  3-grain  doses  every  six  hours  for  three  or  four  days. 

The  diet  in  chronic  valve-diseases  is  often  very  difficult  to  regulate. 
With  the  dilatation  and  venous  engorgement  come  nausea  and  often  a  great 
distaste  for  food.  The  amount  of  liquid  should  be  restricted,  and  milk, 
beef-Juice,  or  egg  albumen  given  every  three  hours.  When  the  serious 
symptoms  have  passed,  eggs,  scraped  meat,  fish,  and  fowl  may  be  allowed. 
Starchy  foods,  and  all  articles  likely  to  cause  flatulency,  should  be  for- 
bidden.    Stimulants  are  usually  necessary,  either  whisky  or  brandy. 


III.  HYPERTROPHY  AND  DILATATION. 

Hypertrophy  is  an  enlargement  of  the  heart  due  to  an  increased  thick- 
ness, total  or  partial,  in  the  muscular  walls.  Dilatation  is  an  increase  in 
size  of  one  or  more  of  the  chambers,  with  or  without  thickening  of  the  walls. 
The  conditions  usually  coexist,  and  could  be  more  correctly  described  to- 
gether under  the  term  enlargement  of  the  heart.  Simple  hypertrophy,  in 
which  the  cavities  remain  of  a  normal  size  and  the  walls  are  increased, 
occurs,  but  simple  dilatation,  in  which  the  cavities  are  increased  and  the 
walls  remain  of  a  normal  diameter,  probably  does  not,  as  it  is  always  asso- 
ciated with  thinning  or  with  thickening  of  the  coats.  Commonly  we  have 
the  forms  of  simple  hypertrophy,  hypertrophy  with  dilatation,  and  dilatation 
with  thinning  of  the  coats. 

Htpeetrophy  of  the  Heaet. 

There  are  two  forms — the  simple  hypertrophy,  in  which  the  cavity  or 
cavities  are  of  normal  size;  and  hypertrophy  with  dilatation  (eccentric 
hypertrophy),  in  which  the  cavities  are  enlarged  and  the  walls  increased  in 
thickness.  The  condition  formerly  spoken  of  as  concentric  hypertrophy, 
in  which  there  is  diminution  in  the  size  of  the  cavity  with  thickening  of 
the  walls,  is,  as  a  rule,  a  post-mortem  change. 

The  enlargement  may  afPect  the  entire  organ,  one  side,  or  only  one 
chamber.  Naturally,  as  the  left  ventricle  does  the  chief  work  in  forcing 
46 


^36  DISEASES  OF  THE  CIECULATORY  SYSTEM. 

the  blood  through  the  systemic  arteries,  the  change  is  most  frequently 
found  in  it. 

Etiology. — Hypertrophy  of  the  heart  follows  the  law  governing  mus- 
cles, that  within  certain  limits,  if  the  nutrition  is  kept  up,  increased  work 
is  followed  by  increased  size — ^i.  e.,  hypertrophy.  Hypertrophy  of  the  left 
yentriele  alone,  or  with  general  enlargement  of  the  heart,  is  brought 
about  by — 

Conditions  affecting  the  heart  itself:  (1)  Disease  of  the  aortic  valve; 
(2)  mitral  insufficiency;  (3)  pericardial  adhesions;  (4)  sclerotic  myocarditis; 
(5)  disturbed  innervation,  with  overaction,  as  in  exophthalmic  goitre,  in 
long-continued  nervous  palpitation,  and  as  a  result  of  the  action  of  certain 
articles,  such  as  tea,  alcohol,  and  tobacco.  In  all  of  these  conditions  the 
work  of  the  heart  is  increased.  In  the  case  of  the  valve  lesions  the  increase 
is  due  to  the  increased  intraventricular  pressure;  in  the  case  of  the  adherent 
pericardium  and  myocarditis,  to  direct  interference  with  the  symmetrical 
and  orderly  contraction  of  the  chambers. 

Conditions  acting  upon  the  blood-vessels:  (1)  G-eneral  arterio-sclerosis, 
with  or  without  renal  disease;  (2)  all  states  of  increased  arterial  t-efision 
induced  by  the  contraction  of  the  smaller  arteries  under  the  influence  of 
certain  toxic  substances,  which,  as  Bright  suggested,  "by  affecting  the 
minute  capillary  circulation,  render  greater  action  necessary  to  send  the 
blood  through  the  distant  subdivisions  of  the  vascular  system  ";  (3)  pro- 
longed muscular  exertion,  which  enormously  increases  the  blood-pressure 
in  the  arteries;  (4)  narrowing  of  the  aorta,  as  in  the  congenital  stenosis. 

Hypertrophy  of  the  right  ventricle  is  met  with  under  the  following 
conditions — 

(1)  Lesions  of  the  mitral  valve,  either  incompetence  or  stenosis,  which 
act  by  increasing  the  resistance  in  the  pulmonary  vessels.  (2)  Pulmonary 
lesions,  obliteration  of  any  number  of  blood-vessels  within  the  lungs,  such 
as  occurs  in  emphysema  or  cirrhosis,  is  followed  by  hypertrophy  of  the 
right  ventricle.  (3)  Valvular  lesions  on  the  right  side  occasionally  cause 
hypertrophy  in  the  adult,  not  infrequently  in  the  foetus.  (4)  Chronic 
valvular  disease  of  the  left  heart  and  pericardial  adhesions  are  sooner  or 
later  associated  with  hypertrophy  of  the  right  ventricle. 

In  the  auricles  simple  hypertrophy  is  never  seenj  there  is  always  dilata- 
tion with  hypertrophy.  In  the  left  auricle  the  condition  develops  in  lesions 
at  the  mitral  orifice,  particularly  stenosis.  The  right  auricle  hypertrophies 
when  there  is  greatly  increased  blood-pressure  in  the  lesser  circulation, 
whether  due  to  mitral  stenosis  or  pulmonary  lesions.  Narrowing  of  the 
tricuspid  orifice  is  a  less  frequent  cause. 

Morbid  Anatomy. — The  heart  of  an  average-sized  man  weighs  about 
9  ounces  (280  grammes);  that  of  a  woman,  about  8  ounces  (250  grammes). 
In  case  of  general  hypertrophy  the  heart  may  weigh  from  16  to  20  ounces. 
Weights  above  25  ounces  are  rare.  So  far  as  I  know,  the  heaviest  heart 
on  record  is  one  of  53  ounces,  described  by  Beverly  Eobinson.  Dulles 
has  reported  one  weighing  48  ounces.  The  measurement  of  the  thickness 
of  the  walls  is,  next  to  weighing,  the  best  means  of  determining  the  hyper- 
trophy.    In  extreme  dilatation  the  walls,  though  actually  thickened,  may 


HYPERTROPHY  AND   DILATATION.  737 

look  thin.  "When  rigor  mortis  is  present,  the  cavity  may  be  small  and  the 
walls  may  appear  greatly  thickened.  The  measurements  should  not  be 
made  until  the  heart  has  been  soaked  in  water  and  thoroughly  relaxed.  In 
the  left  ventricle  a  thickness  of  ten  lines,  or  from  20  to  25  mm.,  indicates 
hypertrophy.  The  right  ventricle  is  thinner  than  the  left,  and  has  an 
average  diameter  of  from  4  to  7  mm.  In  hypertrophy  it  may  measure  from 
13  to  20  mm.  The  left  auricle  has  a  normal  thickness  of  about  3  mm., 
which  may  be  doubled  in  hypertrophy.  The  wall  of  the  right  auricle  is 
thinner  than  that  of  the  left,  rarely  exceeding  2  mm.  in  diameter.  The 
appendices  of  the  auricles  often  present  marked  increase  in  thickness  and 
the  musculi  pectinati  are  greatly  developed. 

The  shape  of  the  heart  is  altered  in  hypertrophy;  with  great  enlarge- 
ment of  the  ventricles,  the  apex  is  broadened,  and  the  conical  shape  is  lost. 
In  the  enormous  enlargement  of  aortic  insufficiency  this  rotundity  of  the 
apex  is  very  marked.  When  the  right  ventricle  is  chiefly  affected  it  occu- 
pies the  largest  share  of  the  apex.  In  mitral  stenosis  the  contrast  is  very 
striking  between  the  large,  broad  right  ventricle,  reaching  to  the  apex,  and 
the  small  left  chamber. 

The  hypertrophied  muscle  has  a  deep  red  color,  is  firm,  and  is  cut  with 
increasing  resistance.  The  right  ventricle,  as  Eokitansky  noted,  may  have 
a  peculiar  hard,  leathery  consistence.  In  simple  hypertrophy  of  the  left 
ventricle  the  papillary  muscles  and  the  columnse  carnese  may  be  enlarged, 
but  the  former  are  often  much  flattened  in  dilated  hypertrophy.  The 
muscular  trabecule  are  more  developed,  as  a  rule,  in  the  right  ventricle 
than  in  the  left. 

The  increase  in  size  of  the  heart  is  probably  due  to  a  definite  numerical 
increase,  resulting  from  development  of  new  fibres. 

Symptoms. — Hypertrophy  is  a  conservative  process,  secondary  to 
some  valvular  or  arterial  lesion,  and  is  not  necessarily  accompanied  by 
symptoms.  So  admirable  is  the  adjusting  power  of  the  heart  that,  for 
example,  an  advancing  stenosis  of  aortic  or  mitral  orifice  may  for  years  be 
perfectly  equalized  by  a  progressive  hypertrophy,  and  the  subject  of  the 
affection  be  happily  unconscious  of  the  existence  of  heart  trouble.  Hyper- 
trophy is  in  almost  all  cases  an  unmixed  good;  the  symptoms  which  arise 
are  usually  to  be  attributed  to  its  failure,  or,  as  we  say,  to  disturbance  of 
compensation. 

Among  the  most  common  symptoms  are  unpleasant  feelings  about  the 
heart — a  sense  of  fulness  and  discomfort,  rarely  amounting  to  pain.  This 
may  be  very  noticeable  when  the  patient  is  recumbent  on  the  left  side. 
Actual  pain  is  rare,  except  in  the  irritable  heart  from  tobacco  or  in  neur- 
asthenics. Palpitation  may  not  occur,  nor  do  patients  always  have  sensa- 
tions from  the  violent  shocks  of  a  greatly  hypertrophied  organ.  There 
are  instances  in  which  very  uneasy  feelings  arise  from  a  moderately  exag- 
gerated pulsation.  The  general  condition  has  much  to  do  with  this.  In 
health  we  are  not  conscious  of  the  heart's  pulsations,  but  one  of  the  first 
indications  of  exhaustion  from  excesses  or  overstudy  is  the  consciousness 
of  the  heart's  action,  not  necessarily  with  palpitation.  Headaches,  flush- 
ings of  the  face,  noises  in  the  ears,  and  flashes  of  light  may  be  present. 


738  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Certain  untoward  efEeets  of  long-continued  hypertrophy  of  the  left 
ventricle  must  be  mentioned^  chief  among  which  is  the  production  of 
arterio-sclerosis.  Particularly  is  this  the  case  when  the  hypertrophy  results 
from  increased  peripheral  resistance.  The  heightened  blood-pressure  (ex- 
pressed by  the  word  strain)  in  the  arteries  gradually  induces  an  endarteritis 
and  a  stiffs  inelastic  state  of  those  vessels  most  exposed  to  it — viz.,  tlie 
aorta  and  its  primary  divisions.  In  overcoming  the  peripheral  obstruction 
the  hypertrophy  "ruins  the  arteries  as  a  sequential  result"  (Fothergill). 
Prolonged  muscular  exertion  also  acts  injuriously  in  this  way. 

Another  danger  is  rupture  of  the  blood-vessels,  particularly  those  of  the 
brain.  In  general  arterial  degeneration  associated  with  contracted  kidneys 
and  hypertrophied  left  heart  apoplexy  is  common.  Indeed,  in  the  majority 
of  cases  of  cerebral  hsemorrhage  there  is  sclerosis  of  the  smaller  vessels, 
often  with  the  development  of  miliary  aneurisms,  and  the  rupture  may  be 
caused  by  the  forcible  action  of  the  heart. 

Physical  Signs. — Inspection  may  show  bulging  of  the  prsecordia,  pro- 
ducing in  children  marked  asymmetry  of  the  chest.  It  may  occur  with- 
out pericardial  adhesions,  which  Schroetter  thinks  are  invariably  associated 
with  this  condition.  The  intercostal  spaces  are  widened,  and  the  area  of 
visible  impulse  is  much  increased.  On  palpation  the  impulse  is  forcible 
and  heaving,  and  with  each  systole  the  hand  or  the  ear  applied  over  the 
heart  may  be  visibly  raised.  A  slow,  heaving  impulse  is  one  of  the  best 
signs  of  simple  hypertrophy.  With  large  dilated  hypertrophy  the  forcible 
impulse  is  often  more  sudden  and  abrupt.  A  second,  weaker  impulse  can 
sometimes  be  felt,  due  perhaps  to  a  rebound  from  the  aortic  valves  (Gowers). 
The  beat  may  be  felt  in  the  sixth,  seventh,  or  eighth  interspace  from  1 
to  3  inches  outside  the  nipple.  This  downward  dislocation  of  the  apex 
is  an  important  sign  in  hypertrophy  of  the  left  ventricle.  In  moderate 
grades,  such  as  are  seen  in  chronic  Bright^s  disease,  the  impulse  may  be  in 
the  sixth  interspace  in  the  nipple  line,  or  a  little  outside  of  it. 

Percussion  reveals  increased  dulness,  which  in  the  parasternal  line  may 
begin  at  the  third  rib  or  in  the  second  interspace,  and  transversely  may 
extend  from  half  an  inch  to  2  inches  beyond  the  nipple  line  and  an 
equal  distance  beyond  the  middle  line  of  the  sternum.  The  dull  area  is 
more  ovoid  than  in  health.  When  carefully  delimited  the  colossal  hyper- 
trophy of  aortic  valve  disease  may  give  an  area  of  dulness  from  7  to  8 
inches  in  transverse  extent.  In  moderate  grades  a  transverse  dulness  of  4 
inches  is  not  uncommon. 

On  auscultation  the  sounds,  when  the  valves  are  healthy,  may  present 
no  special  changes,  but  the  first  sound  is  often  prolonged  and  dull.  When 
there  is  dilatation  as  well,  it  may  be  very  clear  and  sharp.  Eeduplication 
is  common  in  the  hypertrophy  of  renal  disease.  A  peculiar  clink — the 
tintement  metallique  of  Bouillaud— may  be  heard  just  to  the  right  of  the 
apex  beat.  The  second  sound  is  clear  and  loud,  sometimes  ringing  in  char- 
acter or  reduplicated.  With  valvular  lesions,  the  sounds,  of  course,  are 
much  altered,  and  are  replaced  or  accompanied  by  murmurs. 

In  simple  hypertrophy  not  dependent  on  valvular  lesions,  the  pulse 
is  usually  regular,  full,  strong,  and  of  bigh  tension.     It  may  be  increased 


HYPERTROPHY  AND  DILATATION.  739 

in  rapidity,  but  is  often  uornial.  In  eccentric  hypertrophy  the  pulse  is  full, 
but  softer,  and  usually  more  rapid.  One  of  the  earliest  signs  of  failure  and 
dilatation  is  irregularity  and  intermittence  of  the  pulse. 

Hypertrophy  of  the  right  ventricle  in  the  adult  very  rarely  follows  valvu- 
lar disease  on  the  right  side,  but  results  from  increased  resistance  in  the 
pulmonary  circulation,  as  in  cirrhosis  of  the  lung  and  emphysema,  or  in 
stenosis  of  the  mitral  orifice.  With  perfect  compensation,  Avhich  fully 
maintains  the  equilibrium  of  the  circulation,  there  are  no  symptoms.  Extra 
exertion,  as  the  ascent  of  stairs  or  running,  may  cause  shortness  of  breath, 
but  in  many  ways  hypertrophy  of  the  right  ventricle  is  the  most  enduring 
and  salutary  form  in  the  whole  cycle  of  cardiac  affections.  For  long 
periods  of  years  the  effects  of  mitral  stenosis  may  be  counterbalanced,  and 
only  sudden  death  by  accident  or  an  acute  disease  reveal  the  existence  of 
an  unsuspected  lesion.  In  the  hypertrophy  secondary  to  emphysema  or 
cirrhosis  of  the  lungs,  there  may  be  sensations  of  distress  in  the  cardiac 
region,  with  cough  and  shortness  of  breath;  but  as  long  as  the  dilatation 
is  moderate  the  symptoms  are  not  marked.  With  great  dilatation  and 
tricuspid  leakage  come  venous  engorgement,  oedema,  and  pulmonary  trou- 
bles. The  increased  pressure  in  the  lesser  circulation  induces  sclerosis  of 
the  pulmonary  arteries  and  the  constant  engorgement  of  the  capillaries 
leads  ultimately  to  a  deposition  of  pigment  and  increase  in  the  fibrous 
elements  in  the  lung — the  brown  induration.  Extreme  pulmonary  con- 
gestion and  apoplexy  are  more  often  associated  with  dilatation.  Haemop- 
tysis may  result  from  rupture  of  vessels  during  sudden  exertion. 

Physical  Signs. — Bulging  of  the  lower  part  of  the  sternum  and  left 
cartilages  occurs.  The  apex  beat  is  forced  to  the  left,  but  is  not  so  often 
displaced  downward.  The  most  marked  impulse  may  be  in  the  angle  be- 
tween the  ensiform  cartilage  and  the  seventh  rib  or  beneath  the  cartilages 
of  the  sixth  and  seventh  ribs.  The  pulsation  is  rather  diffuse,  not  punc- 
tate, particularly  if  there  is  much  dilatation.  In  thin-walled  chests  there 
may  be  pulsation  in  the  third  and  fourth  right  interspaces.  The  cardiac 
dulness  is  increased  transversely  and  toward  the  right;  it  may  extend  an 
inch  or  more  beyond  the  border  of  the  sternum.  On  auscultation  the  first 
sound  at  the  lower  part  of  the  sternum  is  louder  and  fuller  than  normal, 
but  the  differences  are  not  very  marked  unless  there  is  much  dilatation, 
when  the  sound  is  clearer  and  sharper.  Accentuation  and  reduplication 
of  the  second  sound  are  heard  in  the  pulmonary  artery  on  account  of  the 
increased  tension.  The  pulse  at  the  wrist  is  usually  small.  Pulsation 
occurs  in  the  jugulars  when  there  is  tricuspid  incompetence. 

Hypertrophy  of  the  auricles  always  occurs  with  dilatation.  It  is  more 
common  in  the  left  chamber,  which  hypertrophies  in  mitral  stenosis  and 
incompetency,  and  naturally  assists  in  restoring  the  balance  of  the  circu- 
lation. There  are  no  distinctive  physical  signs,  and  we  usually  can  infer 
its  presence  only  by  the  existence  of  mitral  stenosis  and  a  presystolic  mur- 
mur. Increased  dulness  may  be  determined  to  the  left  of  the  sternum,  and 
there  may  be  a  presystolic  wave  in  the  second  left  interspace. 

Hypertrophy  and  dilatation  of  the  right  auricle  are  met  with  (associ- 
ated with  a  similar  condition  in  the  right  ventricle  and  incompetency  of 


740  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  tricuspid)  in  emphysema,  cirrhosis  of  the  lung,  chronic  bronchitis,  and 
mitral  disease.  In  comparison  with  the  left  auricle  the  greater  develop- 
ment and  hypertrophy  of  the  appendix  and  its  musculi  pectinati  are  very 
striking.  The  latter  may  be  distributed  over  the  anterior  wall  of  the  sinus 
to  a  greater  extent  than  in  health.  There  are  increased  dulness  in  the 
third  and  fourth  interspaces,  pulsation  sometimes  presystolic  in  rhythm, 
signs  of  venous  engorgement,  jugular  pulsation,  and  other  evidences  of 
dilatation  of  the  right  heart. 

Diagnosis. — Among  conditions  to  be  distinguished  are: 

(1)  ISTeurotic  palpitation,  from  whatever  cause,  even  when  very  forcible, 
has  not  the  heaving  impulse  of  genuine  hypertrophy.  Enlargement  of  the 
organ  may,  however,  follow  prolonged  overaction,  as  in  the  smoker's  heart, 
the  irritable  heart  of  neurasthenics,  and  in  exophthalmic  goitre,  but  it  is 
usually  slight. 

(2)  The  increased  area  of  dulness  may  be  due  to  a  variety  of  causes, 
some  of  which  may  closely  simulate  hypertrophy,  such  as  pericardial  effu- 
sion, aneurism,  mediastinal  growths,  or  displacement  of  the  heart  from 
pressure,  or  the  existence  of  malformation  of  the  chest.  With  the  exer- 
cise of  ordinary  care,  however,  the  diagnosis  can  usually  be  made.  There 
are  two  opposite  conditions  which  frequently  give  trouble.  With  the  left 
lung  contracted  from  pleurisy,  phthisis,  or  cirrhosis,  a  large  surface  of  the 
heart  is  exposed;  the  pulsation  may  be  extensive  and  forcible,  and  may  at 
first  sight  suggest  hypertrophy.  In  this  condition  there  is  dislocation 
upward  and  to  the  left.  The  existence  of  pulmonary  or  pleuritic  disease 
and  the  fixation  of  the  lung  on  deep  inspiration  will  suffice  to  prevent 
mistakes.  A  less  extensive  exposure  of  the  heart  may  occur  without  any 
disease  in  very  narrow-chested  persons  with  ill-developed  lungs;  here, 
though  the  area  of  dulness  may  be  much  increased,  the  normal  position 
of  the  apex,  the  absence  of  forcible,  heaving  impulse,  and  of  any  obvious 
cause  of  hypertrophy  will  afford  satisfactory  criteria  for  a  diagnosis.  The 
reverse  condition  exists  in  some  cases  in  which  emphysema  masks  moderate 
cardiac  hypertrophy.  The  area  of  dulness  may  be  normal,  or  ^ven  dimin- 
ished, and  the  pulse  and  character  of  the  sounds  will  help  in  the  diagnosis; 
but  a  decision  is  sometimes  difficult. 

Prognosis. — The  course  of  any  case  of  cardiac  hypertrophy  may  be 
divided  into  three  stages: 

(a)  The  period  of  development,  which  varies  with  the  nature  of  the 
primary  lesion.  For  example,  in  rupture  of  an  aortic  valve,  during  a  sud- 
den exertion,  it  may  require  months  before  the  hypertrophy  becomes  fully 
developed;  or,  indeed,  it  may  never  do  so,  and  death  may  follow  from  an 
uncompensated  dilatation.  On  the  other  hand,  in  sclerotic  affections  of  the 
valves,  with  stenosis  or  incompetency,  the  hypertrophy  develops  step  by 
step  with  the  lesion,  and  may  continue  to  counterbalance  the  progressive 
and  increasing  impairment  of  the  valve. 

(&)  The  period  of  full  compensation — the  latent  stage — during  which 
the  heart's  vigor  meets  the  requirements  of  the  circulation.  This  period 
may  last  an  indefinite  time,  and  a  patient  may  never  be  made  aware  by 
any  symptoms  that  he  has  a  valvular  lesion. 


HYPERTROPHY  AND   DILATATION.  ^41 

(c)  The  period  of  broken  compensation,  which  may  come  on  suddenly 
during  very  severe  exertion.  Death  may  result  from  acute  dilatation;  but 
more  commonly  it  takes  place  slowly  and  results  from  degeneration  and 
weakening  of  the  heart-muscle. 

The  breaking  or  rupture  of  cardiac  compensation  may  be  induced  by 
many  causes,  among  which  the  most  important  are:  (1)  Failure  of  the 
general  nutrition.  In  many  instances  of  heart-disease,  exposure,  poor  food, 
and  alcohol  combine  to  bring  about  disturbance  of  a  well-balanced  heart 
lesion.  Acute  illnesses,  particularly  the  fevers,  may  induce  general  debility 
and  with  it  weakening  of  the  heart-muscle.  (2)  Disturbance  of  the  local 
nutrition  of  the  heart,  owing  to  gradual  sclerosis  of  the  coronary  arteries, 
is  a  common  cause.  (3)  Very  severe  muscular  exertion,  which  may  disturb 
a  compensation,  perfect  for  years,  and  induce  death  in  a  few  days  (Traube). 
(4)  Mental  emotions.  Severe  grief  or  fright  may  bring  on  failure  of  com- 
pensation. 

The  prognosis  is  largely,  as  already  stated,  a  matter  of  maintained  com- 
pensation. Once  established,  the  hypertrophy  rarely,  if  ever,  disappears, 
Inasmuch  as  the  cause  usually  persists.  Occasionally,  perhaps,  the  hyper- 
trophy associated  with  neurotic  palpitation  from  tobacco,  or  other' causes, 
or  the  hypertrophy  following  muscular  overexertion,  may  disappear. 

Dilatation  of  the  Heart. 

Two  varieties  are  recognized,  dilatation  with  thickening  and  dilatation 
with  thinning.  The  former  is  the  more  common,  and  corresponds  to  the 
dilated  or  eccentric  hypertrophy. 

Etiology. — Two  important  causes  combine  to  produce  dilatation — 
increased  pressure  within  the  cavities  and  impaired  resistance,  due  to  weak- 
ening of  the  muscular  wall — which  may  act  singly,  but  are  often  combined. 
A  weakened  wall  may  yield  to  a  normal  distending  force,  or  a  normal  wall 
may  yield  under  a  heightened  blood-pressure. 

(1)  Heightened  endocardiac  pressure  results  either  from  an  increased 
quantity  of  blood  to  be  moved  or  an  obstacle  to  be  overcome,  and  is  the 
more  frequent  cause.  It  does  not  necessarily  bring  about  dilatation;  simple 
hypertrophy  may  follow,  as  in  the  early  period  of  aortic  stenosis,  and  in  the 
hypertrophy  of  the  left  ventricle  in  Bright's  disease. 

A  majority  of  the  important  causes  of  increased  endocardiac  pressure 
have  already  been  discussed  under  hypertrophy.  One  or  two  may  be  con- 
sidered more  in  detail. 

The  size  of  the  cardiac  chambers  varies  in  health.  With  slow  action 
of  the  heart  the  dilatation  is  complete  and  fuller  than  it  is  with  rapid 
action.  Physiologically,  the  limits  of  dilatation  are  reached  when  the 
chamber  does  not  empty  itself  during  the  systole.  This  may  occur  as  an 
acute,  transient  condition  in  severe  exertion — during,  for  example,  the 
ascent  of  a  mountain.  There  may  be  great  dilatation  of  the  right  heart, 
as  shown  by  the  increased  epigastric  pulsation,  and  even  increase  in  the 
cardiac  dulness.  The  safety-valve  action  of  the  tricuspid  valves  may  here 
come  into  play,  relieving  the  lungs  by  permitting  regurgitation  into  the 


^42  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

auricle.  With  rest  the  condition  is  removed,  but  if  it  has  been  extreme, 
the  heart  may  suifer  a  strain  from  which  it  may  recover  slowly,  or,  indeed, 
the  individual  may  never  be  able  again  to  undertake  severe  exertion.  In 
the  process  of  training,  the  getting  wind,  as  it  is  called,  is  largely  a  gradual 
increase  in  the  capability  of  the  heart,  particularly  of  the  right  chambers. 
A  degree  of  exertion  can  be  safely  maintained  in  full  training  which  would 
be  quite  impossible  under  other  circumstances,  because,  by  a  gradual  process 
of  what  we  may  call  physical  education,  the  heart  has  strengthened  its 
reserve  force — widened  enormously  its  limits  of  physiological  work.  En- 
durance in  prolonged  contests  is  measured  by  the  capabilities  of  the  heart, 
and  its  essence  consists  in  being  able  to  meet  the  continuous  tendency  to 
overstep  the  limits  of  dilatation. 

We  have  no  positive  knowledge  of  the  nature  of  the  changes  in  the 
heart  which  occur  in  this  process,  but  it  must  be  in  the  direction  of  in- 
creased muscular  and  nervous  energy.  The  large  heart  of  athletes  may  be 
due  to  the  prolonged  use  of  their  muscles,  but  no  man  becomes  a  great 
runner  or  oarsman  who  has  not  naturally  a  capable  if  not  a  large  heart. 
Master  McGrath,  the  celebrated  grejdiound,  and  Eclipse,  the  race-horse, 
both  famous  for  endurance  rather  than  speed,  had  very  large  hearts. 

Excessive  dilatation  during  severe  muscular  effort  results  in  heart- 
strain.  A  man,  perhaps  in  poor  condition,  calls  upon  his  heart  for  extra 
work-  during  the  ascent  of  a  high  mountain,  and  is  at  once  seized  with 
pain  about  the  heart  and  a  sense  of  distress  in  the  epigastrium.  He 
breathes  rapidly  for  some  time,  is  "  puffed,"  as  we  say,  but  the  symptoms 
pass  off  after  a  night's  quiet.  An  attempt  to  repeat  the  exercise  is  followed 
by  another  attack,  or,  indeed,  an  attack  of  cardiac  dyspnoea  may  come  on 
while  he  is  at  rest.  Eor  months  such  a  man  may  be  unfitted  for  severe  exer- 
tion, or  he  may  be  permanently  incapacitated.  In  some  way  he  has  over- 
strained his  heart  and  become  "  broken-winded."  Exactly  what  has  taken 
place  in  these  hearts  we  cannot  say,  but  their  reserve  force  is  lost,  and  with 
it  the  power  of  meeting  the  demands  exacted  in  maintaining  the  circula- 
tion during  severe  exertion.  The  "  heart-shock  "  of  Latham  includes  cases 
of  this  nature — sudden  cardiac  breakdown  during  exertion,  not  due  to  rup- 
ture of  a  valve.  It  seems  probable  that  sudden  death  in  men  during  long- 
continued  efforts,  as  in  a  race,  is  sometimes  due  to  overdistention  and  paraly- 
sis of  the  heart. 

Examples  of  dilatation  occur  in  all  forms  of  valve  lesions.  In  aortic 
incompetency  blood  enters  the  left  ventricle  during  diastole  from  the  un- 
guarded aorta  and  from  the  left  auricle,  and  the  quantity  of  blood  at  the 
termination  of  diastole  subjects  the  walls  to  an  extreme  degree  of  pressure, 
under  which  they  inevitably  yield.  In  time  they  augment  in  thickness, 
and  present  the  typical  eccentric  hypertrophy  of  this  condition. 

In  mitral  insufficiency  blood  which  should  have  been  driven  into  the 
aorta  is  forced  into  and  dilates  the  auricle  from  which  it  came,  and  then 
in  the  diastole  of  the  ventricle  a  large  amount  is  returned  from  the  auri- 
cle, and  with  increased  force.  In  mitral  stenosis  the  left  auricle  is  the 
seat  of  greatly  increased  tension  during  diastole,  and  dilates  as  well  as 
hypertrophies;  the  distention,  too,  may  be  enormous.     Dilatation  of  the 


HYPEETROPHY  AND  DILATATION.  743 

right  ventricle  is  produced  by  a  number  of  conditions,  which  were  con- 
sidered under  hypertrophy.  All  circumstances,  such  as  mitral  stenosis, 
emphysema,  etc.,  which  permanently  increase  the  tension  of  the  blood  in 
the  pulmonary  vessels,  cause  its  dilatation. 

(2)  Impaired  nutrition  of  the  heart- walls  may  lead  to  a  diminution  of 
the  resisting  power  so  that  dilatation  readily  occurs. 

The  loss  of  tone  due  to  parenchymatous  degeneration  or  myocarditis 
in  fevers  may  lead  to  a  fatal  condition  of  acute  dilatation.  It  is  a  recog- 
nized cause  of  death  in  scarlatinal  dropsy  (Goodhart),  and  may  occur  in 
rheumatic  fever,  typhus,  typhoid,  erysipelas,  etc.  The  changes  in  the 
heart-muscle  which  accompany  acute  endocarditis  or  pericarditis  may  lead 
to  dilatation,  especially  in  the  latter  disease.  In  anaemia,  leukasmia,  and 
chlorosis  the  dilatation  may  be  considerable.  In  sclerosis  of  the  walls,  the 
yielding  is  always  where  this  process  is  most  advanced,  as  at  the  left  apex. 
Under  any  of  these  circumstances  the  walls  may  yield  with  normal  blood- 
pressure. 

Pericardial  adhesions  are  a  cause  of  dilatation,  and  we  generally  find 
in  cases  with  extensive  and  firm  union  considerable  hypertrophy  and  dila- 
tation. There  is  usually  here  some  impairment  as  well  of  the  superficial 
layers  of  muscle. 

Morbid  Anatomy. — The  condition  usually  exists  with  hypertrophy 
in  two  or  mure  chambers.  It  is  more  common  on  the  right  than  on  the 
left  side.  The  most  extreme  dilatation  is  in  cases  of  aortic  incompetency, 
in  which  all  the  cavities  may  be  enormously  distended.  In  mitral  stenosis 
the  left  auricle  is  often  trebled  in  capacity,  and  the  right  chambers  also  are 
very  capacious.  The  auricles  may  contain  from  18  to  20  ounces  of  blood. 
In  chronic  lesions  of  the  lungs  the  right  chambers  are  chiefly  involved. 
In  great  distention  of  one  ventricle  the  septum  may  bulge  toward  the  other 
side.  The  auriculo-ventricular  rings  are  often  dilated,  and  there  may  be 
an  increase  in  the  circumference  of  1^-  or  even  2  inches.  Thus,  the  tricus- 
pid orifice,  the  circumference  of  which  is  about  4^  inches,  may  freely  admit 
a  graduated  heart-cone  of  above  6  inches;  and  the  mitral  orifice,  which 
normally  is  about  3^  inches,  may  admit  the  cone  to  5-^  inches  or  even 
more.  Great  dilatation  is  always  accompanied  by  relative  incompetency 
of  the  valves,  so  that  free  regurgitation  into  the  auricles  is  permitted. 
The  orifices  of  the  venae  cavas  and  of  the  pulmonary  veins  may  be  greatly 
dilated. 

The  endocardium  is  often  opaque,  particularly  that  of  the  auricles. 
The  muscle  substance  varies  according  to  the  presence  or  absence  of  de- 
generations. The  microscope  may  show  marked  fatty  or  parenchymatous 
change,  but  in  some  instances  no  special  alteration  may  be  noticeable. 
There  is  much  truth  in  Niemeyer's  assertion  "that  it  is  not  possible  by 
means  of  the  microscope  to  recognize  all  the  alterations  of  the  muscular 
fibrillse  which  diminish  the  functional  power  of  the  heart."  Of  the  changes 
in  the  ganglia  of  the  heart  we  know  very  little.  As  centres  of  control 
they  probaljly  have  more  to  do  with  cardiac  atony  and  breakdown  than  we 
generally  admit.  Degeneration  of  them  has  been  noted  by  Putjakin,  Ott, 
and  others. 


'j'44  DISEASES   OF  THE  CIECULATORY  SYSTEM. 

Symptoms  and  Physical  Signs. — Dilatation  causes  weakness  of 
the  cardiac  walls,  diminishes  the  vigor  of  their  contractions,  and  is  there- 
fore the  reverse  of  hypertrophy.  So  long  as  compensation  is  maintained 
the  enlargement  of  a  cavity  may  be  considerable.  The  limit  is  reached 
when  the  hypertrophied  walls  in  the  systole  can  no  longer  expel  all  the 
contents,  part  of  which  remain,  so  that  at  each  diastole  the  chamber  is 
abnormally  full.  Thus,  in  aortic  incompetency  blood  enters  the  left  ven- 
tricle from  the  aorta  as  well  as  the  auricle;  dilatation  ensues,  and  also 
hypertrophy  as  a  direct  effect  of  the  increased  pressure  and  increased 
amount  of  blood  to  be  moved.  But  if  from  any  cause  the  hypertrophy 
weakens  and  the  ventricle  during  systole  fails  to  empty  itself  completely, 
a  still  larger  amount  is  in  it  at  the  end  of  each  diastole,  and  the  dilatation 
becomes  greater.  The  amount  remaining  after  systole  prevents  the  blood 
from  entering  freely  from  the  auricle.  Incompetency  of  the  auriculo- 
ventricular  valves  follows,  with  dilatation  of  the  auricle  and  impeded 
blood-flow  in  the  pulmonary  veins.  Dilatation  and  hypertrophy  of  the 
right  heart  may  compensate  for  a  time,  but  when  this  fails  the  venous 
system  becomes  engorged  and  dropsy  may  result.  The  consideration  of 
the  symptoms  of  chronic  valvular  lesions  is  la-gely  that  of  dilatation  and 
its  effects.  Acute  dilatation,  such  as  we  see  in  severs  or  in  sudden  failure 
of  a  hypertrophied  heart,  is  accompanied  by  three  chief  symptoms — weak, 
usually  rapid,  impulse,  dyspnoea,  and  signs  of  obstructed  venous  circula- 
tion.   Cardiac  pain  may  be  present,  but  is  often  absent. 

The  physical  signs  of  dilatation  are  those  of  a  weak  and  enlarged 
organ.  The  impulse  is  diffuse,  often  undulatory,  and  is  felt  over  a  wide 
area,  and  an  apex  beat  or  a  point  of  maximum  intensity  may  not  be  found. 
When  it  does  exist,  it  may  be  visible  and  yet  cannot  be  felt — a  valuable 
observation  made  by  Walshe.  An  extensive  area  of  impulse  with  a  quick, 
weak  maximum  apex  beat  may  be  present.  When  the  right  heart  is  chiefly 
dilated  the  left  may  be  pushed  over  so  as  to  occupy  a  much  less  extensive 
area  in  front  of  the  heart,  and  the  true  apex  beat  cannot  be  felt;  but  the 
chief  impulse  is  just  below,  or  to  the  right  of,  the  xiphoid  cartilage,  and 
there  is  a  wavy  pulsation  in  the  fourth,  fifth,  and  sixth  interspaces  to  the 
left  of  the  sternum.  In  extreme  dilatation  of  the  right  auricle  a  pulsation 
may  sometimes  be  seen  in  the  third  right  interspace  close  to  the  sternum, 
and  with  free  tricuspid  regurgitation  this  may  be  systolic  in  character. 
The  pulsation  frequently  seen  in  the  second  left  interspace  is  never  due  to 
a  dilated  left  auricle  as  was  formerly  thought.  It  is  always  the  throbbing 
conus  arteriosus,  and  the  rhythm  can  be  determined  to  be  systolic  in  timet 
Post  mortem,  it  is  rare  in  the  most  extreme  distention  to  see  the  auricular 
appendix  so  far  forward  as  to  warrant  the  belief  that  it  could  beat  against 
the  second  interspace.  The  area  of  dulness  is  increased,  but  an  emphysema- 
tous lung  or  the  fully  distended  organ  in  a  state  of  brown  induration  may 
cover  over  the  heart  and  greatly  limit  the  extent.  The  directions  of  in- 
crease were  considered  in  connection  with  hypertrophy. 

The  first  sound  is  shorter,  sharper,  more  valvular  in  character,  and 
more  like  the  second.  As  the  dilatation  becomes  excessive  it  gets  weaker. 
Eeduplication  is  not  common,  but  occasionally  differences  may  be  heard 


HYPERTROPHY  AND   DILATATION.  745 

in  the  first  sound  over  the  right  and  left  hearts.  The  sounds  are  frequently 
obscured  by  murmurs,  which  are  produced  by  incompetency  of  the  valves 
due  to  the  great  dilatation,  or  are  associated  with  the  chronic  valve  dis- 
ease on  which  the  condition  depends.  The  aortic  second  sound  is  replaced 
by  a  murmur  in  aortic  regurgitation.  The  pulmonary  sound  is  accentuated 
in  mitral  regurgitation  and  pulmonary  congestion,  but  with  extreme  dilata- 
tion it  may  be  much  weakened.  The  heart's  action  is  irregular  and  inter- 
mittent, and  the  pulse  is  small,  weak,  and  quick. 

On  auscultation  both  the  sounds  may  be  free  from  murmur.  There 
is  the  condition  known  as  embryocardia  or  foetal  heart-rhythm,  in  which 
the  first  and  second  sounds  are  very  alike,  and  the  long  pause  is  shortened. 
In  other  instances  there  is  the  typical  and  characteristic  gallop  rhythm, 
rarely  found  apart  from  conditions  of  dilatation.  With  the  various  valvu- 
lar lesions  the  corresponding  murmurs  may  be  heard.  Murmurs,  however, 
which  have  been  present  may  disappear,  as  in  the  case  of  mitral  stenosis. 
In  other  instances  a  loud  systolic  murmur  may  be  heard  at  the  apex,  and 
when  the  case  first  comes  under  observation  it  may  be  impossible  to  say 
whether  this  is  due  to  organic  mitral  lesion.  The  murmur  may  be  con- 
fined to  the  apex  region,  or  propagated  well  to  the  back.  It  is  extremely 
common  in  the  dilatation  which  follows  the  hypertrophy  of  the  left  ventri- 
cle in  arterio-sclerosis.  Under  treatment,  with  the  gradual  disappearance 
of  the  dilatation,  a  murmur  of  this  kind,  even  though  most  intense,  may 
completely  disappear,  showing  that  it  has  been  due  to  a  relative  insuificiency, 
not  to  a  valvular  lesion.  All  varieties  of  arrhythmia  may  occur  in  dilata- 
tion of  the  heart.  The  pulse,  as  a  rule,  is  small,  weak,  quick,  and  often 
irregular. 

Dilation  and  Hypertrophy  due  to  Overexertion  and  Alcohol. — There 
is  a  group  of  cases  of  dilatation  and  hypertrophy  dependent  upon  pro- 
longed overexertion,  which  rarely  comes  under  observation  until  compen- 
sation has  failed,  and  which  then  may  be  very  difficult  to  distinguish  from 
the  similar  conditions  produced  by  valvular  disease.  The  patients  are 
able-bodied  men  at  the  middle  period  of  life,  and  complain  first  of  pal- 
pitation or  irregularity  of  the  action  of  the  heart  and  shortness  of  breath; 
subsequently  the  ^sual  symptoms  of  cardiac  insufficiency  develop.  On  in- 
quiring into  the  history  of  these  patients  none  of  the  usual  etiological 
factors  causing  valve-disease  are  present,  but  they  have  always  been  en- 
gaged in  laborious  occupations  and  have  usually  been  in  the  habit  of  taking 
stimulants  freely.  This  is  the  affection  which  has  been  specially  studied 
by  McLean,  Clifford  Allbutt,  Seitz,  and  others,  and  in  its  earlier  condition 
by  Da  Costa,  in  what  he  termed  the  irritable  heart.  It  is  met  with  very 
frequently  in  soldiers.  These  cases  may  return  to  hospital  three  or  four 
times  with  cardiac  insufficiency,  sometimes  with  slight  anasarca,  haemop- 
tysis, and  signs  of  pulmonary  engorgement.  The  condition  is  by  no  means 
infrequent.  Bollinger  has  called  attention  to  the  common  occurrence  of 
dilatation  and  hypertrophy  in  beer-drinkers,  particularly  in  the  workers 
in  the  German  breweries,  who  drink  20  or  more  litres  in  the  day.  Striim- 
pell,  at  his  Erlangen  clinic,  told  me  that  this  condition  was  very  common 
in  the  draymen  and  workers  in  the  breweries  of  that  town,  very  few  of 


746  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

whom  pass  the  forty-fifth  year  without  indications  of  liypertrophy  and 
dilatation  of  the  heart.  On  post-mortem  examination  the  valves  may  be 
quite  healthy,  the  aorta  smooth,  and  extensive  arterio-sclerosis  or  renal  dis- 
ease absent.  The  heart  weighs  from  18  to  25  ounces;  the  chambers  are 
dilated.  The  condition  has  been  met  with  also  in  animals,  and  Houghton 
states  that  the  heart  of  the  celebrated  greyhound  Master  McGratli  weighed 
9.57  ounces,  just  threefold  in  excess  of  the  normal  proportion  of  heart- 
weight  to  body-weight. 

Idiopathic  Dilatation. — And,  lastly,  there  are  other  cases  in  which  dila- 
tation of  the  heart  occurs  without  discoverable  cause.  In  some  instances 
there  has  been  a  history  of  sudden  exercise  or  of  mental  emotion,  but  in 
other  cases  the  condition  seems  to  have  come  on  spontaneously.  In  some 
it  is  acute  and  the  patient  has  dyspnoea,  slight  cyanosis,  cough,  and  great 
cardiac  distress.  Death  may  occur  in  a  few  days,  or  dropsy  may  supervene 
and  the  case  may  become  chronic.  Delafield  has  reported  an  interesting 
series  of  cases  of  this  group. 

Treatment. — The  treatment  of  hypertrophy  and  dilatation  has  al- 
ready been  considered  under  the  section  on  valvular  lesions.  I  would 
only  here  emphasize  the  fact  that  with  signs  of  dilatation,  as  indicated  by 
gallop  rhythm,  urgent  dyspnoea,  and  slight  lividity,  venesection  is  in  many 
cases  the  only  means  by  which  the  life  of  the  patient  may  be  saved,  and 
from  25  to  30  ounces  of  blood  should  be  abstracted  without  delay.  Subse- 
quently stimulants,  such  as  ammonia  and  digitalis,  may  be  administered, 
but  they  are  accessories  only  to'  the  bleeding  in  the  critical  condition  of 
acute  dilatation,  which  is  so  frequently  met  with  in  cardiac  lesions. 


IV.    AFFECTIONS    OF   THE    MYOCARDIUM. 

1.  Lesions  due  to  Disease  of  the  Coronary  Arteries. — A  knowledge  of  the 
changes  produced  in  the  myocardium  by  disease  of  the  coronary  vessels 
gives  a  key  to  the  understanding  of  many  problems  in  cardiac  pathology. 
The  terminal  branches  of  the  coronary  vessels  are  end-arteries;  that  is,  the 
communication  between  neighboring  branches  is  through  capillaries  only. 
F.  H.  Pratt  *  has  lately  shown  that  the  vessels  of  Thebesius,  which  open 
from  the  ventricles  and  auricles  into  a  system  of  fine  branches  and  thus 
communicate  with  the  cardiac  capillaries  and  coronary  veins,  may  be  ca- 
pable of  feeding  the  myocardium  sufficiently  to  keep  it  alive  even  when  the 
coronary  arteries  are  occluded.  The  blocking  of  one  of  these  vessels  by  a 
thrombus  or  an  embolus  leads  usually  to  a  condition  which  is  known  as — 

(a)  Ancemic  necrosis,  or  white  infarct.  When  this  does  not  occur  the 
reason  may  be  sought  in  (1)  the  existence  of  abnormal  anastomoses,  which 
by  their  presence  take  the  coronary  system  out  of  the  group  of  end-arteries; 
or  (2)  the  vicarious  flow  through  the  vessels  of  Thebesius  and  the  coronary 
veins.  The  condition  is  most  commonly  seen  in  the  left  ventricle  and  in  the 
septum,  in  the  territory  of  distribution  of  the  anterior  coronary  artery.    The 

*  The  American  Journal  of  Physiology,  vol,  i,  1898. 


AFFECTIONS  OF   THE  MYOCARDIUM.  747 

affected  area  has  a  yellowisli-white  color,  sometiraes  a  turbid,  parboiled 
asjaect,  at  other  times  a  grayish-red  tint.  It  may  be  somewhat  wedge-shaped, 
more  often  it  is  irregular  in  contour  and  projects  above  the  surface.  Micro- 
scopically the  changes  are  very  characteristic.  The  nuclei  either  disappear 
from  the  muscle  fibres  or  they  undergo  fragmentation.  Leucocytes  wander 
in  from  the  surrounding  tissue,  and  these  may  suffer  disintegration.  At  a 
later  stage  a  new  growth  of  fibrous  tissue  is  found  in  the  periphery  of  the  in- 
farct which  ultimately  may  entirely  replace  the  dead  fibres.  The  fibres  pre- 
sent a  homogeneous,  hyaline  appearance.  In  some  instances  there  is  com- 
plete transformation,  and  even  to  the  naked  eye  a  firm  white  patch  of  hyaline 
degeneration  may  appear  in  the  centre  of  the  area.  Sudden  death  not  in- 
frequently follows  the  blocking  of  one  of  the  branches  of  the  coronary  ar- 
tery and  the  production  of  this  anemic  necrosis.  In  medico-legal  cases  it 
is  a  ijoint  of  primary  importance  to  remember  that  this  is  one  of  the  common 
causes  of  sudden  death.  This  condition  should  be  carefully  sought  for,  in- 
asmuch as  it  may  be  the  sole  lesion,  except  a  general,  sometimes  slight 
arterio-sclerosis.  Eupture  of  the  heart  may  be  associated  with  anaemic 
necrosis. 

(&)  The  second  important  effect  of  coronary-artery  disease  upon  the 
myocardium  is  seen  in  the  production  of  fibrous  myocarditis.  This  may 
result  from  the  gradual  transformation  of  areas  of  anaemic  necrosis.  More 
commonly  it  is  caused  by  the  narrowing  of  a  coronary  branch  in  a  process 
of  obliterative  endarteritis.  Where  the  process  is  gradual  evidences  of  gran- 
ulation tissue  are  often  wanting,  and  any  distinction  between  the  necrotic 
muscle  fibres  and  the  new  scar  tissue  is  difficult  to  establish.  J.  B.  Mac- 
Callum  has  shown  that  the  muscle  fibres  undergo  a  change  the  reverse  of 
that  of  their  normal  development  and  lose  their  fibril  bundles  preliminary 
to  their  complete  replacement  by  connective  tissue.  The  sclerosis  is  most 
frequently  seen  at  the  apex  of  the  left  ventricle  and  in  the  septum,  but  it 
may  occur  in  any  portion.  In  the  septum  and  walls  there  are  often  streaks 
and  patches  which  are  only  seen  in  carefully  made  systematic  sections. 
Hypertrophy  of  the  heart  is  commonly  associated  with  this  degeneration. 
It  is  the  invariable  precursor  of  aneurism  of  the  heart. 

Complete  obliteration  of  one  coronary  artery,  if  produced  suddenly,  is 
usually  fatal.  When  induced  slowly,  either  by  arterio-sclerosis  at  the  ori- 
fice of  the  artery  at  the  root  of  the  aorta  or  by  an  obliterating  endarteritis 
in  the  course  of  the  vessel,  the  circulation  may  be  carried  on  through  the 
other  vessel.  Sudden  death  is  not  uncommon,  owing  to  thrombosis  of  a 
vessel  which  has  become  narrowed  by  sclerosis.  In  the  mtfst  extreme  grade 
one  coronary  artery  may  be  entirely  blocked,  with  the  production  of  ex- 
tensive fibroid  disease,  and  a  main  branch  of  the  other  also  may  be  occluded. 
A  large,  powerfully  built  imbecile,  aged  thirty-five,  at  the  Elwyn  Institu- 
tion, Pennsylvania,  who  had  for  years  enjoyed  doing  the  heavy  work  about 
the  place,  died  suddenly,  without  any  preliminary  symptoms.  The  heart, 
which  is  in  my  collection,  weighed  over  20  ounces;  the  anterior  coronary 
artery  was  practically  occluded  by  obliterating  endarteritis,  and  of  the 
posterior  artery  one  main  branch  was  blocked. 

(c)  Septic  Infarcts. — In  pyaemia  the  smaller  branches  of  the  coronary 


Y48  DISEASES  OF  THE  CmCULATORY  SYSTEM. 

arteries  may  be  blocked  with  emboli  which  give  rise  to  infectious  or  septic 
infarcts  in  the  myocardium  in  the  form  of  abscesses,  varying  in  size  from 
a  pea  to  a  pin's  head.  These  may  not  cause  any  disturbance,  but  when 
large  they  may  perforate  into  the  ventricle  or  into  the  pericardium,  form- 
ing what  has  been  called  acute  ulcer  of  the  heart. 

2.  Acute  Interstitial  Myocarditis.— In  some  infectious  diseases  and  in 
acute  pericarditis  the  intermuscular  connective  tissue  may  be  swollen  and 
infiltrated  with  small  round  cells  and  leucocytes,  the  blood-vessels  dilated, 
and  the  muscle  fibres  the  seat  of  granular,  fatty,  and  hyaline  degeneration. 
Occasionally,  in  pyaemia  the  infiltration  with  pus-cells  has  been  diffuse  and 
confined  chiefly  to  the  interstitial  tissue.  Councilman  has  described  this 
condition  of  the  heart  wall  in  gonorrhoea,  and  succeeded  in  demonstrating 
the  gonococcus  in  the  diseased  areas.  The  commonest  examples  are  found 
in  diphtheria,  typhoid  fever,  and  acute  endocarditis,  as  shown  by  the  studies 
of  Eomberg.  The  foci  may  be  the  starting-points  of  patches  of  fibrous 
myocarditis. 

3.  Fragmentation  and  Segmentation. — This  condition  was  described  by 
Eenaut  and  Landouzy  in  1877,  and  has  been  carefully  studied  by  different 
pathologists.*  Two  forms  are  met  with:  1.  Segmentation.  The  muscle 
fibres  have  separated  at  the  cement  line.  2.  Fragmentation.  The  fracture 
has  been  across  the  fibre  itself,  and  perhaps  at  the  level  of  the  nucleus. 
Longitudinal  division  is  unusual.  Although  the  condition  doubtless  arises 
in  some  instances  during  the  death  agony,  as  in  cases  of  sudden  death  by 
violence,  in  others  it  would  seem  to  have  clinical  and  pathological  signifi- 
cance. It  is  found  associated  with  other  lesions,  fibrous  myocarditis,  infarc- 
tion, and  fatty  degeneration.  J.  B.  MacCallum  distinguishes  a  simple  from 
a  degenerative  fragmentation.  The  first  takes  place  in  the  normal  fibre, 
which,  however,  shows  irregular  extensions  and  contractions.  The  second 
succeeds  degeneration  in  the  fibre.  Hearts  the  seat  of  marked  fragmenta- 
tion are  lax,  easily  torn,  the  muscle  fibres  widely  separated,  and  often  pale 
and  cloudy. 

4.  Parenchymatous  Degeneration. — This  is  usually  met  with  in  fevers, 
or  in  connection  with  endocarditis  or  pericarditis,  and  in  infections  and  in- 
toxications generally.  It  is  characterized  by  a  pale,  turbid  state  of  the  car- 
diac muscle,  which  is  general,  not  localized.  Turbidity  and  softness  are  the 
special  features.  It  is  the  softened  heart  of  Laennec  and  Louis.  Stokes 
speaks  of  an  instance  in  which  "  so  great  was  the  softening  of  the  organ 
that  when  the  heart  was  grasped  by  the  great  vessels  and  held  with  the  apex 
pointing  upward,  it  fell  down  over  the  hand,  covering  it  like  a  cap  of  a 
large  mushroom." 

Histologically,  there  is  a  degeneration  of  the  muscle  fibres,  which  are 
infiltrated  to  a  various  extent  with  granules  which  resist  the  action  of  ether, 
but  are  dissolved  in  acetic  acid.  Sometimes  this  granular  change  in  the 
fibres  is  extreme,  and  no  trace  of  the  striae  can  be  detected.  It  is  probably 
the  effect  of  a  toxic  agent,  and  is  seen  in  its  most  exquisite  form  in  the 
lumbar  muscles  in  cases  of  toxic  h^emoglobinuria  in  the  horse.     It  is  met 

*  Hektoen,  American  .Tournal  of  the  Medical  Sciences.  1897, 


AFFECTIONS  OF  THE  MYOCARDIUM.  749 

with  in  cases  of  typhoid,  typhus,  small-pox,  and  other  infections  diseases, 
particularly  when  the  course  is  protracted.  There  is  no  definite  relation 
between  it  and  the  high  temperature. 

5.  Fatty  Heart. — Under  this  term  are  embraced  fatty  degeneration  and 
fatty  overgrowth. 

(a)  Fatty  degeneration  is  a  very  common  condition,  and  mild  grades  are 
met  with  in  many  diseases.  It  is  found  in  the  failing  nutrition  of  old  age, 
of  wasting  diseases,  and  of  cachectic  states;  in  prolonged  infectious  fevers, 
in  which  it  may  follow  or  accompany  the  parenchymatous  change;  associ- 
ated with  acute  and  chronic  anaemias.  Certain  poisons,  such  as  phos|)horus, 
produce  an  intense  fatty  degeneration.  Local  causes:  Pericarditis  is  usu- 
ally associated  with  fatty  or  parenchymatous  changes  in  the  superficial 
layers  of  the  myocardium.  Disease  of  the  coronary  arteries  is  a  much 
more  common  cause  of  fibroid  degeneration  than  of  fatty  heart.  Lastly,  in 
the  hypertrophied  ventricular  wall  in  chronic  heart-disease  fatty  change  is 
by  no  means  infrequent.  This  degeneration  may  be  limited  to  the  heart  or 
it  may  be  more  or  less  general  in  the  solid  viscera.  The  diaphragm  may 
also  be  involved,  even  when  the  other  muscles  show  no  special  changes. 
There  appears  to  be  a  special  proneness  to  fatty  degeneration  in  the  heart- 
muscle,  which  may  perhaps  be  connected  with  its  incessant  activity.  So 
great  is  its  need  of  an  abundant  oxygen  supply  that  it  feels  at  once  any  de- 
ficiency, and  is  in  consequence  the  first  muscle  to  show  nutritional  changes. 

Anatomically  the  condition  may  be  local  or  general.  The  left  ventricle 
is  most  frequently  afEected.  If  the  process  is  advanced  and  general,  the 
heart  looks  large  and  is  flabby  and  relaxed.  It  has  a  light  yellowish-brown 
tint,  or,  as  it  is  called,  a  faded-leaf  color.  Its  consistence  is  reduced  and 
the  substance  tears  easily.  In  the  left  ventricle  the  papillary  columns  and 
the  muscle  beneath  the  endocardium  show  a  streaked  or  patchy  appearance. 
Microscopically,  the  fibres  are  seen  to  be  occupied  by  minute  globules  dis- 
tributed in  rows  along  the  line  of  the  primitive  fibres  (Welch).  In  ad- 
vanced grades  the  fibres  seem  completely  occupied  by  the  minute  globules. 

(&)  Fatty  Overgrowth. — This  is  usually  a  simple  excess  of  the  normal 
subpericardial  fat,  to  which  the  term  cor  adiposum  was  given  by  the  older 
writers.  In  pronounced  instances  the  fat  infiltrates  between  the  muscular 
substance  and,  separating  the  strands,  may  reach  even  to  the  endocardium. 
In  corpulent  persons  there  is  always  much  pericardial  fat.  It  forms  part 
of  the  general  obesity,  and  occasionally  leads  to  dangerous  or  even  fatal 
impairment  of  the  contractile  power  of  the  heart.  Of  122  cases  analyzed 
by  Forchheimer  there  were  88  males  and  34  females.  Over  80  per  cent 
occurred  between  the  fortieth  and  seventieth  years. 

The  entire  heart  may  be  enveloped  in  a  thick  sheeting  of  fat  through 
which  not  a  trace  of  muscle  substance  can  be  seen.  On  section,  the  fat 
infiltrates  the  muscle,  separating  the  fibres,  and  in  extreme  cases — particu- 
larly in  the  right  ventricle — reaches  the  endocardium.  In  some  places  there 
may  be  even  complete  substitution  of  fat  for  the  muscle  substance.  In 
rare  instances  the  fat  may  be  in  the  papillary  muscles.  The  heart  is  usually 
much  relaxed  and  the  chambers  are  dilated.  Microscopically  the  muscle 
fibres  may  show,  in  addition  to  the  atrophy,  marked  fatty  degeneration. 


Y50  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

6.  Other  Degenerations  of  the  Myocardium,  (a)  Brown  Atrophy. — 
This  is  a  common  change  in  the  heart-muscle,  particularly  in  chronic  val- 
vular lesions  and  in  the  senile  heart.  When  advanced,  the  color  of  the 
muscles  is  a  dark  red-brown,  and  the  consistence  is  usually  increased.  The 
fibres  present  an  accumulation  of  yellow-brown  pigment  chiefly  about  the 
nuclei.  The  cement  substance  is  often  unusually  distinct,  but  seems  more 
fragile  than  in  healthy  muscle. 

(&)  Amyloid  degeneration  of  the  heart  is  occasionally  seen.  It  occurs 
in  the  intermuscular  connective  tissue  and  in  the  blood-vessels,  not  in  the 
fibres. 

(c)  The  hyaline  transformation  of  Zenker  is  sometimes  met  with  in  pro- 
longed fevers.  The  affected  fibres  are  swollen,  homogeneous,  translucent, 
and  the  striae  are  very  faint  or  entirely  absent. 

{d)  Calcareous  degeneration  may  occur  in  the  myocardium,  and  the 
muscle  fibres  may  be  infiltrated  and  yet  retain  their  appearance  as  figured 
and  described  by  Coats  in  his  Text-book  of  Pathology. 

Symptoms  of  Myocardial  Disease. — These  are  notoriously  un- 
certain. A  man  with  advanced  fibroid  myocarditis  may  drop  dead  sud- 
denly, while  doing  heavy  work,  without  having  complained  of  cardiac  dis- 
tress. On  the  other  hand,  a  patient  may  present  enfeebled,  irregular  action 
and  signs  of  dilatation;  he  may  have  shortness  of  breath,  cedema,  and  the 
general  symptoms  believed  to  be  characteristic  of  cases  of  fibroid  and  fatty 
heart,  and  the  post  mortem  show  little  or  no  change  in  the  myocardium. 

Cardio-sclerosis  or  fibroid  heart  is  in  some  cases  characterized  by  a 
feeble,  irregular,  slow  pulse,  with  dyspnoea  on  exertion  and  occasional  at- 
tacks of  angina.  Irregularity  is  present  in  many,  but  not  in  all  cases. 
The  pulse  may  be  very  slow,  even  30  or  40  per  minute.  .  Ultimately  the 
cases  come  under  observation  with  the  symptoms  of  cardiac  insufficiency. 
The  arrhythmia,  which  may  have  been  present,  becomes  aggravated  and, 
according  to  Eiegel,  may  not  only  precede,  but  also  persist  after  the  car- 
diac insufficiency  has  passed  away. 

Fatty  degeneration  of  the"  heart  presents  the  same  difiiculties.  Extreme 
fatty  changes,  as  in  pernicious  anaemia,  may  be  consistent  with  a  full,  regular 
pulse  and  a  regularly  acting  heart.  In  some  of  these  cases  the  fat  does  not 
appear  to  interfere  seriously  with  the  function  of  the  organ.  The  truth 
is,  it  may  exist  in  an  extreme  grade  without  producing  symptoms,  so  long  as 
great  dilatation  of  the  chambers  does  not  occur.  The  cardiac  irregularity, 
the  dyspnoea,  palpitation,  and  small  pulse  are  in  reality  not  symptoms  of 
the  fatty  degeneration,  but  of  dilatation  which  has  supervened.  The  fatty 
arcus  senilis  is  of  no  moment  in  the  diagnosis  of  fatty  heart.  The  heart- 
sounds  may  be  weak  and  the  action  irregular.  When  dilatation  occurs, 
there  is  often  the  gallop  rhythm,  shortening  of  the  long  pause,  and  a  sys- 
tolic murmur  at  the  apex.  Shortness  of  breath  on  exertion  is  an  early 
feature  in  many  cases,  and  anginal  attacks  may  occur.  There  is  some- 
times a  tendency  to  syncope,  and  in  both  fibroid  and  fatty  heart  there  are 
attacks  in  which  the  patient  feels  cold  and  depressed  and  the  pulse  sinks 
to  40  or  30,  or  even,  as  in  one  case  which  I  saw,  to  26.  The  patient  may 
wake  from  sleep  in  the  early  morning  with  an  attack  of  severe  cardiac 


AFFECTIONS  OF  THE  MYOCARDIUM.  ■  'J'SI 

asthma.  These  "  spells "  may  be  associated  with  nausea  and  may  alter- 
nate with  others  in  which  there  are  anginal  symptoms.  These  are  the 
cases,  too,  in  which  for  weeks  there  may  be  mental  symptoms.  The  pa- 
tient has  delusions  and  may  even  become  maniacal.  Toward  the  close, 
the  type  of  breathing  known  as  Cheyne-Stokes  may  occur.  It  was  described 
in  the  following  terms  by  John  Cheyne,  speaking  of  a  case  of  fatty  heart 
(Dublin  Hospital  Eeports,  vol.  ii,  p.  221,  1818):  "For  several  days  his 
breathing  was  irregular;  it  would  entirely  cease  for  a  quarter  of  a  minute, 
then  it  would  become  perceptible,  though  very  low,  then  by  degrees  it  be- 
came heaving  and  quick,  and  then  it  would  gradually  cease  again:  this 
revolution  in  the  state  of  his  breathing  lasted  about  a  minute,  during  which 
there  were  about  thirty  acts  of  respiration."  It  is  seen  much  more  fre- 
quently in  arterio-sclerosis  and  ursemic  states  than  in  fatty  heart. 

Fatty  overgrowth  of  the  heart  is  a  condition  certain  to  exist  in  very 
obese  persons.  It  produces  no  symptoms  until  the  muscular  fibre  is  so 
weakened  that  dilartation  occurs.  These  patients  may  for  years  present  a 
feeble  but  regular  pulse;  the  heart-sounds  are  weak  and  muffled,  and  a 
murmur  may  be  heard  at  the  apex.  Attacks  of  cardiac  asthma  are  not 
uncommon,  and  the  patient  may  suffer  from  bronchitis.  Dizziness  and 
pseudo-apoplectic  seizures  may  occur.  Sudden  death  may  result  from  syn- 
cope or  from  rupture  of  the  heart.  The  physical  examination  is  often  diffi- 
cult because  of  the  great  increase  in  the  fat,  and  it  may  be  impossible  to 
define  the  area  of  dulness. 

For  clinical  purposes  we  may  group  the  cases  of  myocardial  disease  as 
follows: 

(1)  Those  in  which  sudden  death  occurs  with  or  without  previous  indi- 
cations of  heart-trouble.  Sclerosis  of  the  coronary  arteries  exists — in  some 
instances  with  recent  thrombus  and  white  infarcts;  in  others,  extensive 
fibroid  disease;  in  others  again,  fatty  degeneration.  Many  patients  never 
complain  of  cardiac  distress,  but,  as  in  the  case  of  Chalmers,  the  celebrated 
Scottish  divine,  enjoy  unusual  vigor  of  mind  and  body. 

(2)  Cases  in  which  there  are  cardiac  arrhythmia,  shortness  of  breath  on 
exertion,  attacks  of  cardiac  asthma,  sometimes  anginal  attacks,  collapse 
symptoms  with  sweats  and  extremely  slow  pulse,  and  occasionally  marked 
m.ental  symptoms. 

(3)  Cases  with  general  arterio-sclerosis  and  hypertrophy  and  dilatation 
of  the  heart.  They  are  robust  men  of  middle  age  who  have  worked  hard 
and  lived  carelessly.  Dyspnoea,  cough,  and  swelling  of  the  feet  are  the  early 
symptoms,  and  the  patient  comes  under  observation  either  with  a  gallop 
rhythm,  embryocardiac,  or  an  irregular  heart  with  an  apex  systolic  murmur 
of  mitral  insufficiency.  Recovery  from  the  first  or  second  attack  is  the  rule. 
It  is  one  of  the  most  common  forms  of  heart-disease. 

Prognosis. — The  outlook  in  affections  of  the  myocardium  is  extreme- 
ly grave.  Patients  recover,  however,  in  a  surprising  way  from  the  most 
serious  attacks,  particularly  those  of  the  third  group. 

Treatment. — Many  cases  never  come  under  treatment;  the  first  are 
the  final  symptoms. 

Cases  with  signs  of  well-markod  cardiac  insufficiency,  as  manifested  by 
dyspnoea,  weak,  irregular,  rapid  lieart,  anrl  nnrloma,  may  be  treated  on  the 
47 


752  DISEASES  OF  THE  CIECULATORY  SYSTEM. 

plan  laid  down  for  the  treatment  of  broken  compensation  in  valvular  dis- 
ease. Digitalis  may  be  given  even  if  fatty  degeneration  is  suspected,  and 
is  often  very  beneficial. 

Much  more  difficult  is  the  management  of  those  cases  in  which  there 
is  marked  cardiac  arrhythmia,  with  a  feeble,  irregular,  very  slow  pulse,  and 
syncope  or  angina.  Dropsy  is  not,  as  a  rule,  present;  the  heart-sounds  may 
be  perfectly  clear,  and  there  are  no  signs  of  dilatation.  Digitalis,  under 
these  circumstances,  is  not  advisable,  particularly  when  the  pulse  is  infre- 
quent. Complete  rest  in  bed,  a  carefully  regulated  diet,  and  the  use  of  the 
aromatic  spirits  of  ammonia,  sulphuric  ether,  and  stimulants  are  indicated. 
For  the  restlessness  and  distressing  feelings  of  anxiety  morphia  is  invalu- 
able. From  an  eightieth  to  a  sixtieth  of  a  grain  of  strychnia  may  be  given 
three  times  a  day.  If,  as  is  sometimes  the  case,  the  pulse  is  hard  and  firm, 
nitroglycerin  may  be  cautiously  administered,  beginning  with  1  minim  of 
the  1-per-cent  solution  three  times  a  day  and  increased  gradually. 

In  certain  cases  of  weak  heart,  particularly  when  it  is  due  to  fatty  over- 
growth, the  plans  recommended  by  Oertel  and  by  Sehott  are  advantageous. 
They  are  invaluable  methods  in  those  forms  of  heart-weakness  due  to  in- 
temperance in  eating  and  drinking  and  defective  bodily  exercise.  The 
Oertel  plan  consists  of  three  parts:  First,  the  reduction  in  the  amount  of 
liquid.  This  is  an  important  factor  in  reducing  the  fat  in  these  patients. 
It  also  slightly  increases  the  density  of  the  blood.  Oertel  allows  daily  about 
36  ounces  of  liquid,  which  includes  the  amount  taken  with  the  solid  food. 
Free  perspiration  is  promoted  by  bathing  (if  advisable,  the  Turkish  bath), 
or  even  by  the  use  of  pilocarpine. 

The  second  important  point  in  his  treatment  is  the  diet,  which  should 
consist  largely  of  proteids. 

Morning. — Cup  of  coffee  or  tea,  with  a  little  milk,  about  6  ounces  alto- 
gether.    Bread,  3  ounces. 

Noo7i. — Three  to  4  ounces  of  soup,  7  to  8  ounces  of  roast  beef,  veal, 
game,  or  poultry,  salad  or  a  light  vegetable,  a  little  fish;  1  ounce  of  bread 
or  farinaceous  pudding;  3  to  6  ounces  of  fruit  for  dessert.  ISTo  liquids  at 
this  meal,  as  a  rule,  but  in  hot  weather  6  ounces  of  light  wine  may  be  taken. 

Afternoon. — Six  ounces  of  coffee  or  tea,  with  as  much  water.  As  an 
indulgence  an  ounce  of  bread. 

Evening. — One  or  2  soft-boiled  eggs,  an  ounce  of  bread,  perhaps  a  small 
slice  of  cheese,  salad,  and  fruit;  6  to  8  ounces  of  wine  with  4  or  5  ounces  of 
water  (Yeo). 

The  most  important  element  of  all  is  graduated  exercise,  not  on  the 
level,  but  up  hills  of  various  grades.  The  distance  walked  each  day  is 
marked  off  and  is  gradually  lengthened.  In  this  way  the  heart  is  systemat- 
ically exercised  and  strengthened. 

The  ScJiott  Treatment. — This  consists  in  a  combination  of  baths  with 
exercises  at  Nauheim.  The  water  has  a  temperature  of  from  82°-95°  F., 
and  is  very  richly  charged  with  COo.  The  good  effects  of  the  bath  are 
claimed  by  Sehott  to  come  from  a  cutaneous  excitation,  induced  by  the 
mineral  and  gaseous  constituents  of  the  bath,  and  a  stimulation  of  the 
sensory  nerves.    There  is  no  question  that  the  bath,  in  suitable  cases,  will 


AFFECTIONS  OF  THE  MYOCARDIUM.  ^753 

alter  the  i30sition  of  the  apex  beat,  and  that  it  lessens  the  area  of  cardiac 
dulness;  this  means  that  it  diminishes  the  dilatation  of  the  heart.  Artificial 
baths  are  used,  consisting  of  forty  gallons  of  water,  with  various  strengths 
of  sodium  chloride  and  calcium  chloride.  The  exercises,  resistance  gym- 
nastics, consist  in  slow  movements  executed  by  the  patient  and  resisted 
by  the  operator.  Any  one  wishing  to  carry  out  in  private  the  Schott  treat- 
ment should  consult  the  work  of  Besley  Thorne.  Camac's  articles  (J.  H. 
H.  Bulletin,  vol.  viii,  and  Jour,  of  the  Am.  Med.  Assoc,  1897,  ii)  give  a 
brief  account  of  our  experience  with  it. 

Aneurism  of  the  Heart. 

(a)  Aneurism  of  a  valve  results  from  acute  endocarditis,  which  pro- 
duces softening  or  erosion  and  may  lead  either  to  perforation  of  the  seg- 
ment or  to  gradual  dilatation  of  a  limited  area  under  the  influence  of  the 
blood-pressure.  The  aneurisms  are  usually  spheroidal  and  project  from 
the  ventricular  face  of  a  sigmoid  valve.  They  are  much  less  common  on 
the  mitral  segments.  They  frequently  rupture  and  produce  extensive  de- 
struction and  incompetency  of  the  valves. 

(&)  Aneurism  of  the  walls  results  from  the  weakening  induced  by 
chronic  myocarditis,  or  occasionally  it  follows  acute  mural  endocarditis, 
which  more  commonly,  however,  leads  to  perforation.  It  has  followed  a 
stab-wound,  a  gumma  of  the  ventricle,  and,  according  to  some  authors,  peri- 
cardial adhesions.  The  left  ventricle  near  the  apex  is  usually  the  seat,  this 
being  the  situation  in  which  fibrous  degeneration  is  most  common.  Fifty- 
nine  of  the  60  cases  collected  by  Legg  were  situated  here.  In  the 
early  stages  the  anterior  wall  of  the  ventricle,  near  the  septum,  sometimes 
even  the  septum  itself,  is  slightly  dilated,  the  endocardium  opaque,  and 
the  muscular  tissue  sclerotic.  In  a  more  advanced  stage  the  dilatation  is 
pronounced  and  layers  of  thrombi  occupy  the  sac.  Ultimately  a  large 
rounded  tumor  may  project  from  the  ventricle  and  may  attain  a  size  equal 
to  that  of  the  heart.  Occasionally  the  aneurism  is  sacculated  and  com- 
municates with  the  ventricle  through  a  very  small  orifice.  The  sac  may  be 
double,  as  in  the  cases  of  Janeway  and  Sailer.  In  the  museum  of  Guy's 
Hospital  there  is  a  specimen  showing  the  wall  of  the  ventricle  covered  with 
aneurismal  bulgings.     Eupture  occurred  in  7  of  the  90  cases  collected  by 

The  symptoms  produced  by  aneurism  of  the  heart  are  indefinite.  Occa- 
sionally there  is  marked  bulging  in  the  apex  region  and  the  tumor  may  per- 
forate the  chest  wall.  In  mitral  stenosis  the  right  ventricle  may  bulge  and 
produce  a  visible  pulsating  tumor  below  the  left  costal  border,  which  I  have 
known  to  be  mistaken  for  cardiac  aneurism.  When  the  sac  is  large  and 
produces  pressure  upon  the  heart  itself,  there  may  be  a  marked  disproportion 
between  the  strong  cardiac  impulse  and  the  feeble  pulsation  in  the  periph- 
eral arteries. 

EUPTUEE    OF    THE    HeART. 

This  rare  event  is  usually  associated  with  fatty  infiltration  or  degenera- 
tion of  the  heart-muscles.     In  some  instances,  acute  softening  in  conse- 


754  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

quenee  of  embolism  of  a  branch  of  the  coronary  artery,  suppurative  myo- 
carditis, or  a  gummatous  growth  has  been  the  cause.  Of  100  cases  col- 
lected by  Quain,  fatty  degeneration  was  noted  in  77.  Two  thirds  of  the 
patients  were  over  sixty  years  of  age. 

The  rent  may  occur  in  any  of  the  chambers,  but  is  found  most  fre- 
quently in  the  left  ventricle  on  the  anterior  wall,  not  far  from  the  septum. 
The  accident  usually  takes  place  during  exertion.  There  may  be  no  pre- 
liminary symptoms,  but  without  any  warning  the  patient  may  fall  and  die 
in  a  few  moments.  Sudden  death  occurred  in  71  per  cent  of  Quain's  cases. 
In  other  instances  there  may  be  in  the  cardiac  region  a  sense  of  anguish  and 
suffocation,  and  life  may  be  prolonged  for  several  hours.  In  a  Montreal 
case,  which  I  examined,  the  patient  walked  up  a  steep  hill  after  the  onset  of 
the  symptoms,  and  lived  for  thirteen  hours.  A  case  is  on  record  in  which 
the  patient  lived  for  eleven  days. 

New  Geovs^ths  and  Paeasites. 

Tubercle  and  syphilis  have  already  been  considered.  Primary  cancer 
or  sarcoma  is  extremely  rare.  Secondary  tumors  may  be  single  or  mul- 
tiple, and  are  usually  unattended  with  symptoms,  even  when  the  disease 
is  most  extensive.  In  one  case  I  found  in  the  wall  of  the  right  ventricle 
a  mass  which  involved  the  anterior  segment  of  the  tricuspid  valve  and 
partly  blocked  the  orifice.  The  surface  was  eroded  and  there  were  numer- 
ous cancerous  emboli  in  the  pulmonary  artery.  In  another  instance  the 
heart  was  greatly  enlarged,  owing  to  the  presence  of  innumerable  masses  of 
colloid  cancer  the  size  of  cherries.  The  mediastinal  sarcoma  may  penetrate 
the  heart,  though  it  is  remarkable  how  extensive  the  disease  of  the  medias- 
tinal glands  may  be  without  involvement  of  the  heart  or  vessels. 

Cysts  in  the  heart  are  rare.  They  are  found  in  different  parts,  and 
are  filled  either  with  a  brownish  or  a  clear  fluid.  Blood-cysts  occasionally 
occur. 

The  parasites  have  been  discussed  under  the  appropriate  section,  but  it 
may  be  mentioned  here  that  both  the  cysticerus  cellulosce  and  the  echino- 
coccus  cysts  occur  occasionally  in  the  heart. 

Wounds  and  Foreign  Bodies. 

Wounds  of  the^heart  may  be  caused  by  external  injuries,  as  stabs  and 
bullet  wounds,  by  foreign  bodies  passing  from  the  gullet  or  oesophagus,  or 
by  puncture  for  therapeutic  purposes. 

(1)  Bullet  wounds  of  the  heart  are  common.  Eecovery  may  take  place, 
and  bullets  have  been  found  encysted  in  the  organ.  Stab  wounds  are  still 
more  common.  A  medical  student,  while  on  a  spree,  passed  a  pin  into 
his  heart.  The  pericardium  was  opened,  and  the  head  of  the  pin  was  found 
outside  of  the  right  ventricle.  It  was  grasped  and  an  attempt  made  to 
remove  it,  but  it  was  withdrawn  into  the  heart  and,  it  is  said,  caused  the 
patient  no  further  trouble  (Moxon).  In  recent  stab  wounds  it  is  a  good 
practice  to  expose  the  heart  and  attempt  to  suture  the  wound.  Sherman 


NEUROSES  OF  THE   HEART.  Y55 

has  collected  34  operations  performed  in  the  last  six  years,  including  1901, 
of  which  13  recovered.  In  a  case  of  stab  wound  Pagenstecher  tied  the  left 
coronary  artery,  which  had  been  divided. 

(2)  Hysterical  girls  sometimes  swallow  pins  and  needles,  which,  passing 
through  the  oesophagus  and  stomach,  are  found  in  various  parts  of  the 
body.  A  remarkable  case  is  reported  by  Allen  J.  Smith  of  a  girl  from 
whom  several  dozen  needles  and  pins  were  removed,  chiefly  from  subcu- 
taneous abscesses.  Several  years  later  she  developed  symptoms  of  chronic 
heart-disease.  At  the  post  mortem  needles  were  found  in  the  tissues  of 
the  adherent  pericardium,  and  between  thirty  and  forty  were  embedded  in 
the  thickened  pleural  membranes  of  the  "left  side. 

(3)  Puncture  of  the  heart  (cardiocentesis)  has  been  recommended  as  a 
therapeutic  procedure,  as  in  chloroform  narcosis,  and  experimental  evi- 
dence has  been  brought  forv^ard  by  B.  A.  Watson  in  favor  of  the  operation. 
He  advises  abstraction  of  blood  in  combination  with  the  puncture — car- 
diocentesis. The  proceeding  is  not  without  risk.  Hgemorrhage  may  take 
place  from  the  puncture,  though  it  is  not  often  extensive.  Sloane  has  re- 
cently urged  its  use  in  all  cases  of  asphyxia  and  in  suffocation  by  drowning 
and  from  coal-gas.  The  successful  case  which  he  reports  illustrates  forcibly 
its  stimulating  action. 


V.    NEUROSES    OF   THE    HEART. 

Palpitation. 

In  health  we  are  unconscious  of  the  action  of  the  heart.  In  some  people 
one  of  the  first  indications  of  debility  or  overwork  is  the  consciousness  of 
the  cardiac  pulsations,  which  may,  however,  be  perfectly  regular  and  or- 
derly. This  is  not  palpitation.  The  term  is  properly  limited  to  irregular 
or  forcible  action  of  the  heart  perceptible  to  the  individual. 

Etiology. — The  expression  "  perceptible  to  the  individual "  covers 
the  essential  element  in  palpitation  of  the  heart.  The  most  extreme  dis- 
turbance of  rhythm,  a  condition  even  of  what  is  termed  delirium  cordis, 
may  be  unattended  with  subjective  sensations  of  distress,  and  there  may 
be  no  consciousness  of  disturbed  action.  On  the  other  hand,  there  are 
cases  in  which  complaint  is  made  of  the  most  distressing  palpitation  and 
sensations  of  throbbing,  in  which  the  physical  examination  reveals  a  regu- 
larly acting  heart,  the  sensations  being  entirely  subjective.  We  meet  with 
this  symptom  in  a  large  group  of  cases  in  which  there  is  increased  excita- 
bility of  the  nervous  system.  Palpitation  may  be  a  marked  feature  at  the 
time  of  puberty,  at  the  climacteric,  and  occasionally  during  menstruation. 
It  is  a  very  common  symptom  in  hysteria  and  neurasthenia,  particularly  in 
the  form  of  the  latter  which  is  associated 'with  dyspepsia.  Emotions,  such 
as  fright,  are  common  causes  of  palpitation.  It  may  occur  as  a  sequence  of 
the  acute  fevers.     Females  are  more  liable  to  the  affection  than  males. 

In  a  second  group  the  palpitation  results  from  the  action  upon  the 
heart  of  certain  substances,  such  as  tobacco,  coffee,  tea,  and  alcohol.  And, 
lastly,  palpitation  may  be  associated  with  organic  disease  of  the  heart, 
either  of  the  myocardium  or  of  the  valves.     As  a  rule,  however,  .it  is  a 


756  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

purely  nervous  phenomenon — seldom  associated  with,  organic  disease — ^in 
which  the  most  violent  action  and  the  most  extreme  irregularity  may  exist 
without  that  subjective  element  of  consciousness  of  the  disturbance  which 
constitutes  the  essential  feature  of  palpitation. 

The  irritable  heart  described  by  Da  Costa,  which  was  so  common  among 
the  young  soldiers  during  the  civil  war,  is  a  neurosis  of  this  kind.  The 
chief  symptoms  were  palpitation  with  great  frequency  of  the  pulse  on  ex- 
ertion, a  variable  amount  of  cardiac  pain,  and  dyspnoea.  The  factors  at 
work  in  producing  this  condition  appeared  to  be  the  mental  excitement, 
the  unwonted  muscular  exertion  associated  with  the  drill,  and  diarrhoea. 
The  condition  is  not  infrequent  in  civil  life  among  young  men,  and  it  leads 
in  some  cases  to  hypertrophy  of  the  heart. 

Symptoms. — In  the  mildest  form,  such  as  occurs  during  a  dyspeptic 
attack,  there  is  slight  fluttering  of  the  heart  and  a  sense  of  what  patients 
sometimes  call  "  goneness."  In  more  severe  attacks  the  heart  beats  vio- 
lently, its  pulsations  against  the  chest  wall  are  visible,  the  rapidity  of  the 
action  is  much  increased,  the  arteries  throb  forcibly,  and  there  is  a  sense 
of  great  distress.  In  some  instances  the  heart's  action  is  not  at  all  quick- 
ened. The  most  striking  cases  are  in  neurasthenic  women,  in  whom  the 
mere  entrance  of  a  person  into  the  room  may  cause  the  most  violent  action 
of  the  heart  and  throbbing  of  the  peripheral  arteries.  The  pulse  may  be 
rapidly  increased  until  it  reaches  150  or  160.  A  diffuse  flushing  of  the 
skin  may  appear  at  the  same  time.  After  such  attacks,  there  may  be  the 
passage  of  a  large  quantity  of  pale  urine.  In  many  cases  of  palpitation, 
particularly  in  young  men,  the  condition  is  at  once  relieved  by  exertion. 
A  patient  with  extreme  irregularity  of  the  heart  may,  after  walking  quickly 
100  yards  or  running  upstairs,  return  with  the  pulse  perfectly  regular. 
This  is  not  infrequently  seen,  too,  in  the  irregular  action  of  the  heart  in 
mitral  valve  disease. 

The  physical  examination  of  the  heart  is  usually  negative.  The  sounds, 
the  shock  of  which  may  be  very  palpable,  are  on  auscultation  clear,  ringing, 
and  metallic,  but  not  associated  with  murmurs.  The  jgecond  sound  at  the 
base  may  be  greatly  accentuated.  A  murmur  may  sometimes  be  heard 
over  the  pulmonary  artery  or  even  at  the  apex  in  cases  of  rapid  action  in 
neurasthenia  or  in  severe  ansemia.  The  attacks  may  be  transient,  lasting 
only  for  a  few  minutes,  or  may  persist  for  an  hour  or  more.  In  some  in- 
stances any  attempt  at  exertion  renews  the  attack. 

The  prognosis  is  usually  good,  though  it  may  be  extremely  difficult  to 
remove  the  conditions  underlying  the  palpitation. 

Aeehythmia. 

An  intermission  occurs  when  one  or  more  beats  of  the  heart  are  dropped. 

Irregularity  is  the  condition  when  the  beats  are  unequal  in  volume  and 

force,  or  follow  each  other  at  unequal  distances.    Allorrhythmia  is  a  term 

which  is  also  used  to  express  deviations  from  the  normal  heart  rhythm. 

The  following  varieties  of  arrhythmical  action  may  be  recognized: 

(1)  The  paradoxical  pulse  of  Kussmaul,  in  which  the  beats  during  in- 


NEUROSES  OF  THE  HEART.  757 

spiration  are  more  frequent  but  less  full  than  during  expiration.  This  is 
found  in  weak  heart,  in  chronic  pericarditis,  and  when  fibrous  bands  en- 
circle the  root  of  the  aorta;  but  it  may  also  occur  normally  from  the  influ- 
ence of  the  respirations  upon  the  heart.  It  is  sometimes  to  be  felt  in  sleeping 
children. 

(3)  Intermittence,  in  which  there  is  simply  an  intermission  or  dropping 
of  a  cardiac  beat.  The  term  deficience  is  more  correctly  applied  to  those 
instances  in  which  the  absence  of  the  heart-sound  proves  that  the  systole 
is  really  omitted.  The  systole  may  be  so  weak  as  not  to  produce  a  pulsa- 
tion, and  yet  at  the  same  time  a  feeble  first  sound  may  be  heard. 

(3)  The  alternate  heart-beat,  in  which  strong  and  weak  contractions 
alternate  regularly  and  which  is  expressed  in  the  peripheral  arteries  by 
alternate  full  and  feeble  pulse-beats. 

(4)  The  bigeminal  and  trigeminal  pulsations  occur  when  two  or  three 
beats  follow  each  other  in  rapid  succession,  each  group  being  separated 
from  the  following  by  a  longer  interval.  This  is  not  very  uncommon  in 
mitral  disease  and  as  an  effect  of  digitalis.  In  the  bigeminal  pulse  the 
first  beat  of  the  pair  is  usually  the  stronger.  Indeed,  in  the  condition 
known  as  heart  bigeminism  the  second  systole  is  so  feeble  that  the  pulse 
wave  does  not  reach  the  peripheral  arteries  and  the  two  systoles  are  repre- 
sented by  only  a  single  pulse-beat  at  the  wrist. 

(5)  Delirium  cordis,  in  which  these  various  factors  are  combined  and 
the  heart's  action  is  wholly  irregular. 

(6)  Fcetal  heart  rhythm — embryocardia — described  by  Stokes,  is  a  very 
common  condition  in  which  the  long  pause  is  shortened  and  the  charac- 
ters of  the  sounds  are  "  almost  completely  identical."  The  resemblance 
to  the  foetal  heart-beat  is  very  striking.  In  the  later  stages  of  fevers 
and  in  extreme  dilatation  this  form  of  heart  rhythm  is  very  frequently 
heard. 

(7)  Gallop  rhythm,  in  which  the  sounds  resemble  the  footfall  of  a  horse 
at  canter,  usually  results  from  the  reduplication  of  the  sounds  in  a  rapidly 
acting  heart.  It  is  expressed  by  the  words  "  rat-ta-tat."  Sometimes  it 
seems  as  if  the  first  sound  was  split;  more  commonly  it  is  the  second. 
It  is  most  frequently  heard  in  the  failing  heart  of  interstitial  nephritis  and 
arterio-sclerosis.  Its  mode  of  origin  has  been  much  discussed,  and  it  is 
doubtful  whether  a  satisfactory  explanation  has  yet  been  given.  As  Graham 
Steell  states,  its  presence  indicates  muscle  weakness.  It  is  interesting  among 
disturbances  of  rhythm  as  the  only  one  which  we  can  see  and  feel  as  well 
as  hear. 

The  causes  of  these  various  disturbances  of  rhythm  are  thus  classified 
by  G.  Baumgarten:  * 

(1)  Those  due  to  central — cerebral — causes,  either  organic  disease,  as 
in  haemorrhage,  or  concussion;  more  commonly  psychical  influences. 

(2)  Keflex  influences,  such  as  produce  the  cardiac  irregularity  in  dys- 
pepsia and  diseases  of  the  liver,  lungs,  and  kidneys. 

(3)  Toxic  influences.     Tobacco,  coffee,  and  tea  are  common  causes  of 

*  Transactions  of  the  Association  of  American  Physicians,  vol.  iii. 


768  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

arrhythmia.  Various  drugS;,  such  as  digitalis^  belladonna^,  and  aconite, 
may  also  induce  it. 

(4)  Changes  in  the  heart  itself,  (a)  In  the  cardiac  ganglia.  Fatty, 
pigmentary,  and  sclerotic  changes  have  been  described  in  cases  of .  this 
sort  and  may  have  an  important  influence  in  producing  disturbances  in  the 
rhythm;  but  as  yet  we  do  not  know  their  exact  significance.  They  may 
be  present  in  cases  which  have  not  presented  arrhythmia.  (&)  Mural  changes 
are  common  in  conditions  of  this  kind.  Simple  dilatation,  fatty  degenera- 
tion, and  sclerosis  are  most  commonly  present,  the  two  latter  usually  asso- 
ciated with  sclerosis  of  the  coronary  arteries. 

The  significance  of  arrhythmia  is  not  always  easy  to  determine.  Simple 
irregular  action  of  the  heart  may  persist  for  years.  The  late  Chancellor 
Terrier,  of  McGill  University,  a  man  of  unusual  bodily  and  mental  vigor, 
who  died  at  the  age  of  eighty-seven,  had  an  extremely  irregular  pulse  for 
almost  fifty  years  of  his  life.  One  or  two  other  instances  have  come  under 
my  notice  of  persons  in  good  health,  without  arterial  or  cardiac  disease,  in 
whom  the  heart's  action  was  persistently  irregular.  The  bigeminal  and 
trigeminal  pulsations  are  found  more  frequently  in  mitral  than  in  other 
conditions.  The  delirium  cordis  is  met  with  in  the  dilatation  associated 
with  valvular  lesions,  particularly  toward  the  latter  stages.  Foetal  heart 
rhythm  is  rarely  found  apart  from  dilatation. 

Eapid  Heart- — Tachtcaedia. 

The  rapid  action  may  be  perfectly  natural.  There  are  individuals 
whose  normal  heart  action  is  at  100  or  even  more  per  minute.  It  may 
be  caused  by  the  various  conditions  which  induce  palpitation;  but  the 
two  are  not  necessarily  associated.  Emotional  causes,  violent  exercise,  and 
fevers  all  produce  great  increase  in  the  rapidity  of  the  heart's  action.  The 
extremely  rapid  action  which  follows  fright  may  persist  for  days,  or  even 
weeks.  Traube  reports  an  instance  in  which,  after  violent  exercise,  the 
rapidity  of  the  heart  continued.  "  Cases  are  not  uncommon  at  the  meno- 
pause. 

There  are  cases  again  in  which  the  condition  can  hardly  be  termed  a 
neurosis,  since  it  depends  upon  definite  changes  in  the  pneumogastrics 
or  in  the  medulla.  Cases  have  been  reported  in  which  tumor  or  clot  in 
or  about  the  medulla  or  pressure  upon  the  vagi  has  been  associated  with 
heart  hurry.  Some  of  the  cases  of  frequent  action  of  the  heart  in  women 
have  been  thought  to  be  due  to  reflex  irritation  from  ovarian  or  uterine 
disease. 

Paroxysmal  tachycardia  is  a  remarkable  affection,  characterized  by  spells 
of  heart  hurry,  during  which  the  action  is  greatly  increased,  the  pulse 
reaching  200  and  over.  The  cases  are  not  common.  The  condition  has 
been  thoroughly  studied  by  Nothnagel.  The  attack  may  be  quite  short 
and  persist  only  for  an  hour  or  so.  A  patient  at  the  Philadelphia  Infirmary 
for  Nervous  Diseases  was  attacked  every  week  or  two;  the  pulse  would  rise 
to  220  or  230,  and  there  were  such  feelings  of  distress  and  uneasiness  that 
the  patient  always  had  to  lie  down.    There  may  be,  however,  no  subjective 


NEUROSES  OF  THE  HEART.  759 

disturbance,  and  in  another  case  the  patient  was  able  to  walk  about  during 
the  paroxysm  and  had  no  dyspnoea.  One  of  the  most  remarkable  cases  is 
reported  by  H.  C.  Wood.  A  physician  in  his  eighty-seventh  year  had  had 
attacks  at  intervals  since  his  thirty-seventh  year.  The  onset  was  al}rupt  and 
the  pulse  would  rapidly  rise  to  200  a  minute.  For  more  than  twenty  years 
the  taking  of  ice-water  or  strong  coffee  would  arrest  the  attacks.  Bouveret 
has  analyzed  a  number  of  cases  of  this  essential  or  idiopathic  form;  he 
finds  that  a  permanent  cure  is  rare,  and  that  the  patients  suffer  for  ten 
or  more  years.  Four  instances  terminated  fatally  from  heart-failure.  Mar- 
tins looks  upon  it  as  a  symptom  of  an  acute  dilatation  of  the  heart,  appear- 
ing paroxysmally.  "Wood  suggests  that  these  cardiac  paroxysms  are  caused 
by  discharging  lesions  affecting  the  centres  of  the  accelerator  nerves. 
Frangois  Franck  has  shown  that  the  acceleration  of  the .  heart's  action  is 
due  to  the  shortening  of  the  diastole,  and  during  the  systole  so  little  blood 
is  expelled  from  the  heart  that  the  average  amount  in  the  minute  is  not 
increased.  Moreover,  the  accelerators  appear  to  have  no  trophic  relation 
to  the  heart,  and  stimulation  of  them  is  not  accompanied  either  by  in- 
creased arterial  pressure  or  by  augmentation  of  the  work  done  by  the  heart. 

Slow  Heart — Brachycaedia  {Bradycardia). 

Slow  action  of  the  heart  is  sometimes  normal  and  may  be  a  family  pecul- 
iarity.   Napoleon  is  stated  to  have  had  a  pulse  of  only  40  per  minute. 

In  any  case  of  slow  pulse  it  is  important  first  to  make  sure  that  the 
number  of  heart  and  arterial  beats  correspond.  In  many  instances  this  is 
not  the  case,  and  with  a  radial  pulse  at  40  the  cardiac  pulsations  may  be 
80,  half  the  beats  not  reaching  the  wrist.  The  heart  contractions,  not  the 
pulse  wave,  should  be  taken  into  account.  A  most  exhaustive  study  of 
this  condition  has  been  made  by  Riegel,  whose  division  is  here  followed: 

(a)  Physiological  brachycardia.  In  the  puerperal  state  the  pulse  may 
beat  from  44  to  60  per  minute,  or  may  even  be  as  low  as  34.  It  is  seen  in 
premature  labor  as  well  as  at  term.  The  explanation  of  its  occurrence  at 
this  period  is  not  clear.  Slowness  of  the  pulse  is  associated  with  hunger. 
Brachycardia  depending  on  individual  peculiarity  is  extremely  rare. 

(&)  Pathological  brachycardia,  which  is  met  with  under  the  following 
conditions:  (1)  In  convalescence  from  acute  fevers.  This  is  extremely 
common,  particularly  after  pneumonia,  typhoid  fever,  acute  rheumatism, 
and  diphtheria.  It  is  most  frequently  seen  in  young  persons  and  in  cases 
which  have  run  a  normal  course.  Traube's  explanation  that  it  is  due  to 
exhaustion  is  probably  the  correct  one.  (2)  In  diseases  of  the  digestive 
system,  such  as  chronic  dyspepsia,  ulcer  or  cancer  of  the  stomach,  and 
jaundice.  The  largest  number  of  Eiegel's  cases  were  of  this  group.  (3) 
In  diseases  of  the  respiratory  system.  Here  it  is  by  no  means  so  common, 
but  is  seen  not  infrequently  in  emphysema.  (4)  In  diseases  of  the  circu- 
latory system.  Excluding  all  cases  of  irregularity  of  the  heart,  brachy- 
cardia is  not  common  in  diseases  of  the  valves.  It  is  most  frequently  seen 
in  fatty  and  fibroid  changes  in  the  heart,  but  is  not  constant  in  them.  (5) 
In  diseases  of  the  urinary  organs.    It  occurs  occasionally  in  nephritis  and 


760  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

may  be  a  feature  of  urs&mia.  (6)  From  the  action  of  toxic  agents.  It  occurs 
in  uraemia,  poisoning  by  lead,  alcohol,  and  follows  the  use  of  tobacco, 
coffee,  and  digitalis.  (7)  In  constitutional  disorders,  such  as  anaemia, 
chlorosis,  and  diabetes.  (8)  In  diseases  of  the  nervous  system.  Apoplexy, 
epilepsy,  the  cerebral  tumors,  affections  of  the  medulla,  and  diseases  and 
injuries  of  the  cervical  cord  may  be  associated  with  very  slow  pulse.  In 
general  paresis,  mania,  and  melancholia  it  is  not  infrequent.  (9)  It  occurs 
occasionally  in  affections  of  the  skin  and  sexual  organs,  and  in  sunstroke, 
or  in  prolonged  exhaustion  from  any  cause. 

The  Stokes-Adams    Syndrome. — Slow  Pulse  with  Syncopal  Attacks.— 
Eobert  Adams  and  Stokes  described  a  remarkable  condition  in  which  the 
pulse  was  permanently  slow  in  association  with  attacks  of  syncope.     The 
patients  are  usually  advanced  in  years  and  show  an  extreme  grade  of  arterio- 
sclerosis.   The  pulse-rate  may  be  30  or  20  to  the  minute,  or,  as  in  Prentice'a 
case,  as  low  as  12,  or  even  10  or  5.     The  cerebral  symptoms  are  very  re- 
markable, and  Stokes  suggested  for  them  the  name  of  false  or  pseudo-  . 
apoplexy.    Attacks  of  vertigo,  which  may  recur  several  times  in  the  day, 
attacks  of  syncope,  in  which  the  patient  is  insensible  for  four  or  five  min- 
utes, or  epileptiform  attacks,  as  in  Ogle's  cases,  are  the  most  pronounced 
cerebral  symptoms.    Huchard  regards  the  condition  as  the  result  of  changes 
in  the  pneumogastric  centres  due  to  disease  of  the  arteries  of  the  medulla. 
(See  Lecture  IV  in  my  monograph  on  Angina  Pectoris  and  Allied  States.) 
Treatment  of  Palpitation  and  Arrhythmia.— An  important 
element  in  many  cases  is  to  get  the  patient's  mind  quieted,  and  he  can  be 
assured  that  there  is  no  actual  danger.    The  mental  element  is  oftentimes 
very  strong.     In  palpitation,  before  using  medicines,  it  is  well  to  try  the 
effect  of  hygienic  measures.     As  a  rule,  moderate  exercise  may  be  taken 
with  advantage.     Eegular  hours  should  be  kept,  and  at  least  ten  houra 
out  of  the  twenty-four  should  be  spent  in  the  recumbent  posture.    A  tepid 
bath  may  be  taken  in  the  morning,  or,  if  the  patient  is  weakly  and  nerv- 
ous, in  the  evening,  followed  by  a  thorough  rubbing.    Hot  baths  and  the 
Turkish  bath  should  be  avoided.     The  dietetic  management  is  most  im- 
portant.    It  is  best  to  prohibit  absolutely  alcohol,  tea,  and  coffee.     The 
diet  should  be  light  and  the  patient  should  avoid  taking  large  meals.    Arti- 
cles of  food  known  to  cause  flatulency  should  not  be  used.     If  a  smoker, 
the  patient  should  give  up  tobacco.     Sexual  excitement  is  particularly 
pernicious,  and  the  patient  should  be  warned  specially  on  this  point.    For 
the  distressing  attacks  of  palpitation  which  occur  with  neurasthenia,  par- 
ticularly in  women,  a  rigid  Weir  Mitchell  course  is  the  most  satisfactory. 
It  is  in  these  cases  that  we  find  the  most  distressing  throbbing  in  the  abdo- 
men, which  is  apt  to  come  on  after  meals,  and  is  very  much  aggravated 
by  flatulency.    The  cases  of  palpitation  due  to  excesses  or  to  errors  in  diet 
and  dyspepsia  are  readily  remedied  by  hygienic  measures. 

A  course  of  iron  is  often  useful.  Strychnia  is  particularly  valuable, 
and  is  perhaps  best  administered  as  the  tincture  of  nux  vomica  in  large 
doses.  Very  little  good  is  obtained  from  the  smaller  quantities.  It  should 
be  given  freely,  20  minims  three  times  a  day. 

If  there  is  great  rapidity  of  action,  aconite  may  be  tried  or  vera.trum 


NEUROSES  OF  THE  HEART.  761 

viride.  There  are  cases  associated  with  sleeplessness  and  restlessness  which 
are  greatly  benefited  by  bromide  of  potassium.  Digitalis  is  very  rarely 
indicated,  but  in  obstinate  cases  it  may  be  tried  with  the  nux  vomica. 

Cases  of  heart  hurry  are  often  extremely  obstinate,  as  may  be  Judged 
from  the  case  of  the  physician  reported  by  H.  C.  Wood,  in  whom  the  con- 
dition persisted  in  spite  of  all  measures  for  fifty  years.  The  bromides  are 
sometimes  useful;  the  general  condition  of  neurasthenia  should  be  treated, 
and  during  the  paroxysm  an  ice-bag  may  be  placed  upon  the  heart,  or 
Leiter's  coil,  through  which  ice-water  may  be  passed.  Electricity,  in  the 
form  of  galvanism,  is  sometimes  serviceable,  and  for  its  mental  effect  the 
Franklinic  current.  For  the  condition  of  slow  pulse  but  little  can  be  done. 
A  great  majority  of  the  cases  are  not  dangerous. 

Angina  Pectoeis. 

Stenocardia,  or  the  breast-pang,  described  by  Heberden,  is  not  an  inde- 
pendent affection,  but  a  symptom  associated  with  a  number  of  morbid 
conditions  of  the  heart  and  vessels,  more  particularly  with  sclerosis  of 
the  root  of  the  aorta  and  changes  in  the  coronary  arteries.  True  angina, 
which  is  a  rare  disease,  is  characterized  by  paroxysms  of  agonizing  pain 
in  the  region  of  the  heart,  extending  into  the  arms  and  neck.  In  violent 
attacks  there  is  a  sensation  of  impending  death. 

Etiology. — It  is  a  disease  of  adult  life  and  occurs  almost  exclusively 
in  men.  In  Huchard's  statistics  of  237  cases  only  42  were  in  women.  In  my 
series  of  40  cases  there  was  only  one  woman.  It  may  occur  through  several 
generations,  as  in  the  Arnold  family.  Gout,  diabetes,  and  syphilis  are  im- 
portant factors.  A  number  of  cases  of  angina  pectoris  have  followed  influ- 
enza. Attacks  are  not  infrequent  in  certain  forms  of  heart-disease,  par- 
ticularly aortic  insufficiency  and  adherent  pericardium.  It  is  much  less 
common  in  disease  of  the  mitral  valve.  Almost  without  exception  the  sub- 
jects of  true  angina  have  arterio-sclerosis,  either  general  or  localized  at  the 
root  of  the  aorta,  with  changes  in  the  coronary  arteries  and  in  the  myo- 
cardium. 

Phenomena  of  the  Attack. — The  exciting  cause  is  in  a  majority  of  all 
cases  well  defined.  In  only  rare  instances  do  the  patients  have  attacks  when 
quiet.  They  come  on  during  exertion  most  frequently,  as  in  walking  up  hill 
or  doing  something  entailing  sudden  muscular  effort;  occasionally  even  the 
effort  of  dressing  or  of  stooping  to  lace  the  shoes  may  bring  on  a  paroxysm. 
Mental  emotion  is  a  second  very  potent  cause.  John  Hunter  appreciated 
this  when  he  said  that  "  his  life  was  in  the  hands  of  any  rascal  who  chose 
to  annoy  and  tease  him."  In  his  case  a  fatal  attack  occurred  during  a  fit 
of  anger.  A  third,  and  in  many  instances  the  most  important,  factor  is 
flatulent  distention  of  the  stomach.  Another  common  exciting  cause  is 
cold;  even  the  chill  of  getting  out  of  bed  in  the  morning  or  on  bathing 
may  bring  on  a  paroxysm. 

Usually  during  exertion  or  intense  mental  emotion  the  patient  is  seized 
with  an  agonizing  pain  in  the  region  of  the  heart  and  a  sense  of  constric- 
tion, as  if  the  heart  had  been  seized  in  a  vice.    The  pains  radiate  up  the 


762  DISEASES  or  THE  CIRCULATORY  SYSTEM. 

neck  and  down  the  arm,  and  there  may  be  numbness  of  the  fingers  or  in 
the  cardiac  region.  The  face  is  usually  pallid  and  may  assume  an  ashy- 
gray  tint,  and  not  infrequently  a  profuse  sweat  breaks  out  over  the  surface. 
The  paroxysm  lasts  from  several  seconds  to  a  minute  or  two,  during  which, 
in  severe  attacks,  the  patient  feels  as  if  death  were  imminent.  As  pointed 
out  by  Latham,  there  are  two  elements  in  the  paroxysm,  the  pain — dolor 
pectoris — and  the  indescribable  feeling  of  anguish  and  sense  of  imminent 
dissolution — angor  animi.  There  are  great  restlessness  and  anxiety,  and 
the  patient  may  drop  dead  at  the  height  of  the  attack  or  faint  and  pass  away 
in  syncope.  The  condition  of  the  heart  during  the  attack  is  variable;  the 
pulsations  may  be  uniform  and  regular.  The  pulse  tension,  however,  is 
usually  increased,  but  it  is  surprising,  even  in  cases  of  extreme  severity, 
how  slightly  the  character  of  the  pulse  may  be  altered.  After  the  attack 
there  may  be  eructations,  or  the  passage  of  a  large  quantity  of  clear  urine. 
The  patient  usually  feels  exhausted,  and  for  a  day  or  two  may  be  badly 
shaken;  in  other  instances  in  an  hour  or  two  the  patient  feels  himself 
again.  While  dyspnoea  is  not  a  constant  feature,  the  paroxysm  is  not  infre- 
quently associated  with  a  form  of  asthma;  there  is  wheezing  in  the  bron- 
chial tubes,  which  may  come  on  very  rapidly,  and  the  patient  gets  short  of 
breath.  Many  patients  the  subjects  of  angina  die  suddenly  without  warn- 
ing and  not  in  a  paroxysm.  In  other  instances  death  follows  in  the  first 
well-marked  paroxysm,  as  in  the  case  of  Thomas  Arnold.  In  a  third  group 
there  are  recurring  attacks  over  long  periods  of  years,  as  in  John  Hunter's 
case;  while  in  a  fourth  group  of  cases  there  are  rapidly  recurring  attacks 
for  several  days  in  succession,  with  progressive  and  increasing  weakness 
of  the  heart. 

With  reference  to  the  radiation  of  pain  in  angina,  the  studies  of  Mac- 
kenzie and  of  Head  are  of  great  interest.  Head  concludes  that  (1)  in  dis- 
eases of  the  heart,  and  more  particularly  in  aortic  disease,  the  pain  is  re- 
ferred along  the  first,  second,  third,  and  fourth  dorsal  areas;  (2)  in  angina 
pectoris  the  pain  may  be  referred  in  addition  along  the  fifth,  sixth,  and 
seventh,  and  even  the  eighth  and  ninth  dorsal  areas,  and  is  always  accom- 
panied by  pain  in  certain  cervical  areas. 

Theories  of  Angina  Pectoris. — (1)  That  it  is  a  neuralgia  of  the  cardiac 
nerves.  In  the  true  form  the  agonizing  cramp-like  character  of  the  pain, 
the  suddenness  of  the  onset,  and  the  associated  features,  are  unlike  any 
neuralgic  affection.  The  pain,  however,  is  undoubtedly  in  the  cardiac 
plexus  and  radiates  to  adjacent  nerves.  It  is  interesting  to  note,  in  con- 
nection with  the  almost  constant  sclerosis  of  the  coronary  arteries  in  an- 
gina, that  Thoma  has  found  marked  sclerosis  of  the  temporal  artery  in 
migraine  and  Dana  has  met  with  local  thickening  of  the  arteries  in  some 
cases  of  neuralgia.  (2)  Heberden  believed  that  it  was  a  cramp  of  the  heart- 
muscle  itself.  Cramp  of  certain  muscular  territories  would  better  ex- 
plain the  attack.  (3)  That  it  is  due  to  the  extreme  tension  of  the  ven- 
tricular walls,  in  consequence  of  an  acute  dilatation  associated,  in  the  ma- 
jority of  cases,  with  affection  of  the  coronary  arteries.  Traube,  who  sup- 
ported this  view,  held  that  the  agonizing  pain  resulted  from  the  great 
stretching  and  tension  of  the  nerves  in  the  muscular  substance.    A  modi- 


NEUROSES  OP  THE  HEART.  763 

fied  form  of  this  view  is  that  there  is  a  spasm  of  the  coronary  arteries  with 
great  increase  of  the  intracardiac  pressure. 

(4)  The  theory  of  Allan  Burns,  revived  by  Potain  and  others,  that  the 
condition  is  one  of  transient  ischsemia  of  the  heart-muscle  in  consequence 
of  disease,  or  spasm,  of  the  coronary  arteries.  The  condition  known  as 
intermittent  claudication  illustrates  what  may  take  place.  In  man  (and 
in  the  horse),  in  consequence  of  thrombosis  of  the  abdominal  aorta  or 
iliacs,  transient  paraplegia  and  spasm  may  follow  exertion.  The  collateral 
circulation,  ample  when  the  limbs  are  at  rest,  is  insufficient  after  the  mus- 
cles are  actively  used,  and  a  state  of  relative  ischsemia  is  induced  with  loss 
of  power,  which  disappears  in  a  short  time.  This  "  intermittent  claudica- 
tion "  theory  has  been  applied  to  explain  the  angina  paroxysm.  •  A  heart 
the  coronary  arteries  of  which  are  sclerotic  or  calcified,  is  in  an  analogous 
state,  and  any  extra  exertion  is  likely  to  be  followed  by  a  relative  ischsemia 
and  spasm.  In  Allan  Burns^s  work  on  The  Heart  (1809)  the  theory  is  dis- 
cussed at  length,  but  he  does  not  think  that  spasm  is  a  necessary  accom- 
paniment of  the  ischsemia. 

In  fatal  cases  of  angina  the  coronary  arteries  are  almost  invariably  dis- 
eased either  in  their  main  divisions,  or  there  is  chronic  endarteritis  with 
great  narrowing  of  the  orifices  at  the  root  of  the  aorta.  Experimentally, 
occlusion  of  the  coronary  arteries  produces  slowing  of  the  heart's  action, 
gradual  dilatation,  and  death  within  a  very  few  minutes.  Cohnheim  has 
shown,  that  in  the  dog  ligation  of  one  of  the  large  coronary  branches  pro- 
duces within  a  minute  a  condition  of  arrhythmia,  and  within  two  minutes 
the  heart  ceases  in  diastole.  These  experiments,  however,  do  not  throw 
much  light  upon  the  etiology  of  angina  pectoris.  Extreme  sclerosis  of  the 
coronary  arteries  is  common,  and  a  large  majority  of  the  cases  present  no 
symptoms  of  angina.  Even  in  the  cases  of  sudden  death  due  to  blocking 
of  an  artery,  particularly  the  anterior  branch  of  the  coronary  artery,  there 
is  usually  no  great  pain  either  before  or  during  the  attack. 

Diagnosis. — There  are  many  grades  of  true  angina.  A  man  may  have 
slight  prsecordial  pain,  a  sense  of  distress  and  uneasiness,  and  radiation  of 
the  pains  to  the  arm  and  neck.  Such  attacks  following  slight  exertion,  an 
indiscretion  in  diet,  or  a  disturbing  emotion,  may  alternate  with  attacks 
of  much  greater  severity,  or  they  may  occur  in  connection  with  a  pulse  of 
increased  tension  and  signs  of  general  arterio-sclerosis.  In  the  milder 
grades  the  diagnosis  cannot  rest  upon  the  symptoms  of  the  attack  itself, 
since  they  may  be  simulated  by  the  pseudo-angina;  but  the  diagnosis  should 
be  based  upon  the  examination  of  the  heart  and  arteries  and  a  careful  con- 
sideration of  the  mode  of  onset  and  symptoms.  The  cases  of  pseudo-angina 
pectoris  in  women  are,  after  all,  the  ones  which  call  for  the  greatest  care 
in  the  diagnosis,  and  attention  to  the  points  given  in  the  table  of  Huchard 
will  be  of  the  greatest  aid. 

Pseudo-Angina  Pectoris. — False  angina  may  be  divided  into  two  main 
groups,  the  neurotic  and  the  toxic.  The  former  embraces  the  hysterical 
and  neurasthenic  cases,  which  are  very  common  in  women.  Huchard  has 
given  an  excellent  differential  table  between  the  true  and  the  spurious  at- 
tacks. 


764  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

TEUE   ANGINA.  PSEUDO-ANGINA. 

Most  common  between  the  ages         At  every  age,  even  six  years, 
of  forty  and  fifty  years. 

Most  common  in  men.     Attacks          Most   common   in   women.      At- 

brought  on  by  exertion.  tacks  spontaneous. 

Attacks  rarely  periodical  or  noc-         Often  periodical  and  nocturnal, 
turnal. 

Not  associated  with  other  symp-  Associated  with  nervous  symp- 
toms, toms. 

Vaso-motor  form  rare.     Agoniz-         Vaso-motor  form  common.    Pain 

ing  pain  and  sensation  of  compres-  less  severe;  sensation  of  distention, 
sion  by  a  vice. 

Pain   of   short    duration.      Atti-         Pain  lasts  one  or  two  hours.    Agi- 

tude:  silence,  immobility.  tation  and  activity. 

Lesions  :    sclerosis    of    coronary         Neuralgia  of  nerves  and  cardio- 

artery.  ^  plexus. 

Prognosis  grave,  often  fatal.  Never  fatal. 

Arterial  medication.  Antineuralgic  medication. 

A  form  which  Nothnagel  has  described  as  vaso-motor  angina  is  not  infre- 
quent. The  symptoms  set  in  with  coldness  and  numbness  in  the  extremi- 
ties, followed  by  great  prsecordial  pain  and  feelings  of  faintness.'  Some 
have  recognized  also  a  reflex  variety. 

Toxic  Angina. — This  embraces  cases  due  to  the  abuse  of  tea,  coffee,  and 
tobacco.  There  are  three  groups  of  cases  of  so-called  tobacco  heart:  First, 
the  irritable  heart  of  smokers,  seen  particularly  in  young  lads,  in  which 
the  symptoms  are  palpitation,  irregularity,  and  rapid  action;  secondly, 
heart  pain  of  a  sharp,  shooting  character,  which  may  be  very  severe;  and, 
thirdly,  attacks  of  such  severity  that  they  deserve  the  name  of  angina. 
Huchard  remarks  that  they  are  usually  of  the  vaso-motor  type,  accom- 
panied with  chilling  of  the  extremities,  feeble  pulse,  and  a  tendency  to  syn- 
cope. This  author  distinguishes  between  functional  tobacco  angina,  due, 
he  thinks,  to  spasmodic  contraction  of  the  coronary  arteries,  and  an  organic 
tobacco  angina  due  to  a  nicotine  arterio-sclerosis  of  these  vessels. 

Prognosis. — Cardiac  pain  without  evidence  of  arterio-sclerosis  or 
valve-disease  is  not  of  much  moment.  True  angina  is  almost  invariably 
associated  with  marked  cardio-vascular  lesions,  in  which  the  prognosis  is 
always  grave.  With  judicious  treatment  the  attacks,  however,  may  be 
long  deferred,  and  a  few  instances  recover  completely.  The  prognosis  is 
naturally  more  serious  with  aortic  insufficiency  and  advanced  arterio-scle- 
rosis. Patients  who  have  had  well-marked  attacks  may  live  for  many  years, 
but  much  depends  upon  the  care  with  which  they  regulate  their  daily  life. 

Treatment. — Patients  subject  to  this  affection  should  live  a  quiet 
life,  avoiding  particularly  excitement  and  sudden  muscular  exertion.  Dur- 
ing the  attack  nitrite  of  amyl  should  be  inhaled,  as  advised  by  Lauder 
Brunton.  From  2  to  5  drops  may  be  placed  upon  cotton-wool  in  a 
tumbler  or  upon  the  handkerchief.  This  is  frequently  of  great  service  in 
the  attack,  relieving  the  agonizing  pain  and  distress.     Subjects  of  the  dis- 


CONGENITAL  AFFECTIONS  OP  THE  HEART.  765 

ease  should  carry  the  pedes  of  the  nitrite  of  amyl  with  them,  and  use  them 
on  the  first  indication  of  an  attack.  In  some  instances  the  nitrite  of  amyl 
is  quite  powerless,  though  given  freely.  If  within  a  minute  or  two  relief  is 
not  obtained  in  this  way,  chloroform  should  at  once  be  given.  A  few  in- 
halations act  promptly  and  give  great  relief.  Should  the  pains  continue, 
a  hypodermic  of  morphia  may  be  administered.  In  severe  and  repeated 
paroxysms  a  patient  may  display  remarkable  resistance  to  the  action  of 
this  drug. 

In  the  intervals,  nitroglycerin  may  be  given  in  full  doses,  as  recom- 
mended by  Murrell,  or  the  nitrite  of  sodium  (Matthew  Hay).  The  nitro- 
glycerin should  be  used  for  a  long  time  and  in  increasing  doses,  beginning 
with  1  minim  three  times  a  day  of  the  l-per-cent  solution,  and  increas- 
ing the  dose  1  minim  every  five  or  six  days  until  the  patient  complains 
of  flushing  or  headache.  The  fluid  extract  of  English  hawthorn — crategus 
oxyacantha — has  been  strongly  recommended  by  Jennings,  Clements,  and 
others. 

Huchard  recommends  the  iodides,  believing  that  their  prolonged  use 
influences  the  arterio-sclerosis.  Twenty  grains  three  times  a  day  may  be 
given  for  several  years,  omitting  the  medicine  for  about  ten  days  in  each 
month.  In  some  instances  this  treatment  is  certainly  beneficial.  Two 
men,  both  with  arterio-sclerosis,  ringing,  accentuated  aortic  sound,  and 
attacks  of  true  angina,  have  under  its  use  remained  practically  free  from 
attacks — one  case  for  nearly  three,  and  the  other  for  fully  eight  years. 
This  treatment  is,  however,  not  always  satisfactory,  and  I  have  had  several 
cases  in  which  the  condition  has  not  been  at  all  relieved  by  it. 

For  the  pseudo-angina,  the  treatment  must  be  directed  to  the  general 
nervous  condition.  Electricity  is  sometimes  very  beneficial,  particularly 
the  Franklinic  form. 


VI.    CONGENITAL   AFFECTIONS    OF   THE    HEART. 

These  have  only  a  limited  clinical  interest,  as  in  a  large  proportion  of 
the  cases  the  anomaly  is  not  compatible  with  life,  and  in  others  nothing 
can  be  done  to  remedy  the  defect  or  even  to  relieve  the  symptoms. 

The  congenital  affections  result  from  interruption  of  the  normal  course 
of  development  or  from  inflammatory  processes — endocarditis;  sometimes 
from  a  combination  of  both. 

(a)  Of  general  anomalies  of  development  the  following  conditions  may 
be  mentioned:  Acardia,  absence  of  the  heart,  which  has  been  met  with 
in  the  monstrosity  known  by  the  same  name;  double  heart,  which  has  occa- 
sionally been  found  in  extreme  grades  of  foetal  deformity;  dextrocardia, 
in  which  the  heart  is  on  the  right  side,  either  alone  or  as  part  of  a  general 
transposition  of  the  viscera;  ectopia  cordis,  a  condition  associated  with 
fission  of  the  chest  wall  and  of  the  al)domen.  The  heart  may  be  situated 
in  the  cervical,  pectoral,  or  abdominal  regions.  Except  in  the  abdominal 
variety  the  condition  is  very  rarely  compatible  with  extra-uterine  life. 
Occasionally,  as  in  a  case  reported  by  Holt,  the  child  lives  for  some  months, 


76G  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

and  the  heart  may  be  seen  and  felt  beating  beneath  the  skin  in  the  epi- 
gastric region.  This  infant  was  live  months  old  at  the  date  of  examina- 
tion. - 

{b)  Anomalies  of  the  Cardiac  Septa. — The  septa  of  both  auricles  and 
ventricles  may  be  defective,  in  which  case  the  heart  consists  of  but  two 
chambers,  the  cor  hiloculare  or  reptilian  heart.  In  the  septum  of  the  auri- 
cles there  is  a  very  common  defect,  owing  to  the  fact  that  the  membrane 
closing  the  foramen  ovale  has  failed  at  one  point  to  become  attached  to  the 
ring,  and  leaves  a  valvular  slit  which  may  be  large  enough  to  admit  the 
handle  of  a  scalpel.  Neither  this  nor  the  small  cribriform  perforations  of 
the  membrane  are  of  any  significance. 

The  foramen  ovale  may  be  patent  without  a  trace  of  membrane  closing 
it.  In  some  instances  this  exists  with  other  serious  defects,  such  as  steno- 
sis of  the  pulmonary  artery,  or  imperfection  of  the  ventricular  septum. 
In  others  the  patent  foramen  ovale  is  the  only  anomaly,  and  in  many  in- 
stances it  does  not  appear  to  have  caused  any  embarrassment,  as  the  con- 
dition has  been  found  in  persons  who  have  died  of  various  affections.  The 
ventricular  septum  may  be  absent,  the  condition  known  as  trilocular  heart. 
Much  more  frequently  there  is  a  small  defect  in  the  upper  portion  of  the 
septum,  either  in  the  situation  of  the  membranous  portion  known  as  the 
"  undefended  space  "  or  in  the  region  situated  just  anterior  to  this.  The 
anomaly  is  very  frequently  associated  with  narrowing  of  the  pulmonary 
orifice  or  of  the  conus  arteriosus  of  the  right  ventricle. 

(c)  Anomalies  and  Lesions  of  the  Valves. — Numerical  anomalies  of  the 
valves  are  not  uncommon.  The  semilunar  segments  at  the  arterial  orifices 
are  not  infrequently  increased  or  diminished  in  number.  Supernumerary 
segments  are  more  frequent  in  the  pulmonary  artery  than  in  the  aorta. 
Four,  or  sometimes  five,  valves  have  been  found.  The  segments  may  be  of 
equal  size,  but,  as  a  rule,  the  supernumerary  valve  is  small. 

Instead  of  three  there  may  be  only  two  semilunar  valves,  or,  as  it  is 
termed,  the  licuspid  condition.  In  my  experience,  this  is  most  frequent 
in  the  aortic  valve.  Of  21  instances  only  2  occurred  aj;  the  pulmonary 
orifice.  Two  of  the  valves  have  united,  and  from  the  ventricular  face 
show  either  no  trace  of  division  or  else  a  slight  depression  indicating  where 
the  union  had  occurred.  From  the  aortic  side  there  is  usually  to  be  seen 
some  trace  of  division  into  two  sinuses  of  Valsalva.  There  has  been  a  dis- 
cussion as  to  the  origin  of  this  condition,  whether  it  is  really  an  anomaly 
or  whether  it  is  not  due  to  endocarditis,  foetal  or  post-natal.  The  com- 
bined segment  is  usually  tliickened,  but  the  fact  that  this  anomaly  is  met 
with  in  the  foetus  without  a  trace  of  sclerosis  or  endocarditis  shows  that  it 
may,  in  some  cases  at  least,  result  from  a  developmental  error. 

Clinically  this  is  a  very  important  congenital  defect,  owing  to  the 
liability  of  the  combined  valve  to  sclerotic  changes.  Except  two  foetal 
specimens  all  of  my  cases  showed  thickening  and  deformity,  and  in  15 
of  those  which  I  have  reported  death  resulted  directly  or  indirectly  from 
the  lesion. 

The  little  fenestrations  at  the  margins  of  the  sigmoid,  valves  have  no 
significance;  they  occur  in  a  considerable  proportion  of  all  bodies. 


CONGENITAL  AFFECTIONS  OF  THE  HEART.  767 

Anomalies  of  the  aiiriculo-ventricular  valves  are  not  often  met  with. 

Foetal  endocarditis  may  occur  either  at  the  arterial  or  auriculo-ven- 
tricular  orifices.  It  is  nearly  always  of  the  chronic  or  sclerotic  variety. 
Very  rarely  indeed  is  it  of  the  warty  or  verrucose  form.  There  are  little 
nodular  hodies,  sometimes  six  or  eight  in  number,  on  the  mitral  and  tri- 
cuspid segments — the  nodules  of  Albini — which  represent  the  remains  of 
fcetal  structures,  and  must  not  be  mistaken  for  endocardial  outgrowths. 
The  little  rounded,  bead-like  haemorrhages  of  a  deep  purple  color,  which 
are  very  common  on  the  heart  valves  of  children,  are  also  not  to  be  mis- 
taken for  the  products  of  endocarditis.  In  foetal  endocarditis  the  segments 
are  usually  thickened  at  the  edges,  shrunken,  and  smooth.  In  the  mitral 
and  tricuspid  valves  the  cusps  are  found  united  and  the  chordae  tendinese 
are  thickened  and  shortened.  In  the  semilunar  valves  all  trace  of  the 
segments  has  disappeared,  leaving  a  stiff  membranous  diaphragm  per- 
forated by  an  oval  or  rounded  orifice.  It  is  sometimes  very  difficult  to  say 
whether  this  condition  has  resulted  from  foetal  endocarditis  or  whether  it 
is  an  error  in  development.  In  very  many  instances  the  processes  are 
combined;  an  anomalous  valve  becomes  the  seat  of  chronic  sclerotic 
changes,  and,  according  to  Eauchfuss,  endocarditis  is  more  common  on 
the  right  side  of  the  heart  only  because  the  valves  are  here  most  often  the 
seat  of  developmental  errors. 

Lesions  at  the  Pulmonary  Orifice. — Stenosis  of  this  orifice  is  one  of  the 
commonest  and  most  important  of  congenital  heart  affections.  A  slow 
endocarditis  causes  gradual  union  of  the  segments  and  narrowing  of  the 
orifice  to  such  a  degree  that  it  only  admits  the  smallest-sized  probe.  In 
some  of  the  cases  the  smooth  membranous  condition  of  the  combined  seg- 
ments is  such  that  it  would  appear  to  be  the  result  of  faulty  development. 
In  some  instances  vegetations  develop.  The  condition  is  compatible  with 
life  for  many  years,  and  in  a  considerable  proportion  of  the  cases  of  heart- 
disease  above  the  tenth  year  this  lesion  is  present.  With  it  there  may  be 
defect  of  the  ventricular  septum.  Pulmonary  tuberculosis  is  a  very  common 
cause  of  death.  Obliteration  or  atresia  of  the  pulmonary  orifice  is  less  fre- 
quent but  a  more  serious  condition  than  stenosis.  It  is  associated  with  de- 
fect of  the  ventricular  septum  or  patency  of  the  foramen  ovale  and  per- 
sistence of  the  ductus  arteriosus  with  hypertrophy  of  the  right  heart.  Ste- 
nosis of  the  conus  arteriosus  of  the  right  ventricle  exists  in  a  considerable 
proportion  of  the  cases  of  obstruction  at  the  pulmonary  orifice.  At  the  out- 
set a  developmental  error,  it  may  be  combined  with  sclerotic  changes.  The 
ventricular  septum  is  imperfect,  the  foramen  ovale  is  usually  open,  and  the 
ductus  arteriosus  patent.  These  three  lesions  at  the  pulmonary  orifice 
constitute  the  most  important  group  of  all  congenital  cardiac  affections. 
Of  181  instances  of  various  congenital  anomalies  collected  by  Peacock  119 
cases  came  under  this  category,  and,  according  to  this  author,  in  8G  per 
cent  of  the  patients  living  beyond  the  twelfth  year  the  lesion  is  at  this 
orifice. 

Congenital  lesions  of  (he  aortic  orifice  are  not  very  frequent.  Eauchfuss 
has  collected  24  cases  of  stenosis  and  atresia;  stenosis  of  the  left  conus 
arteriosus  may  also  occur,  a  condition  which  is  not  incompatible  with  pro- 

46 


^68  DISEASES  OF  THE  CIRCULATOEY  SYSTEM. 

longed  life.  Ten  of  the  16  cases  tabulated  by  Dilg  were  over  thirty  years 
of  age. 

Transposition  of  tJie  large  arterial  trunlcs  is  a  not  iincommon  anomaly. 
There  may  be  neither  hypertrophy,  cyanosis,  nor  heart  murmur. 

Symptoms  of  Congenital  Heart-disease. — Cyanosis  occurs  in 
over  90  per  cent  of  the  cases,  and  forms  so  distinctive  a  feature  that  the 
terms  "  blue  disease "  and  "  morbus  c^ruleus "  are  practically  synonyms 
for  congenital  heart-disease.  The  lividity  in  a  majority  of  cases  appears 
easly,  within  the  first  week  of  life,  and  may  be  general  or  confined  to  the 
lips,  nose,  and  ears,  and  to  the  fingers  and  toes.  In  some  instances  there 
is  in  addition  a  general  dusky  suffusion,  and  in  the  most  extreme  grades 
the  skin  is  almost  purple.  It  may  vary  a  good  deal  and  may  only  be  in- 
tense on  exertion.  The  external  temperature  is  low.  Dyspnoea  on  exertion 
and  cough  are  common  symptoms.  A  great  increase  in  the  number  of  the 
red  corpuscles  has  been  noted  by  Gibson  and  by  Vaquez.  In  a  case  of  Gib- 
son's there  were  above  eight  millions  of  red  blood-corpuscles  to  the  cubic 
millimetre.  The  children  rarely  thrive,  and  often  display  a  lethargy  of  both 
mind  and  body.  The  fingers  and  toes  are  clubbed  to  a  degree  rarely  met 
with  in  any  other  affection.  The  cause  of  the  cyanosis  has  been  much  dis- 
cussed. Morgagni  referred  it  to  the  general  congestion  of  the  venous  sys- 
tem due  to  obstruction,  and  this  view  was  supported  in  a  papfir,  one  of  the 
ablest  that  has  been  written  on  the  subject,  by  Moreton  Stille.  Morrison's 
recent  analysis  of  75  cases  of  congenital  heart-disease  shows  that  closure 
of  the  pulmonary  orifice  and  patency  of  the  foramen  ovale  and  the  ven- 
tricular septum  are  the  lesions  most  frequently  associated  with  cyanosis, 
and  he  concludes  that  the  deficient  aeration  of  the  blood  owing  to  dimin- 
ished lung  function  is  the  most  important  factor.  Another  view,  often 
attributed  erroneously  to  William  Hunter,  was  that  the  discoloration  was 
due  to  the  admixture  in  the  heart  of  venous  and  arterial  blood;  but  lesions 
may  exist  which  permit  of  very  free  mixture  without  producing  cyanosis. 
The  question  of  the  cause  of  cyanosis  really  can  not  be  considered  as  set- 
tled. Variot  has  recently  made  the  suggestion  that  the  cafuse  is  not  en- 
tirely cardiac,  but  is  associated  with  disturbance  throughout  the  whole 
circulatory  system,  and  particularly  a  vaso-motor  paresis  and  malaeration 
of  the  red  blood-corpuscles. 

Diagnosis. — In  the  case  of  children,  cyanosis,  with  or  without  en- 
largement of  the  heart,  and  the  existence  of  a  murmur  are  sufficient,  as  a 
rule,  to  determine  the  presence  of  a  congenital  heart-lesion.  The  cyanosis 
gives  us  no  clew  to  the  precise  nature  of  the  trouble,  as  it  is  a  symptom 
common  to  many  lesions  and  it  may  be  absent  in  certain  conditions.  The 
murmur  is  usually  systolic  in  character.  It  is,  however,  not  always  pres- 
ent, and  there  are  instances  on  record  of  complicated  congenital  lesions  in 
which  the  examination  showed  normal  heart-sounds.  In  two  or  three  in- 
stances foetal  endocarditis  has  been  diagnosed  in  gravida  by  the  presence 
of  a  rough  systolic  murmur,  and  the  condition  has  been  corroborated  sub- 
sequent to  the  birth  of  tlie  child.  Hypertrophy  is  present  in  a  majority  of 
the  cases  of  congenital  defect.  The  fatal  event  may  be  caused  by  abscess 
of  the  brain.     It  is  impossible  in  a  work  of  this  sort  to  enter  upon  elabo- 


CONGENITAL  AFFECTIONS  OF  THE  HEART.  769 

rate  details  in  differential  diagnosis  between  the  various  congenital  heart- 
lesions.     I  here  abstract  the  conclusions  of  Hochsinger: 

"  (1)  In  childhood,  loud,  rough,  musical  heart-murmurs,  with  normal 
or  only  slight  increase  in  the  heart-dulness,  occur  only  in  congenital  heart- 
disease.  The  acquired  endocardial  defects  with  loud  heart-murmurs  in 
young  children  are  almost  always  associated  with  great  increase  in  the 
heart-dulness.  In  the  transposition  of  the  large  arterial  trunks  there  may 
be  no  cyanosis,  no  heart-murmur,  and  an  absence  of  hypertrophy. 

"  (3)  In  young  children  heart-murmurs  with  great  increase  in  the  car- 
diac dulness  and  feeble  apex  beat  suggest  congenital  changes.  The  in- 
creased dulness  is  chiefly  of  the  right  heart,  whereas  the  left  is  only  slightly 
altered.  On  the  other  hand,  in  the  acquired  endocarditis  in  children,  the 
left  heart  is  chiefly  affected  and  the  apex  beat  is  visible;  the  dilatation  of 
the  right  heart  comes  late  and  does  not  materially  change  the  increased 
strength  of  the  apex  beat. 

"  (3)  The  entire  absence  of  murmurs  at  the  apex,  with  their  evident 
presence  in  the  region  of  the  auricles  and  over  the  pulmonary  orifice,  is  al- 
ways an  important  element  in  differential  diagnosis,  and  points  rather  to 
septum  defect  or  pulmonary  stenosis  than  to  endocarditis. 

"  (4)  An  abnormally  weak  second  pulmonic  sound  associated  with  a 
distinct  systolic  murmur  is  a  symptom  which  in  early  childhood  is  only  to 
be  explained  by  the  assumption  of  a  congenital  pulmonary  stenosis,  and 
possesses  therefore  an  importance  from  a  point  of  differential  diagnosis 
which  is  not  to  be  underestimated. 

"  (5)  Absence  of  a  palpable  thrill,  despite  loud  murmurs  which  are 
heard  over  the  whole  precordial  region,  is  rare  except  with  congenital  de- 
fects in  the  septum,  and  it  speaks  therefore  against  an  acquired  cardiac 
affection. 

"  (6)  Loud,  especially  vibratory,  systolic  murmurs,  with  the  point  of 
maximum  intensity  over  the  upper  third  of  the  sternum,  associated  with 
a  lack  of  marked  symptoms  of  hypertrophy  of  the  left  ventricle,  are  very 
important  for  the  diagnosis  of  a  persistence  of  the  ductus  Botalli,  and  can- 
not be  explained  by  the  assumption  of  an  endocarditis  of  the  aortic  valve." 

Escherich  suggests  that  the  systolic  basic  murmur  heard  sometimes  in 
the  newborn,  particularly  if  premature,  may  originate  in  the  ductus  Botalli 
before  its  closure. 

Treatment. — The  child  should  be  warmly  clad  and  guarded  from  all 
circumstances  liable  to  excite  l)ronchitis.  In  the  attacks  of  urgent  dysp- 
noea with  lividity  blood  should  be  freely  let.  Saline  cathartics  arc  also 
useful.  Digitalis  must  be  used  with  care;  it  is  sometimes  beneficial  in  the 
later  stages.  When  the  compensation  fails,  the  indications  for  treatment 
are  those  of  valvular  disease  in  adults. 

Chronic  Cyanosis. — There  is  a  remarkable  form  of  chronic  cyanosis,  of 
which  cases  have  been  reported  by  E.  C.  Cabot,  Saundby,  and  others,  in 
which  the  skin  is  puffy  and  dusky,  and  there  is  a  condition  of  extreme 
hyperglobula^mia;  the  red  corpuscles  may  be  above  12,000,000  per  cubic 
millimetre,  and  this  without  any  discoverable  cause  (Lancet,  1902,  i,  516). 


770  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

III.    DISEASES  OF  THE  AETERIES. 
I.    DEGENERATIONS. 

Fatty  degeneration  of  the  intima  is  extremely  common,  and  is  seen  in 
the  form  of  yellowish-white  spots  in  the  aorta  and  larger  vessels.  Calcifica- 
tion of  the  arterial  wall  follows  fatty  degeneration  and  sclerosis,  and  is  asso- 
ciated with  atheromatous  changes.  It  occurs  in  the  intima  and  the  media. 
In  the  latter  it  produces  what  is  sometimes  known  as  annular  calcification, 
which  occurs  particularly  in  the  middle  coat  of  medium-sized  vessels  and 
may  convert  them  into  firm  tubes. 

Hyaline  degeneration  may  attack  either  the  larger  or  the  smaller  vessels. 
In  the  former  the  intima  is  converted  into  a  smooth,  homogeneous  sub- 
stance; this  is  commonly  an  initial  stage  of  arterio-sclerosis;  here  it  is  a 
transformation  of  the  endothelial  lining.  Of  the  smaller  arteries  and  capil- 
laries hyaline  metamorphosis  is  oftenest  seen  in  the  glomeruli  of  the  kidneys. 
It  is  not  to  be  confounded  with  the  amyloid  change  which  is  prone  to 
occur  in  the  same  situation.  The  condition  is  variously  regarded  as  due 
to  coagulation  of  an  albuminous  fluid  and  hyaline  metamorphosis 
of  leucocytes  or  of  fibrin.  This  substance  reacts  like  the  last  with  Weigerf  s 
fibrin  stain. 


II.    ARTERIO-SCLEROSIS  (Arterio-capUlary  Fibrosis). 

The  conception  of  arterio-sclerosis  as  an  independent  affection — a  gen- 
eral disease  of  the  vascular  system — is  due  to  Gull  and  Sutton. 

Definition. — A  condition  of  thickening,  diffuse  or  circumscribed,  be- 
ginning in  the  intima,  consequent  upon  primary  changes  in  the  media  and 
adventitia,  but  which  later  involves  the  other  coats.  The  process  leads,  in 
the  larger  arteries,  to  what  is  known  as  atheroma  and  to  endarteritis  defor- 
mans, and  seriously  interferes  with  the  normal  functions  of  various  organs. 

Etiology. — (1)  As  an  involution  process  arterio-sclerosis  is  an  accom- 
paniment of  old  age,  and  is  the  expression  of  the  natural  wear  and  tear  to 
which  the  tubes  are  subjected.  Longevity  is  a  vascular  question,  which  has 
been  well  expressed  in  the  axiom  that  "  a  man  is  only  as  old  as  his  arte- 
ries." To  a  majority  of  men  death  comes  primarily  or  secondarily  through 
this  portal.  The  onset  of  what  may  be  called  physiological  arterio-sclerosis 
depends,  in  the  first  place,  upon  the  quality  of  arterial  tissue  (vital  rub- 
ber) which  the  individual  has  inherited,  and  secondly  upon  the  amount  of 
wear  and  tear  to  which  he  has  subjected  it.  That  the  former  plays  a 
most  important  role  is  shown  in  the  cases  in  which  arterio-sclerosis  sets  in 
early  in  life  in  individuals  in  whom  none  of  the  recognized  etiological  fac- 
tors can  be  found.  Thus,  for  instance,  a  man  of  twenty-eight  or  twenty- 
nine  may  have  the  arteries  of  a  man  of  sixty,  and  a  man  of  forty  may  pre- 
sent vessels  as  much  degenerated  as  they  should  be"  at  eighty.  Entire  fami- 
lies sometimes  show  this  tendency  to  early  arterio-sclerosis — a  tendency 


ARTERIO-SCLBROSIS.  771 

which  cannot  be  explained  in  any  other  way  than  that  in  the  make-up  of  the 
machine  bad  material  was  used  for  the  tubing. 

More  commonly  the  arterio-sclerosis  results  from  the  bad  use  of  good 
vessels,  and  among  the  circumstances  which  tend  to  produce  this  condi- 
tion are  the  following: 

(3)  Chronic  Intoxications. — Alcohol,  lead,  gout,  and  syphilis  play  an 
important  role  in  the  causation  of  arterio-sclerosis,  although  the  precise 
mode  of  their  action  is  not  yet  very  clear.  They  may  act,  as  Traube  sug- 
gests, by  increasing  the  peripheral  resistance  in  the  smaller  vessels  and  in 
this  way  raising  the  blood  tension,  or  possibly,  as  Bright  taught,  they  alter 
the  quality  of  the  blood  and  render  more  difficult  its  passage  through  the 
capillaries. 

The  poisons  of  syphilis  and  of  gout,  as  well  as  of  many  of  the  acute  in- 
fections, may  produce  degenerative  changes  in  the  media  and  adventitia. 

(3)  Overeating. — I  am  more  and  more  impressed  with  the  part  played  by 
overeating  in  inducing  arterio-sclerosis.  There  are  many  cases  in  which 
there  is  no  other  factor.  The  high  pressure  at  which  many  men  now  live 
must  also  be  taken  into  account.  George  Cheyne's  advice,  which  I  quote 
at  page  470,  was  never  more  needed  than  by  the  present  generation. 

(4)  Overwork  of  the  muscles,  which  acts  by  increasing  the  peripheral  re- 
sistance and  by  raising  the  blood-pressure. 

(5)  Renal  Disease. — The  relation  between  the  arterial  and  kidney  lesions 
has  been  much  discussed,  some  regarding  the  arterial  degeneration  as  sec- 
ondary, others  as  primary.  There  are  two  groups  of  cases,  one  in  which  the 
arterio-sclerosis  is  the  first  change,  and  the  other  in  which  it  is  secondary 
to  a  primary  affection  of  the  kidneys.  The  former  occurs,  I  believe,  with 
much  greater  frequency  than  has  been  supposed. 

Morbid  Anatomy. — Thoma  divides  the  cases  into  primary  arterio- 
sclerosis, in  which  there  are  local  changes  in  the  arteries  leading  to  dilata- 
tion and  a  compensatory  increase  of  the  connective  tissue  of  the  intima; 
secondary  arterio-sclerosis,  due  to  changes  in  the  arteries  which  follow  in- 
creased resistance  to  the  blood-flow  in  the  peripheral  vessels.  This  in- 
creased tension  leads  to  dilatation  and  to  slowing  of  the  blood-stream  and  a 
secondary  compensatory  development  of  the  intima. 

In  a  study  of  41  autopsies  upon  arterio-sclerotic  cases  from  my  wards, 
Councilman  follows  the  useful  division  into  nodular,  senile,  and  diffuse 
forms. 

(a)  Nodular  Form. — In  the  circumscribed  or  nodular  variety  the  ma- 
croscopic changes  are  very  characteristic.  The  aorta  presents,  in  the  early 
stages,  from  the  ring  to  bifurcation,  numerous  flat  projections,  yellowish 
or  yellowish-white  in  color,  hemispherical  in  outline,  and  situated  particu- 
larly about  the  orifices  of  the  branches.  In  the  early  stage  these  patches 
are  scattered  and  do  not  involve  the  entire  intima.  In  more  advanced 
grades  the  patches  undergo  atheromatous  changes.  The  material  constitut- 
ing the  button  undergoes  softening  and  breaks  up  into  granular  material, 
consisting  of  molecular  debris — the  so-called  atheromatous  abscess. 

In  the  circumscribed  or  nodular  arterio-sclerosis  the  primary  alteration 
consists  in  a  rlegenoration  or  a  local  infiltration  in  the  media  and  adven- 
titia, chiefly  about  the  vasa  vasorum.     The  affection  is  really  a  mesarteritis 


772  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

and  a  periarteritis.  These  changes  lead  to  the  weakening  of  the  wall  lib 
the  affected  area,  at  which  spot  the  proliferative  changes  commence  in  the 
intima,  partictilarly  in  the  subendothelial  structures,  with  gradual  thick- 
ening and  the  formation  of  an  atheromatous  button  or  a  patch  of  nodular 
arterio-sclerosis.  The  researches  of  Thoma  haye  shown  that  this  is  really 
a  compensatory  process,  and  that  before  its  degeneration  the  nodular  but- 
ton, which  post  mortem  projects  beyond  the  lumen,  during  life  fills  up  and 
obliterates  what  would  otherwise  be  a  depression  of  the  wall  in  consequence 
of  the  weakening  of  the  media.  A  similar  process  goes  on  in  the  smaller 
vessels,  and  in  any  one  of  the  smaller  branches  it  can  be  readily  seen  on  sec- 
tion that  each  patch  of  endarteritis  corresponds  to  a  defect  in  the  media 
and  often  to  changes  in  the  adventitia.  The  condition  is  one  which  may 
lead  to  rapid  dilatation  or  to  the  production  of  an  aneurism,  particularly  in 
the  early  stage,  before  the  weakened  spot  is  thickened  and  strengthened  by 
the  intimal  changes. 

(&)  Senile  Arteriosclerosis. — The  larger  arteries  are  dilated  and  tortu- 
ous, the  walls  thin  but  stiff,  and  often  converted  into  rigid  tubes.  The 
subendothelial  tissue  undergoes  degeneration  and  in  spots  breaks  down, 
forming  the  so-called  atheromatous  abscess,  the  contents  of  which  con- 
sist of  a  molecular  debris.  They  may  open  into  the  lumen,  when  they  are 
known  as  atheromatous  ulcers.  The  greater  portion  of  the  intima  may 
be  occupied  by  rough  calcareous  plates,  with  here  and  there  fissures  and 
losses  of  substance,  upon  which  not  infrequently  white  thrombi  are  de- 
posited. Microscopically  there  is  extreme  degeneration  of  the  coats,  par- 
ticularly of  the  media.  Senile  atrophy  of  the  liver  and  kidneys  usually  ac- 
companies these  changes.  Senile  changes  are  common  in  other  organs. 
The  heart  may  be  small  and  is  not  necessarily  hypertrophied.  In  7  of  14 
cases  of  Councilman's  series  there  was  no  enlargement.  Brown  atrophy  is 
common. 

(c)  Diffuse  Arterio-sclerosis. — The  process  is  widespread  throughout  the 
aorta  and  its  branches,  in  the  former  usually,  but  not  necessarily,  associated 
with  the  nodular  form.  The  subjects  of  this  variety  are  usually  middle- 
aged  men,  but  it  may  occur  early.  Of  the  27  in  Councilman's  series  be- 
longing to  this  group  the  majority  were  between  the  ages  of  forty  and  fifty- 
five.  The  youngest  was  a  negro  of  twenty-three  and  the  oldest  a  man  of 
sixty.  The  affection  is  very  prevalent  among  negroes;  less  than  50  per  cent 
were  in  whites,  whereas  the  ratio  of  colored  to  white  patients  in  the  wards 
is  one  to  seven.  The  affection  is  met  with  in  strongly  built,  muscular  men 
and,  as  Councilman  remarks,  they  rarely  present  on  the  autopsy  table  signs 
of  general  anasarca  or,  if  oedema  exists,  it  has  come  on  during  the  last  few 
days  of  life.  The  aorta  and  its  branches  are  more  or  less  dilated,  the 
branches  sometimes  more  than  the  trunk.  The  intima  may  be  smooth  and 
show  very  slight  changes  to  the  naked  eye;  more  commonly  there  are  scat- 
tered elevated  areas  of  an  opaque  white  color,  some  of  which  may  have  un- 
dergone atheromatous  changes  as  in  the  senile  form. 

Microscopically  in  the  several  forms  the  media  shows  necrotic  and  hya- 
line changes,  involving  in  the  larger  arteries  both  muscular  and  elastic  ele- 
ments, and  the  intima  presents  a  great  increase  in  the  subendothelial  con- 


ARTERIO-SCLEROSIS.  Y73 

nective  tissue,  which  is  particularly  marked  opposite  areas  of  advanced 
degeneration  in  the  media.  The  small  arteries — those  in  the  kidneys,  for 
example — show  "  a  thickening  of  the  wall,  due  to  the  formation  of  a  homo- 
geneous hyaline  tissue  within  the  muscular  coat.  This  tissue  contains  but 
few  cells,  is  faintly  striated,  and  stains  a  light  brown  in  the  osmic  acid  used 
in  the  hardening  solution.  In  many  of  the  smallest  vessels  nothing  can  be 
seen  of  the  elastic  lamina,  in  others  only  fragments  can  be  made  out,  in 
others  it  is  preserved.  .  .  .  The  muscular  fibres  of  the  media  show  marked 
atrophic  changes.  Fatty  degeneration  of  the  cells  can  be  made  out  both  in 
fresh  sections  and  after  hardening  in  Flemming's  solution.  The  nuclei  are 
thin  and  atrophic  and  vacuoles  are  sometimes  seen  in  them.  In  some  ar- 
teries the  muscle-fibres  have  almost  disappeared  and  the  media  is  changed 
into  a  homogeneous  tissue,  similar  to  that  in  the  thickened  intima  "  (Coun- 
cilman). The  degeneration  of  the  media  is  most  marked  in  the  smaller 
arteries.  The  capillaries  are  thickened,  particularly  those  of  the  glomeruli 
of  the  kidneys,  which  are  often  obliterated  and  involved  in  extensive  hya- 
line degeneration. 

It  is  in  this  group  of  cases  that  the  heart  shows  the  most  important 
changes.  The  average  weight  in  the  cases  referred  to  was  over  450  grammes, 
and  there  were  two  cases  in  which  without  valvular  disease  the  weight  was 
over  800  grammes.  Fibrous  myocarditis  is  often  present,  particularly  when 
the  coronary  arteries  are  involved.  The  semilunar  valves  are  sometimes 
opaque  and  sclerotic,  and  may  be  incompetent.  The  kidneys  may  show 
extensive  sclerosis,  but  in  many  cases  the  changes  are  so  slight  that  macro- 
scopically  they  might  be  overlooked.  They  may  be  increased  in  size. '  The 
capsule  is  usually  adherent,  the  surface  a  little  rough,  and  very  often  pre- 
sents atrophic  areas  at  a  lower  level,  of  a  deep-red  color.  Increased  consist- 
ence is  always  present. 

Sclerosis  of  the  pulmonary  artery  is  met  with  in  all  conditions  which 
for  a  long  time  increase  the  tension  in  the  lesser  circulation,  particularly 
in  mitral  valve  disease  and  in  emphysema.  Sometimes  the  sclerosis  reaches 
a  high  gra,de  and  is  accompanied  with  aneurismal  dilatation  of  the  primary 
and  secondary  branches,  more  rarely  with  insufficiency  of  the  pulmonary 
valve.  In  a  remarkable  case  of  a  young  man  of  twenty-four,  reported  by 
Romberg  from  Curschmann's  clinic,  the  pulmonary  arteries  were  involved 
in  most  extensive  arterio-sclerosis;  the  main  branches  were  dilated,  and  the 
smaller  branches  were  the  seat  of  the  most  extreme  sclerotic  changes.  On 
the  other  hand,  the  aorta  and  its  branches  were  normal.  The  heart  was 
greatly  hypertrophied,  and  the  clinical  symptoms  were  those  of  a  congeni- 
tal heart  affection.  In  many  cases  of  arterio-sclerosis  the  condition  is  not 
confined  to  the  arteries,  but  extends  not  only  to  the  capillaries  but  also  to 
the  veins,  and  may  properly  be  termed  an  angio-sclerosis. 

Sclerosis  of  the  veins — phleho-sclerosis — is  not  at  all  an  uncommon  ac- 
companiment of  arterio-sclerosis,  and  is  a  condition  to  which  of  late  a  good 
deal  of  attention  has  been  paid.  It  is  seen  in  conditions  of  heightened 
blood-pressure,  as  in  the  portal  system  in  cirrhosis  of  the  liver  and  in  the 
pulmonary  veins  in  mitral  stenosis.  The  affected  vessels  arc  usually  dilated, 
and  the  intirna  shows,  as  in  the  arteries,  a  compensatory  thickening,  which 


'J'74:  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

is  particularly  marked  in  those  regions  in  which  the  media  is  thinned. 
The  new-formed  tissue  in  the  endophlebitis  may  undergo  hyaline  degenera- 
tion^ and  is  sometimes  extensively  calcified.  In  a  case  of  fibroid  oblitera- 
tion of  the  portal  vein  of  long  standing,  I  found  the  intima  of  the  greatly 
dilated  gastric,  splenic,  and  mesenteric  veins  extensively  calcified.  Without 
existing  arterio-sclerosis  the  peripheral  veins  may  be  sclerotic,  usually  in 
conditions  of  debility,  but  occasionally  in  young  persons. 

Symptoms. — Increased  Tension. — The  pressure  with  which  the  blood 
flows  in  the  arteries  depends  upon  the  degree  of  peripheral  resistance  and 
the  force  of  the  ventricular  contraction.  A  high-tension  pulse  may  exist 
with  very  little  arterio-sclerosis;  but,  as  a  rule,  when  the  condition  has  been 
persistent,  the  sclerosis  and  high  tension  are  found  together.  The  pulse 
wave  is  slow  in  its  ascent,  enduring,  subsides  slowly,  and  in  the  intervals 
between  the  beats  the  vessel  remains  full  and  firm.  It  may  be  very  difhcult 
to  obliterate  the  pulse,  and  the  firmest  pressure  on  the  radial  or  the  tem- 
poral artery  may  not  be  sufficient  to  annihilate  the  pulse  wave  beyond  the 
point  of  pressure.  This  is  not  always  a  sign  of  high  tension.  The  anas- 
tomotic or  recurrent  pulse  may  be  felt  even  when  the  tension  is  low,  as  in 
the  early  stage  of  typhoid  fever.  Pressure  on  the  ulnar  artery  at  once  ob- 
literates it.*  The  sphygmographic  tracing  shows  a  sloping,  short  up-stroke, 
no  percussion  wave,  and  a  slow,  gradual  descent,  in  w-hich  the  dicrotic  wave 
is  very  slightly  marked.  It  may  be  difficult  to  estimate  how  much  of  the 
hardness  and  firmness  is  due  to  the  tension  of  the  blood  within  the  vessel, 
and  how  much  to  the  thickening  of  the  wall.  But  if,  for  example,  when 
the  radial  is  compressed  with  the  index-finger  the  artery  can  be  felt  beyond 
the  point  of  compression,  its  walls  are  sclerosed. 

Hypertrophy  of  the  Heart. — In  consequence  of  the  peripheral  resistance 
and  increased  work  the  left  ventricle  increases  in  size,  and  some  of  the 
purest  examples  of  simple  hypertrophy  occur  in  this  condition.  The  cham- 
ber may  be  little,  if  at  all,  dilated.  The  apex  beat  is  dislocated  in  advanced 
cases  an  inch  or  more  beyond  the  nipple  line.  The  impulse  is  heaving  and 
forcible.     The  aortic  second  sound  is  clear,  ringing,  and  accentuated. 

The  combination  of  increased  arterial  tension,  a  palpable  thickening 
of  the  arteries,  hypertrophy  of  the  left  ventricle,  and  accentuation  of  the 
aortic  second  sound  are  signs  pathognomonic  of  arterio-sclerosis.  From 
this  period  of  establishment  the  course  of  the  disease  may  be  very  varied. 
For  years  the  patient  may  have  good  health,  and  be  in  a  condition  analo- 
gous to  that  of  a  person  with  a  well-compensated  valvular  lesion.  There 
may  be  no  renal  symptoms,  or  there  may  be  the  passage  of  a  larger  amoimt 
of  urine  than  normal,  with  transient  albuminuria,  and  now  and  then 
hyaline  tube-casts.  The  subsequent  history  is  extraordinarily  diverse,  de- 
pending upon  the  vascular  territory  in  which  the  sclerosis  is  most  advanced, 
or  upon  the  accidents  which  are  so  liable  to  happen,  and  the  symptoms  may 
be  cardiac,  cerebral,  renal,  etc. 

(1)  Cardiac. — The  involvement  of  the  coronary  arteries  may  lead  to 
the  various  symptoms  already  referred  to  under  that  section — thrombosis 

*  The  student  is  referred  to  Ewart's  and  to  Broadbent's  manuals  on  the  pulse. 


ARTERIO-SCLEROSIS.  775 

with  sudden  death,  fihroid  degeneration  of  the  heart,  aneurism  of  the  heart, 
rupture,  and  angina  pectoris.  Angina  pectoris  is  not  uncommon,  and  in 
the  true  variety  is  almost  always  associated  with  arterio-sclerosis.  A  sec- 
ond important  group  of  cardiac  symptoms  results  from  the  dilatation  which 
ultimately  may  follow  the  hypertrophy.  The  patient  then  presents  all  the 
symptoms  of  cardiac  insufficiency — dyspnoea,  scanty  urine,  and  very  often 
serous  efEusions.  If  the  case  has  come  under  observation  for  the  first  time 
the  clinical  picture  is  that  of  chronic  valvular  disease,  and  the  existence  of 
a  loud  blowing  murmur  at  the  apex  may  throw  the  practitioner  off  his 
guard.    Many  cases  terminate  in  this  way. 

(2)  The  cerebral  symptoms  of  arterio-sclerosis  are  varied  and  important, 
and  embrace  those  of  many  degenerative  diseases,  acute  and  chronic  (which 
follow  sclerosis  of  the  smaller  branches),  and  cerebral  haemorrhage. 

Transient  hemiplegia,  monoplegia,  or  aphasia  may  occur  in  advanced 
arterio-sclerosis.  Eecovery  may  be  perfect.  It  is  difficult  to  say  upon 
what  these  attacks  depend.  Spasm  of  the  arteries  has  been  suggested,  but 
the  condition  of  the  smallest  arteries  is  not  very  favorable  to  this  view. 
Peabody  has  recently  called  attention  to  these  cases,  which  are  more  com- 
mon than  is  indicated  in  the  literature.  Vertigo  occurs  frequently,  and  may 
be  either  simple,  or  is  associated  with  slow  pulse  and  syncopal  or  epilepti- 
form attacks — the  Stokes- Adams  syndrome. 

(3)  Renal  symptoms  supervene  in  a  large  number  of  the  cases.  A  sclero- 
sis, patchy  or  diffuse,  is  present  in  a  majority  of  the  cases  at  the  time  of 
autopsy,  and  the  condition  is  practically  that  of  contracted  kidney.  It  is 
seen  in  a  typical  manner  in  the  senile  form,  and  not  infrequently  develops 
early  in  life  as  a  direct  sequence  of  the  diffuse  variety.  It  is  often  difificult 
to  decide  clinically  (and  the  question  is  one  upon  which  good  observers 
might  not  agree  in  a  given  case)  whether  the  arterial  or  the  renal  disease 
has  been  primary. 

(4)  Among  other  events  in  arterio-sclerosis  may  be  mentioned  gangrene 
of  the  extremities,  due  either  directly  to  endarteritis  or  to  the  dislodgment 
of  thrombi.  Sudden  transient  paraplegia  may  occur,  and  the  remarkable 
cbndition  known  as  intermittent  claudication. 

Treatment. — In  the  late  stages  the  conditions  must  be  treated  as  they 
arise  in  connection  with  the  various  viscera.  In  the  early  stages,  before 
any  local  symptoms  are  manifest,  the  patient  should  be  enjoined  to  live  a 
quiet,  well-regulated  life,  avoiding  excesses  in  food  and  drink.  It  is  usu- 
ally best  to  explain  frankly  the  condition  of  affairs,  and  so  gain  his  intelli- 
gent co-operation.  Special  attention  should  be  paid  to  the  state  of  the 
bowels  and  urine,  and  the  secretion  of  the  skin  should  be  kept  active  by 
daily  baths.  Alcohol  in  all  forms  should  be  prohibited,  and  the  food  should 
be  restricted  to  plain,  wholesome  articles.  The  use  of  mineral  waters  or  a 
residence  every  year  at  one  of  the  mineral  springs  is  usually  serviceable. 
If  there  has  been  a  syphilitic  history  an  occasional  course  of  iodide  of  po- 
tassium is  indicated,  and  whenever  the  pulse  tension  is  high  nitroglvcerin 
may  be  used. 

In  cases  which  come  under  observation  for  the  first  time  with  dyspncea, 
slight  lividity,  and  signs  of  cardiac  insufficiency,  venesection  is  indicated. 


/j'Ye  DISEASES  OF  THE  CIECULATOEY  SYSTEM. 

In  some  instances,  with  very  high  tension,  striking  relief  is  afforded  by  the 
abstraction  of  20  ounces  of  blood. 


III.    ANEURISM. 

Th6  following  forms  of  aneurism  are  usually  recognized: 

(a)  The  true,  in  which  the  sac  is  formed  of  one  or  more  of  the  arterial 
coats.  This  may  be  fusiform,  cylindrical,  or  cirsoid  (in  which  the  dilatation 
is  in  an  artery  and  its  branches),  or  it  may  be  circumscribed  or  sacculated. 
Aneurisms  are  usually  fusiform,  resulting  from  uniform  dilatation  of  the 
vessel,  or  saccular. 

(&)  The  false  aneurism,  in  which  there  is  rupture  of  all  the  coats,  and 
the  blood  is  free  (or  circumscribed)  in  the  tissues. 

(c)  The  dissecting  aneurism,  which  results  from  injury  or  laceration  of 
the  internal  coat.  The  blood  dissects  betwen  the  layers;  hence  the  name, 
dissecting  aneurism.     This  occurs  usually  in  the  aorta,  persisting  for  years. 

(d)  Arterio-venous  aneurism  results  when  a  communication  is  established 
between  an  artery  and  a  vein.  A  sac  may  intervene,  in  which  case  we  have 
what  is  called  a  varicose  aneurism;  but  in  many  cases  the  communication  is 
direct  and  the  chief  change  is  in  the  vein,  which  is  dilated,  tortuous,  and 
pulsating,  the  condition  being  termed  an  aneurismal  varix. 

Etiology  and  Pathology. — Aneurisms  arise:  (a)  By  the  gradual 
diffuse  distention  of  the  arterial  coats,  which  have  been  weakened  by  arterio- 
sclerosis, particularly  in  its  early  stages,  before  compensatory  endarteritis 
develops.  The  arch  of  the  aorta  is  often  dilated  in  this  way  so  as  to  form 
an  irregular  aneurism. 

(h)  In  consequence  of  circumscribed  loss  of  resisting  power  in  the  media 
and  adventitia,  and  often  from  a  laceration  of  the  media.  This  is  the 
most  common  cause  of  sacculated  aneurism.  The  laceration  is  frequently 
found  in  the  ascending  portion  of  the  arch  and  occurs  early  in  the  process 
of  arterio-sclerosis,  before  the  compensatory  thickening  has  taken  place. 
Occasionally  one  meets  with  remarkable  specimens  illustrating  the  impor- 
tant part  played  by  this  process.  The  intima  may  also  be  torn.  In  a  case 
of  Daland's  there  was  just  above  the  aortic  valves  an  old  transverse  tear 
of  the  intima,  extending  almost  the  entire  circumference  of  the  vessel. 
Sclerosis  of  the  media  and  adventitia  had  taken  place  and  the  process  was 
evidently  of  some  standing.  An  inch  or  more  above  it  was  a  fresh  trans- 
verse rent  which  had  produced  a  dissecting  aneurism.  These  arterio-scle- 
rotic  aneurisms,  as  they  are  called,  are  found  also  in  the  smaller  vessels. 

(c)  Embolic  Aneurism. — When  an  embolus  has  lodged  in  a  vessel  and 
permanently  plugged  it,  aneurismal  dilatation  may  follow  on  the  proximal 
side.  The  embolus  itself  may,  if  a  calcified  fragment  from  a  valve,  lacer- 
ate the  wall,  or  if  infected  may  produce  inflammation  and  softening. 

(d)  Mycotic  Aneurism. — The  importance  of  this  form  has  been  specially 
considered  by  Eppinger  in  his  exhaustive  monograph.  The  occurrence  of 
multiple  aneurisms  in  malignant  endocarditis  has  been  observed  by  several 
writers.     Probably  the  first  case  in  which  the  mycotic  nature  was  recog- 


ANEURISM.  777 

nized  was  one  which  occurred  at  the  Montreal  General  Hospital  and  is  re- 
ported in  full  in  my  lectures  on  malignant  endocarditis.  In  addition  to  the 
ulceration  of  the  valves  there  were  four  aneurisms  of  the  arch,  of  which 
one  was  large  and  saccular,  and  three  w^ere  not  bigger  than  cherries.  An  ex- 
tensive growth  of  micrococci  was  present. 

A  form  of  parasitic  aneurism  which  occurs  with  great  frequency  in  the 
mesenteric  arteries  of  the  horse  is  due  to  the  development  of  the  strongylus 
armatus. 

Thoma  has  described  a  "  traction  "  aneurism  of  the  concavity  of  the 
arch  at  the  point  of  insertion  of  the  remnant  of  the  ductus  Botalli  (Vir- 
chow's  Archiv,  Bd.  122). 

And,  lastly,  there  are  cases  in  which  without  any  definite  cause  there 
is  a  tendency  to  the  development  of  aneurisms  in  various  parts  of  the 
body.  A  remarkable  instance  of  it  in  our  profession  was  afforded  by  the 
brilliant  Thomas  King  Chambers,  who  first  had  an  aneurism  in  the  left 
popliteal  artery,  eleven  years  subsequently  an  aneurism  in  the  right 
leg  which  was  cured  by  pressure,  and  finally  aneurisms  of  the  carotid 
arteries. 

Tncidence  of  Aneurism. — At  St.  Bartholomew's  Hospital  during  thirty 
years  there  were  631  cases  of  aneurism.  In  468  the  disease  affected  the 
aorta,  in  80  the  popliteal,  in  21  the  femoral,  in  14  the  subclavian,  in  8  the 
carotid,  in  6  the  external  iliac  artery  (Oswald  A.  Browne). 

Aneueism  of  the  Thoeacic  Aoeta. 

The  causes  which  favor  the  development  of  arterio-sclerosis  prevail  in 
aortic  aneurism,  particularly  alcohol,  syphilis,  and  overwork.  The  great- 
est danger  probably  is  in  strong  muscular  men  with  commencing  degen- 
erative processes  in  the  arteries  (a  consequence  of  syphilis  or  alcohol  or  a 
result  of  hereditary  w^eakness  of  the  arterial  tissues),  who  during  a  sudden 
muscular  exertion  are  liable  to  lacerate  the  media,  the  intima  not  yet  being 
strengthened  by  compensatory  thickening  over  a  spot  of  mesarteritis.  Aneu- 
risms of  the  thoracic  aorta  vary  greatly  in  size  and  shape.  A  majority  of 
thein  are  saccular.  They  may  be  small  and  situated  just  above  the  aortic 
ring.  Others  form  large  tumors  which  project  externally  and  occupy  a 
large  portion  of  the  upper  thorax.  Small  sacs  from  the  descending  por- 
tion of  the  arch  may  compress  the  trachea  or  the  bronchi.  In  the  tho- 
racic portion  the  sac  may  erode  the  vertebrse  or  grow  into  the  pleural  cavity 
and  compress  the  lung.  In  some  instances  it  grows  through  the  ribs  and 
appears  in  the  back. 

Symptoms. — The  chief  influence  of  an  aneurism  is  manifested  in 
w^hat  are  known  as  pressure  effects.  In  the  absence  of  these  the  aneurisms 
attain  a  large  size  wdthout  producing  symptoms  or  seriously  interfering 
wdth  the  circulation.  Indeed,  a  useful  clinical  subdivision  as  given  by 
Bramwell  is  into  three  groups — aneurisms  which  are  entirely  latent  and 
give  no  physical  signs;  aneurisms  which  present  signs  of  intrathoracic 
pressure,  although  it  is  difficult  or  impossible  to  determine  the  nature  of  the 
lesion  producing  the  pressure;  and,  lastly,  aneurisms  which  produce  dis- 


778  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

tinct  tumors  with  well-marked  pressure  symptoms,  and  external  signs. 
Broadbent  makes  another  useful  division  into  aneurism  of  symptoms  and 
aneurism  of  physical  signs.  It  is  perhaps  best  to  consider  aneurisms  of  the 
aorta  according  to'  the  situation  of  the  tumor. 

(a)  Aneurisms  ■  of  the  Ascending  Portion  of  the  Arch. — When  just  above 
the  sinuses  of  Valsalva  they  are  often  small  and  latent.  The  first  symp- 
tom may  be  rupture^,  which  usually  takes  place  into  the  pericardium  and 
causes  instant  death.  Above  the  sinuses,  along  the  convex  border  of  the 
ascending  part,  aneurism  frequently  develops,  and  may  grow  to  a  large 
size,  either  passing  out  into  the  right  pleura  or  forward,  pointing  at  the 
second  or  third  interspace,  eroding  the  ribs  and  sternum,  and  producing 
large  external  tumors.  In  this  situation  the  sac  is  liable,  indeed,  to  com- 
press the  superior  vena  cava,  causing  engorgement  of  the  vessels  of  the 
head  and  arm,  sometimes  compressing  only  the  subclavian  vein,  and  caus- 
ing enlargement  and  oedema  of  the  right  arm.  Perforation  may  take  place 
into  the  superior  vena  cava,  of  which  accident  Pepper  and  Griffith  have 
collected  39  cases.  In  rare  instances,  when  the  aneurism  springs  from  the 
concave  side  of  the  vessels,  the  tumor  may  appear  to  the  left  of  the  sternum. 
Large  aneurisms  in  this  situation  may  cause  much  dislocation  of  the 
heart,  pushing  it  down  and  to  the  left,  and  sometimes  compressing  the 
inferior  vena  cava,  and  causing  swelling  of  the  feet  and  ascites.  The  right 
recurrent  laryngeal  nerve  is  often  pressed  upon  by  these  tumors.  The  in- 
nominate artery  is  rarely  involved.  Death  commonly  follows  from  rupture 
into  the  pericardium,  the  pleura,  or  into  the  superior  cava;  less  commonly 
from  rupture  externally,  sometimes  from  syncope. 

{h)[  Aneurisms  of  the  Transverse  Arch. — The  direction  of  their  growth  is 
most  commonly  backward,  but  they  may  grow  forward,  erode  the  sternum, 
and  produce  large  tumors.  The  tumor  presents  in  the  middle  line  and  to 
the  right  of  the  sternum  much  more  often  than  to  the  left,  which  occurred 
in  only  4  of  35  aneurisms  in  this  situation  (0.  A.  Browne).  Even  when 
small  and  producing  no  external  tumor  they  may  cause  marked  pressure 
signs  in  their  growth  backward  toward  the  spine,  involving  the  trachea 
and  the  oesophagus,  and  giving  rise  to  cough,  which  is  often  of  a  parox- 
ysmal character,  and  dysphagia.  The  left  recurrent  laryngeal  is  often  in- 
volved in  its  course  round  the  arch.  A  small  aneurism  from  the  lower  or 
posterior  wall  of  the  arch  may  compress  a  bronchus,  inducing  bronchor- 
rhoea,  gradual  bronchiectasy,  and  suppuration  in  the  lung — a  process  which 
by  no  means  infrequently  causes  death  in  aneurism,  and  a  condition  which 
at  the  Montreal  General  Hospital  we  were  in  the  habit  of  terming  aneu- 
rismal  phthisis.  Occasionally  enormous  aneurisms  develop  in  this  situa- 
tion, and  grow  into  both  pleurre,  extending  between  the  manubrium  and  the 
vertebrae;  they  may  persist  for  years.  The  sac  may  be  evident  at  the  sternal 
notch.  The  innominate  artery,  less  commonly  the  left  carotid  and  sub- 
clavian, may  be  involved  in  the  sac,  and  the  radial  or  carotid  pulse  may  be 
absent  or  retarded.  Pressure  on  the  sympathetic  may  at  first  cause  dilata- 
tion and  subsequently  contraction  of  the  pupil.  Sometimes  the  thoracic 
duct  is  compressed. 

The  ascending  and  transverse  portions  of  the  arch  are  not  infrequently 


ANEURISM.  779 

involved  together,  usually  without  the  branches;  the  tumor  grows  upward, 
or  upward  and  to  the  right. 

(c)  Aneurisms  of  the  Descending  Portion  of  the  Arch. — The  sac  projects 
to  the  left  and  backward,  and  often  erodes  the  vertebrse  from  the  third  to 
the  sixth  dorsal,  causing  great  pain  and  sometimes  compression  of  the  spinal 
cord.  Dysphagia  is  common.  Pressure  on  the  bronchi  may  induce  bron- 
chiectasy,  with  retention  of  secretions,  and  fever.  A  tumor  may  appear 
externally  in  the  region  of  the  scapula,  and  here  attain  an  enormous  size. 
Death  not  infrequently  occurs  from  rupture  into  the  pleura. 

(d)  Aneurisms  of  the  Descending  Thoracic  Aorta. — The  larger  number 
occur  close  to  the  diaphragm,  the  sac  lying  upon  or  to  the  left  of  the  bodies 
of  the  lower  dorsal  vertebrse,  which  are  often  eroded.  The  sac  may  reach 
a  large  size  and  form  a  very  large  tumor  in  the  back. 

Diagnosis  and  Physical  Signs. — Inspection. — A  good  light  is  es- 
sential; cases  are  often  overlooked  owing  to  a  hasty  inspection.  In  many 
instances  it  is  negative.  On  either  side  of  the  sternum  there  may  be  abnor- 
mal pulsation,  due  to  dislocation  of  the  heart,  to  deformity  of  the  thorax, 
or  to  retraction  of  the  lung.  The  aneurismal  pulsation  is  usually  above 
the  level  of  the  third  rib  and  most  commonly  to  the  right  of  the  sternum, 
either  in  the  first  or  second  interspace.  It  may  "he  only  a  diffuse  heaving 
impulse  without  any  external  tumor.  Often  the  impulse  is  noticed  only 
when  the  chest  is  looked  at  obliquely  in  a  favorable  light.  Wlien  the  in- 
nominate is  involved  the  throbbing  may  pass  into  the  neck  or  be  apparent 
•at .the  sternal  notch.  Posteriorly,  when  pulsation  occurs,  it  is  most  com- 
monly found  to  the  left  of  the  spine.  An  external  tumor  is  present  in 
many  cases,  projecting  either  through  the  upper  part  of  the  sternum  or  to 
the  right,  sometimes  involving  the  sternum  and  costal  cartilages  on  both 
sides,  forming  a  swelling  the  size  of  a  cocoa-nut  or  even  larger.  The  skin 
is  thin,  often  blood-stained,  or  it  may  have  ruptured,  exposing  the  laminae 
of  the  sac.  The  apex  beat  may  be  much  dislocated,  particularly  when  the 
sac  is  large.  It  is  more  commonly  a  dislocation  from  pressure  than  from 
enlargement  of  the  heart  itself. 

Palpation. — The  area  and  degree  of  pulsation  are  best  determined  by 
palpation.  When  the  aneurism  is  deep-seated  and  not  apparent  externally, 
the  bimanual  method  should  be  used,  one  hand  upon  the  spine  and  the 
other  on  the  sternum.  When  the  sac  has  perforated  the  chest  wall  the 
impulse  is,  as  a  rule,  forcible,  slow,  heaving,  and  expansile.  The  resistance 
may  be  very  great  if  there  are  thick  laminae  beneath  the  skin;  more  rarely 
the  sac  is  soft  and  fluctuating.  The  hand  upon  the  sac,  or  on  the  region 
in  which  it  is  in  contact  with  the  chest  wall,  feels  in  many  cases  a  diastolic 
shock,  often  of  great  intensity,  which  forms  one  of  the  valuable  physical 
signs  of  aneurism.  A  systolic  thrill  is  sometimes  present,  not  so  often  in 
saccular  aneurisms  as  in  the  dilatation  of  the  arch.  The  pulsation  may 
sometimes  be  felt  in  the  suprasternal  notch. 

Percussion. — The  small  and  deep-seated  aneurisms  are  in  this  respect 
negative.  In  the  larger  tumors,  as  soon  as  the  sac  reaches  the  chest  wall, 
there  is  produced  an  area  of  abnormal  dulness,  the  position  of  which  de- 
pends upon  the  part  of  the  aorta  affected.     Aneurisms  of  the  ascending 


780  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

arch  grow  forward  and  to  the  right,  producing  dulness  on  one  side  of  the 
manubrium;  those  from  the  transverse  arch  produce  dulness  in  the  middle 
line,  extending  toward  the  left  of  the  sternum,  while  aneurisms  of  the 
descending  portion  most  commonly  produce  dulness  in  the  left  inter- 
scapular and  scapular  regions.  The  percussion  note  is  flat  and  gives  a 
feeling  of  increased  resistance. 

Auscultation. — Adventitious  sounds  are  not  always  to  be  heard.  Even 
in  a  large  sac  there  may  be  no  murmur.  Much  depends  upon  the  thick- 
ness of  the  laminge  of  fibrin.  An  important  sign,  particularly  if  heard 
over  a  dull  region,  is  a  ringing,  accentuated  second  sound,  a  phenomenon 
rarely  missed  in  large  aneurisms  of  the  aortic  arch.  A  systolic  murmur 
may  be  present;  sometimes  a  double  murmur,  in  which  case  the  diastolic 
hruit  is  usually  due  to  associated  aortic  insufficiency.  The  systolic  mur- 
mur alone  is  of  little  moment  in  the  diagnosis  of  an  aneurismal  sac.  "With 
the  single  stethoscope  the  shock  of  the  impulse  with  the  first  sound  is 
sometimes  very  marked. 

Among  other  physical  signs  of  importance  are  retardation  of  the  pulse 
in  the  arteries  beyond  the  aneurism,  or  in  those  involved  in  the  sac.  There 
may,  for  instance,  be  a  marked  difference  between  the  right  and  left  radial, 
both  in  volume  and  time.  A  physical  sign  of  large  thoracic  aneurism, 
which  I  have  not  seen  referred  to,  is  obliteration  of  the  pulse  in  the  ab- 
dominal aorta  and  its  branches.  My  attention  was  called  to  this  in  a 
patient  who  was  stated  to  have  aortic  insufficiency.  There  was  a  well- 
marked  diastolic  murmur,  but  in  the  femorals  and  in  the  aorta  I  was 
surprised  to  find  no  trace  of  pulsation,  and  not  the  slightest  throbbing  in 
the  abdominal  aorta  or  in  the  peripheral  arteries  of  the  leg.  The  circula- 
tion was,  however,  unimpaired  in  them  and  there  was  no  dilatation  of  the 
veins.  Attracted  by  this,  I  then  made  a  careful  examination  of  the  pa- 
tient's back,  when  the  circumstance  was  discovered,  which  neither  the 
patient  himself  nor  any  of  his  physicians  had  noticed,  that  he  had  a  very 
large  area  of  pulsation  in  the  left  scapular  region.  The  sac  probably  was 
large  enough  to  act  as  a  reservoir  annihilating  the  ventricular  systole,  and 
converting  the  intermittent  into  a  continuous  stream. 

The  tracheal  tugging,  a  valuable  sign  in  deep-seated  aneurisms,  was 
described  by  Surgeon-Major  Oliver,  and  was  specially  studied  by  my  col- 
leagues Eoss  and  MacDonnell  *  at  the  Montreal  General  Hospital.  Oliver 
gives  the  following  directions:  "Place  the  patient  in  the  erect  position, 
and  direct  him  to  close  his  mouth  and  elevate  his  chin  to  almost  the  full 
extent;  then  grasp  the  cricoid  cartilage  between  the  finger  and  thumb, 
and  use  steady  and  gentle  upward  pressure  on  it,  when,  if  dilatation  or 
aneurism  exists,  the  pulsation  of  the  aorta  will  be  distinctly  felt  trans- 
mitted through  the  trachea  to  the  hand."  On  several  occasions  I  hnve 
known  this  to  be  a  sign  of  great  value  in  the  diagnosis  of  deep-seated  aneu- 
risms. I  have  never  felt  it  in  tumors,  or  in  the  extreme  dynamic  dilatation 
of  aortic  insufficiency.     It  may  be  visible  in  the  thyroid  cartilage. 

Occasionally  a  systolic  murmur  may  be  heard  in  the  trachea,  as  pointed 


*  LoiiadU  Lancet,  1891. 


ANEURISM.  781 

out  by  David  Drummond,  or  even  at  the  patient's  mouth,  when  opened. 
This  is  either  the  sound  conveyed  from  the  sac,  or  is  produced  by  the  air 
as  it  is  driven  out  of  the  Avind-pipe  during  the  systole. 

An  important  but  variable  feature  in  thoracic  aneurism  is  paiii,  which 
is  particularly  marked  in  deep-seated  tumors.  It  is  usually  paroxysmal, 
sharp,  and  lancinating,  often  very  severe  when  the  tumor  is  eroding  the 
vertebrae,  or  perforating  the  chest  wall.  In  the  latter  case,  after  perfora- 
tion the  pain  may  cease.  Anginal  attacks  are  not  uncommon,  particularly 
in  aneurisms  at  the  root  of  the  aorta.  Frequently  the  pain  radiates  down 
the  left  arm  or  up  the  neck,  sometimes  along  the  upper  intercostal  nerves. 
Cough  results  either  from  the  direct  pressure  on  the  wind-pipe,  or  is  as- 
sociated with  bronchitis.  The  expectoration  in  these  instances  is  abundant, 
thin,  and  watery;  subsequently  it  becomes  thick  and  turbid.  Paroxysmal 
cough  of  a  peculiar  brazen,  ringing  character  is  a  characteristic  symptom 
in  some  cases,  particularly  when  there  is  pressure  on  the  recurrent  laryn- 
geal nerves,  or  the  cough  may  have  a  peculiar  wheezy  quality — the  "  goose 
cough." 

Dyspnoea,  which  is  common  in  cases  of  aneurism  of  the  transverse  por- 
tion, is  not  necessarily  associated  with  pressure  on  the  recurrent  laryn- 
geal nerves,  but  may  be  due  directly  to  compression  of  the  trachea  or  the 
left  bronchus.  It  may  occur  with  marked  stridor.  Loss  of  voice  and 
hoarseness  are  consequences  of  pressure  on  the  recurrent  laryngeal,  usually 
the  left,  inducing  either  a  spasm  in  the  muscles  of  the  left  vocal  cord  or 
paralysis. 

Paralysis  of  an  abductor  on  one  side  may  be  present  without  any  symp- 
toms. It  is  more  particularly,  as  Semon  states,  when  the  paralytic  con- 
tractures supervene  that  the  attention  is  called  to  laryngeal  symptoms. 

Hcemorrhage  in  thoracic  aneurism  may  come  from  (a)  the  soft  granula- 
tions in  the  trachea  at  the  point  of  compression,  in  which  case  the  sputa  are 
blood-tinged,  but  large  quantities  of  blood  are  not  lost;  (&)  from  rupture 
of  the  sac  into  the  trachea  or  bronchi;  (c)  from  perforation  into  the  lung 
or  erosion  of  the  lung  tissue.  The  bleeding  may  be  profuse,  rapidly  prov- 
ing fatal,  and  is  a  connnon  cause  of  death.  It  may  persist  for  weeks  or 
months,  in  which  case  it  is  simply  hsemorrhagic  weeping  through  the  sac, 
which  is  exposed  in  the  trachea.  In  some  instances,  even  after  a  very 
profuse  haBmorrhage,  the  patient  recovers  and  may  live  for  years.  A  man 
with  well-marked  thoracic  aneurism,  whom  I  showed  to  my  class  at  the 
University  of  Pennsylvania  and  who  had  had  several  brisk  haemorrhages, 
died  four  years  after,  having  in  the  meantime  enjoyed  average  health. 
Death  from  haemorrhage  is  relatively  more  common  in  aneurism  of  the 
third  portion  of  the  arch  and  of  the  descending  aorta. 

Difficulty  of  swallowing  is  a  comparatively  rare  symptom,  and  may  be 
due  either  to  spasm  or  to  direct  compression.  The  sound  should  never 
be  passed  in  these  cases,  as  the  oesophagus  may  be  almost  eroded  and  a  per- 
foration may  be  made. 

Heart  Symptoms. — Pain  has  been  referred  to;  it  is  often  anginal  in 
character,  and  is  most  common  when  the  root  of  the  aorta  is  involved.  The 
heart  is  hypertrophied  in  less  tlian  one  half  the  cases.     The  aortic  valves 


782  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

are  sometimes  incompetent,  either  from  disease  of  the  segments  or  from 
stretching  of  the  aortic  ring. 

Among  other  signs  and  symptoms,  venous  compression,  which  has 
already  been  mentioned,  may  involve  one  subclavian  or  the  superior  vena 
cava.  A  curious  phenomenon  in  intrathoracic  aneurism  is  the  clubbing 
of  the  fingers  and  incurving  of  the  nails  of  one  hand,  of  which  two  ex- 
amples have  been  under  my  care,  in  both  without  any  special  distention 
or  signs  of  venous  engorgement.  Tumors  of  the  arch  may  involve  the 
pulmonary  artery,  producing  compression,  or  in  some  instances  adhesion 
of  the  pulmonary  segments  and  insufficiency  of  the  valve;  or  the  sac  may 
rupture  into  the  artery,  an  accident  which  happened  in  two  of  my  cases, 
producing  instantaneous  death. 

Pressure  on  the  sympathetic  is  particularly  liable  to  occur  in  growths 
from  the  ascending  portion  of  the  arch.  Either  the  upper  dorsal  or  the 
lower  cervical  ganglion  is  involved.  The  symptoms  are  variable.  If  the 
nerve  is  simply  irritated,  there  is  stimulation  of  the  vaso-dilator  fibres  and 
dilatation  of  the  pupil.  With  this  may  be  associated  pallor  of  the  same 
side  of  the  face.  On  the  other  hand,  destruction  of  the  cilio-spinal  branches 
causes  paralysis  of  the  dilator  fibres,  in  consequence  of  which  the  iris  con- 
tracts, the  vessels  on  the  side  of  the  head  dilate,  causing  congestion,  and 
in  some  instances  unilateral  sweating.  It  is  much  more  common  to  see 
the  pupillary  symptoms  alone  than  in  combination  either  with  pallor,  red- 
ness, or  sweating. 

The  clinical  picture  of  aneurism  of  the  aorta  is  extremely  varied.  Many 
cases  present  characteristic  symptoms  and  no  physical  signs,  while  others 
have  well-marked  physical  signs  and  no  symptoms.  As  Broadbent  re- 
marks, the  aneurism  of  physical  signs  springs  from  the  ascending  portion 
of  the  aorta;  the  aneurism  of  symptoms  grows  from  the  transverse  arch. 

Aneurism  of  the  aorta  may  be  confounded  with:  (a)  The  violent  throb- 
bing impulse  of  the  arch  in  aortic  insufficiency.  I  have  already  referred 
to  a  case  of  this  kind  in  which  the  diagnosis  of  aneurism  was  made  by  sev- 
eral good  observers. 

(h)  Simple  Dynamic  Pulsation. — No  instance  of  this,  which  is  common 
in  the  abdominal  aorta,  has  ever  come  under  my  notice.  One  which  came 
under  the  care  of  William  Murray  and  Bramwell  presented,  without  any 
pain  or  pressure  symptoms,  pulsation  and  dulness  over  the  aorta.  The  con- 
dition gradually  disappeared  and  was  thought  to  be  neurotic. 

(c)  Dislocation  of  the  heart  in  curvature  of  the  spine  may  cause  great 
displacement  of  the  aorta,  so  that  it  has  been  known  to  pulsate  forcibly 
to  the  right  of  the  sternum. 

(d)  Solid  Tumors. — When  the  tumor  projects  externally  and  pulsates 
the  difficulty  may  be  considerable.  In  tumor  the  heaving,  expansile  pulsa- 
tion is  absent,  and  there  is  not  that  sense  of  force  and  power  which  is  so 
striking  in  the  throbbing  of  a  perforating  aneurism.  There  is  not  to  be 
felt  as  in  aortic  aneurism  the  shock  of  the  heart-sounds,  particularly  the 
diastolic  shock.  Auscultatory  sounds  are  less  definite,  as  large  aneurisms 
may  occur  without  murmur;  and,  on  the  other  hand,  murmurs  may  be 
heard  over  tumors.     The  greatest  difficulty  is  in  the  deep-seated  thoracic 


ANEURISM.  Y83 

tumors,  and  here  the  diagnosis  may  be  impossible,  I  have  already  re- 
ferred to  the  case  "which  was  regarded  by  Skoda  as  aneurism  and  by  Op- 
polzer  as  tumor.  The  physical  signs  may  be  indefinite.  The  ringing 
aortic  second  sound  is  of  great  importance  and  is  rarely,  if  ever,  heard 
over  tumor.  Tracheal  tugging  is  here  a  valuable  sign.  Pressure  phe- 
nomena are  less  common  in  tumor,  whereas  pain  is  more  frequent.  The 
general  appearance  of  the  patient  in  aneurism  is  much  better  than  in 
tumor,  in  which  there  may  be  cachexia  and  enlargement  of  the  glands  in 
the  axilla  or  in  the  neck.  Healthy,  strong  males  who  have  worked  hard 
and  have  had  syphilis  are  the  most  common  subjects  of  aneurism.  Occa- 
sionally cancer  of  the  oesophagus  may  simulate  aneurism,  producing  pressure 
on  the  left  bronchus.  In  doubtful  cases  the  X-ray  picture  may  give  most 
valuable  information  as  to  the  situation  and  relations  of  the  aneurism. 

(e)  Pulsating  Pleurisy. — In  cases  of  empyema  necessitatis,  if  the  pro- 
jecting tumor  is  in  the  neighborhood  of  the  heart  and  pulsates,  the  condi- 
tion may  readily  be  mistaken  for  aneurism.  The  absence  of  the  heaving, 
firm  distention  and  of  the  diastolic  shock  would,  together  with  the  his- 
tory and  the  existence  of  pleural  effusion,  determine  the  nature  of  the  case. 
If  necessary,  puncture  may  be  made  with  a  fine  hypodermic  needle.  In  a 
majority  of  the  cases  of  pulsating  pleurisy  the  throbbing  is  diffuse  and 
widespread,  moving  the  whole  side. 

Prognosis. — The  outlook  in  thoracic  aneurism  is  always  grave.  Life 
may  be  prolonged  for  some  years,  but  the  patients  are  in  constant  jeopardy. 
Spontaneous  cure  is  not  very  infrequent  in  the  small  sacculated  tumors  of 
the  ascending  and  thoracic  portions.  The  cavity  becomes  filled  with  lam- 
inae of  firm  fibrin,  which  become  more  and  more  dense  and  hard,  the  sac 
shrinks  considerably,  and  finally  lime  salts  are  deposited  in  the  old  fibrin. 
The  lamiuEe  of  fibrin  may  be  on  a  level  with  the  lumen  of  the  vessel,  caus- 
ing complete  obliteration  of  the  sac.  The  cases  which  rupture  externally, 
as  a  rule  run  a  rapid  course,  although  to  this  there  are  exceptions;  the 
sac  may  contract,  become  firm  and  hard,  and  the  patient  may  live  for  five, 
or  even,  as  in  a  case  mentioned  by  Balfour,  for  ten  years.  The  cases  which 
have  lasted  longest  in  my  experience  have  been  those  in  which  a  saccular 
aneurism  has  projected  from  the  ascending  arch.  One  patient  in  Mont- 
real had  been  known  to  have  aneurism  for  eleven  years.  The  aneurism 
may  be  enormous,  occupying  a  large  area  of  the  chest,  and  yet  life  be  pro- 
longed for  many  years,  as  in  the  case  mentioned  as  under  the  care  of 
Skoda  and  Oppolzer.  One  of  the  most  remarkable  instances  is  the  case  of 
dissecting  aneurism  reported  by  Graham.  The  patient  was  invalided  after 
the  Crimean  War  with  aneurism  of  the  aorta,  and  for  years  was  under  the 
observation  of  J.  H.  Eichardson,  of  Toronto,  under  whose  care  he  died 
in  1885.  The  autopsy  showed  a  healed  aneurism  of  the  arch,  with  a  dis- 
secting aneurism  extending  the  whole  length  of  the  aorta,  which  formed  a 
double  tube. 

Treatment. — In  a  large  proportion  of  the  cases  this  can  only  be  pal- 
liative. Still  in  every  instance  measures  should  be  taken  which  are  known 
to  promote  clotting  and  consolidation  within  the  sac.  In  any  large  series 
of  cured  aneurisms  a  considerable  majority  of  the  patients  have  not  been 
49 


^^S4:  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

known  to  be  subjects  of  the  disease,  but  the  obliterated  sac  has  been  found 
accidentally  at  the  post  mortem. 

The  most  satisfactory  plan  in  early  cases,  when  it  can  be  carried  out 
thoroughly,  is  that  advised  by  the  late  Mr.  Tufnell,  of  Dublin,  the  essen- 
tials of  which  are  rest  and  a  restricted  diet.  Rest  is  essential  and  should, 
as  far  as  possible,  be  absolute.  The  reduction  of  the  daily  number  of 
heart-beats,  when  a  patient  is  recumbent  and  makes  no  exertion  whatever, 
amounts  to  many  thousands,  and  is  one  of  the  principal  advantages  of 
this  plan.  Mental  quiet  should  also  be  enjoined.  The  diet  advised  by 
Tufnell  is  extremely  rigid — for  breakfast,  2  ounces  of  bread  and  butter 
and  2  ounces  of  milk  or  tea;  dinner,  3  ounces  of  mutton  and  3  of  potatoes  or 
bread  and  3  ounces  of  claret;  supper,  2  ounces  of  bread  and  butter  and  2 
ounces  of  tea.  This  low  diet  diminishes  the  blood-volume  and  is  thought 
also  to  render  the  blood  more  fibrinous.  "  Total  per  diem,  10  ounces  of  solid 
food  and  8  ounces  of  fluid,  and  no  more."  This  treatment  should  be 
pursued  for  several  months,  but,  except  in  persons  of  a  good  deal  of  mental 
stamina,  it  is  impossible  to  carry  it  out  for  more  than  a  few  weeks  at  a 
time.  It  is  a  form  of  treatment  adapted  only  for  the  saccular  form  of 
aneurism,  and  in  cases  of  large  sacs  communicating  with  the  aorta  by  a 
comparatively  small  orifice  the  chances  of  consolidation  are  fairly  good. 
Unquestionably  rest  and  the  restriction  of  the  liquids  are  the  important 
parts  of  the  treatment,  and  a  greater  variety  and  quantity  of  food  may 
be  allowed  with  advantage.  If  this  plan  cannot  be  thoroughly  carried  out, 
the  patient  should  at  any  rate  be  advised  to  live  a  very  quiet  life,  moving 
about  with  deliberation  and  avoiding  all  sudden  mental  or  bodily  excite- 
ment. The  bowels  should  be  kept  regular,  and  constipation  and  strain- 
ing should  be  carefully  avoided.  Of  medicines,  iodide  of  potassium,  as 
advised  by  Balfour,  is  of  great  value.  It  may  be  given  in  doses  of  from 
10  to  15  or  20  grains  three  times  a  day.  Larger  doses  are  not  necessary.  The 
mode  of  action  is  not  well  understood.  It  may  act  by  increasing  the  secre- 
tions and  so  inspissating  the  blood,  by  lowering  the  blood-pressure,  or, 
as  Balfour  thinks,  by  causing  thickening  and  contraction  of  the  sac.  The 
most  striking  effect  of  the  iodide  in  my  experience  has  been  the  relief  of 
the  pain.  The  evidence  is  not  conclusive  that  the  syphilitic  cases  are  more 
benefited  by  it  than  the  non-syphilitic.  All  these  measures  have  little  value 
unless  the  sac  is  of  a  suitable  form  and  size.  The  large  tumors  with  wide 
mouths  communicating  with  the  ascending  portion  of  the  aorta  may  be 
treated  on  the  most  approved  plans  for  months  without  the  slightest  influ- 
ence other  than  reduction  in  the  intensity  of  the  throbbing.  A  patient 
with  a  tumor  projecting  into  the  right  pleura  remained  on  the  most  rigid 
Tufnell  treatment  for  more  than  one  hundred  days,  during  which  time  he 
also  took  iodide  of  potassium  faithfully.  The  pulsations  were  greatly  re- 
duced and  the  area  of  dulness  diminished,  and  we  congratulatefl  ourselves 
that  the  sac  was  probably  consolidating.  Sudden  death  followed  rupture 
into  the  pleura,  and  the  sac  contained  only  fluid  blood,  not  a  shred  of 
fibrin.  In  cases  in  which  the  tumor  is  large,  or  in  which  there  seems  to  be 
very  little  prospect  of  consolidation,  it  is  perhaps  better  to  advise  a  man 
to  go  on  quietly  with  his  occupation,  avoiding  excitement  and  worry.     Our 


ANEURISM.  785 

profession  lias  ofEered  many  examples  of  good  work,  tlioroughly  and  con- 
scientiously carried  out,  by  men  with  aneurism  of  the  aorta,  who  wisely, 
I  think,  preferred,  as  did  the  late  Hilton  Fagge,  to  die  in  harness. 

Surgical  Measures. — In  a  few  cases  consolidation  may  be  promoted  in 
the  sac  by  the  introduction  of  a  foreign  body,  such  as  wire,  horse-hair,  or 
by  the  combination  of  wiring  and  electrolysis.  Moore,  in  1864,  first  wired 
a  sac,  putting  in  78  feet  of  fine  wire.  Death  occurred  on  the  fifth  day. 
Corradi  proposed  the  combined  method  of  wiring  with  electrolysis,  which 
was  first  used  by  Burresi  in  1879.  His  patient  lived  for  three  and  a  half 
months.  Horse-hair,  watch-spring  wire,  catgut,  and  Florence  silk  have 
been  used.  Hunner  reports  the  statistical  results  of  both  methods  up  to 
October,  1900.  With  Moore's  method  (wiring)  14  cases  were  treated,  8  of 
thoracic  aneurism,  all  fatal;  6  aneurisms  of  the  abdominal  aorta,  3  of  which 
were  successful.  Of  23  cases  treated  by  wiring  and  electrolysis  (Moore- 
Corradi  method),  17  were  thoracic  and  6  abdominal.  The  thoracic  cases 
of  Eosenstirn,  Stewart,  and  Kerr,  and  the  abdominal  cases  of  Noble  and 
Finney  (Case  V),  were  suceessfu.1.  In  eight  of  the  23  cases  there  were 
amelioration  of  symptoms  and  probable  prolongation  of  life.  The  most 
favorable  cases  are  those  in  which  the  aneurism  is  sacculated,  but  this  is 
a  point  not  easily  determined,  and  often  from  a  sac  particularly  favorable 
for  wiring  there  may  be  secondary  projections  of  great  thinness.  The  sud- 
den filling  by  clot  of  an  aneurism  of  the  coeliac  axis  or  of  the  superior 
mesenteric  artery  may  result  fatally  from  infarct  of  the  intestine. 

Other  Symptoms  requiring  Treatment. — Pressure  on  veins  causing  en- 
gorgement, particularly  of  the  head  and  arms,  is  sometimes  promptly  re- 
lieved by  free  venesection,  and  at  any  time  during  the  course  of  a  thoracic 
aneurism,  if  attacks  of  dyspnoea  with  lividity  supervene,  bleeding  may  be 
resorted  to  with  great  benefit.  It  has  the  advantage  also  of  promptly- 
checking  the  pain,  for  which  symptom,  as  already  mentioned,  the  iodide 
of  potassium  often  gives  relief.  In  the  final  stages  morphia  is,  as  a  rule, 
necessary.  Dyspnoea,  if  associated  with  cyanosis,  is  best  relieved  by  bleed- 
ing. Chloroform  inhalations  may  be  necessary.  The  question  sometimes 
comes  up  with  reference  to  tracheotomy  in  these  cases  of  urgent  dyspnoea. 
If  it  can  be  shown  by  laryngoscopic  examination  that  it  is  due  to  bilateral 
abductor  paralysis  the  trachea  may.  be  opened,  but  this  is  extremely  rare, 
and  in  nearly  every  instance  the  urgent  dyspnoea  is  caused  by  pressure 
about  the  bifurcation.  When  the  sac  appears  externally  and  grows  large, 
an  ice-cap  may  be  applied  upon  it,  or  a  belladonna  plaster  to  allay  the 
pain.  In  some  instances  an  elastic  support  may  be  used  with  advantage, 
and  I  saw  a  physician  with  an  enormous  external  aneurism  in  the  right 
mammary  region  who  for  many  months  had  obtained  great  relief  by  the 
elastic  support,  passing  over  the  shoulder  and  under  the  arm  of  the  oppo- 
site side. 

Digitalis,  ergot,  aconite,  and  veratrum  viride  are  rarely,  if  ever,  of  serv- 
ice in  thoracic  aneurism. 


786  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Aneurism  of  the  Abdominal  Aorta. 

The  sac  is  most  common  just  below  the  diaphragm  in  the  neighborhood 
of  the  coeliac  axis.  This  variety  is  rare  in  comparison  with  thoracic  aneu- 
rism. Of  the  468  cases  of  aortic  aneurism  at  St.  Bartholomew's  Hospital,  23 
involved  the  abdominal  aorta.  The  tumor  may  be  fusiform  or  sacculated, 
and  it  is  sometimes  multiple.  Projecting  backward,  it  erodes  the  vertebrae 
and  may  cause  numbness  and  tingling  in  the  legs  and  finally  paraplegia,  or 
it  may  pass  into  the  thorax  and  burst  into  the  pleura.  More  commonly  the 
sac  is  on  the  anterior  wall  and  projects  forward  as  a  definite  tumor,  which 
may  be  either  in  the  middle  line  or  a  little  to  the  left.  The  tumor  may 
project  in  the  epigastric  region  (which  is  most  common),  in  the  left  hypo- 
chondrium,  in  the  left  flank,  or  in  the  lumbar  region.  When  high  up 
beneath  i;he  pillar  of  the  diaphragm  it  may  attain  considerable  size  without 
being  very  apparent  on  palpation. 

The  symptoms  are  chiefly  pain,  very  often  of  a  cardialgic  nature,  pass- 
ing round  to  the  sides  or  localized  in  the  back,  and  gastric  symptoms,  par- 
ticularly vomiting.  Eetardation  of  the  pulse  in  the  femoral  is  a  very  com- 
mon symptom. 

Diagnosis  and  Physical  Signs. — Inspection  may  show  marked 
pulsation  in  the  epigastric  region,  sometimes  a  definite  tumor.  A  thrill 
is  not  uncommon.  The  pulsation  is  forcible,  expansile,  and  sometimes 
double  when  the  sac  is  large  and  in  contact  with  the  pericardium.  On  pal- 
pation a  definite  tumor  can  he  felt.  If  large,  there  is  some  degree  of  dul- 
ness  on  percussion  which  usually  merges  with  that  of  the  left  lobe  of  the 
liver.  On  auscultation,  a  systolic  murmur  is,  as  a  rule,  audible,  and  is 
sometimes  best  heard  at  the  back.  A  diastolic  murmur  is  occasionally 
present,  usually  very  soft  in  quality.  One  of  the  commonest  of  clinical 
errors  is  to  mistake  a  throbbing  aorta  for  an  aneurism.  It  is  to  be  remem- 
bered that  no  pulsation,  however  forcible,  or  the  presence  of  a  thrill  or  a 
systolic  murmur  justifies  the  diagnosis  of  abdominal  aneurism  unless  there 
is  a  definite  tumor  which  can  he  grasped  and  which  has  an  expansile  pulsa- 
tion. Attention  to  this  rule  will  save  many  errors.  The  throbbing  aorta 
— the  "  preternatural  pulsation  in  the  epigastrium,^'  as  Allan  Burns  calls 
it — is  met  with  in  all  neurasthenic  conditions,  particularly  in  women.  In 
auEcmia,  particularly  in  some  instances  of  traumatic  anaemia,  the  throbbing 
may  be  very  great.  In  the  case  of  a  large,  stout  man  with  severe  haemor- 
rhages from  a  duodenal  ulcer  the  throbbing  of  the  abdominal  aorta  not 
only  shook  violently  the  whole  abdomen,  but  communicated  a  pulsation 
to  the  bed,  the  shock  of  which  was  distinctly  perceptible  to  any  one  sitting 
upon  it.  Very  frequently  a  tumor  of  the  pylorus,  of  the  pancreas,  or  of 
the  left  lobe  of  the  liver  is  lifted  with  each  impulse  of  the  aorta  and  may 
be  confounded  with  aneurism.  The  absence  of  the  forcible  expansile  im- 
pulse and  the  examination  in  the  knee-elbow  position,  in  which  the  tumor, 
as  a  rule,  falls  forward,  and  the  pulsation  is  not  then  communicated,  suf- 
fice for  differentiation.  The  tumor  of  abdominal  aneurism,  though  usually 
fixed,  may  be  very  freely  movable. 

The  outlook  in  abdominal  aneurism  is  bad.     A  few  cases  heal  spon- 


ANEURISM.  Y87 

taneously.  Death  may  result  from  (a)  complete  obliteration  of  the  lumen 
by  clots;  (h)  compression  paraplegia;  (c)  rupture  (which  is  almost  the 
rule)  either  into  the  pleura,  retroperitoneal  tissues,  peritonasum,  or  the  in- 
testines,  very  commonly  the  duodenum;  (cZ)  embolism  of  the  superior  mesen- 
teric artery,  producing  infarction  of  the  intestines. 

The  treatment  is  such  as  already  advised  in  thoracic  aneurism.  When 
the  aneurism  is  low  down  pressure  has  been  successfully  applied  in  a  case 
by  Murray,  of  Newcastle.  It  must  be  kept  up  for  many  hours  under  chloro- 
form. The  plan  is  not  without  risk,  as  patients  have  died  from  bruising 
and  injury  of  the  sac. 

Aneurism  of  the  Beanches  of  the  Abdominal  Aorta. 

The  cceliac  axis  is  itself  not  infrequently  involved  in  aneurism  of  the 
first  portion  of  the  abdominal  aorta.  Of  its  branches,  the  splenic  artery  is 
occasionally  the  seat  of  aneurism.  This  rarely  causes  a  tumor  large  enough 
to  be  felt;  sometimes,  however,  the  tumor  is  of  large  size.  I  have  reported 
a  case  in  a  man,  aged  thirty,  who  had  an  illness  of  several  months'  dura- 
tion, severe  epigastric  pain  and  vomiting,  which  led  his  physicians  in  New 
York  to  diagnose  gastric  ulcer.  There  was  a  deep-seated  tumor  in  the  left 
hypochondriac  region,  the  dulness  of  which  merged  with  that  of  the  spleen. 
There  was  no  pulsation,  but  it  was  thought  on  one  occasion  that  a  hruit 
was  heard.  The  chief  symptoms  while  under  observation  were  vomiting, 
severe  epigastric  pain,  occasional  hsematemesis,  and  finally  severe  hgemor- 
rhage  from  the  bowels.  An  aneurism  of  the  splenic  artery  the  size  of  a 
cocoa-nut  was  situated  between  the  stomach  above  and  the  transverse  colon 
below,  and  extended  to  the  right  as  far  as  the  level  of  the  navel.  The  sac 
contained  densely  laminated  fibrin.  It  had  perforated  the  colon.  I  have 
twice  seen  small  aneurisms  on  the  splenic  artery.  Of  39  instances  of  aneu- 
rism on  the  branches  of  the  abdominal  aorta  collected  by  Lebert,  10  were 
of  the  splenic  artery. 

Aneurism  of  the  hepatic  artery  is  very  rare,  and  there  are  only  10  or  13 
cases  on  record.  The  symptoms  are  extremely  indefinite;  the  condition 
could  rarely  be  diagnosed.  In  the  ease  reported  by  Eoss  and  myself,  a  man 
aged  twenty-one  had  the  symptoms  of  pyasmia.  The  liver  was  greatly 
enlarged,  weighed  nearly  5,000  grammes,  and  presented  innumerable  small 
abscesses.  An  oval  aneurism,  half  the  size  of  a  small  lemon,  involved  the 
right  and  part  of  the  left  branches.  In  J.  B.  S.  Jackson's  case  the  aneu- 
rism perforated  the  hepatic  duct. 

A  few  cases  of  aneurism  of  the  superior  mesenteric  artery  are  on  record. 
The  diagnosis  is  scarcely  possible.  Plugging  of  the  branches  or  of  the  main 
stem  may  cause  the  symptoms  of  infarction  of  the  bowels  which  have  al- 
ready been  considered. 

Renal  Artery. — Henry  Morris  has  collected  21  instances  of  aneurism 
(Lancet,  Oct.  6,  1900),  12  of  which  arose  from  injury.  Many  of  them  were 
false.  Pulsation  and  a  bruit  are  not  always  present.  Four  cases  were 
operated  upon;  3  recovered.  In  a  case  of  Keen's  the  tumor  and  the  kidney 
were  remo-ved  together. 


788  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

Aeteeio-venous  Aneueism. 

In  this  form  there  is  abnormal  communication  between  an  artery  and 
a  vein.  When  a  tumor  lies  between  the  two  it  is  known  as  yaricose  aneu- 
rism; when  there  is  a  direct  communication  without  tumor  the  vein  is 
chiefly  distended  and  the  condition  is  known  as  aneurismal  varix. 

An  aneurism  of  the  ascending  portion  of  the  arch  may  open  directly 
into  the  vena  cava.  Twenty-nine  cases  of  this  lesion  have  been  analyzed 
by  Pepper  and  Griffith.  Cyanosis^  oedema^  and  great  distention  of  the 
veins  of  the  upper  part  of  the  body  are  the  most  frequent  symptoms,  and 
develop,  as  a  rule,  with  suddenness.  Of  the  physical  signs  a  thrill  is  pres- 
ent in  some  cases.  A  continuous  murmur  with  systolic  intensification  is 
of  great  diagnostic  value.  In  a  recent  case,  after  the  existence  for  some 
time  of  pressure  s3rmptoms,  intense  cyanosis  developed  with  engorgement 
of  the  veins  of  the  head  and  arms.  Over  the  aortic  region  there  was  a 
loud  continuous  murmur  vrith  systolic  intensification. 

A  majority  of  the  cases  of  arterio-venous  aneurism  and  of  aneurismal 
varix  result  from  the  accidental  opening  of  an  artery  and  vein  as  in  vene- 
section, and  are  met  with  at  the  bend  of  the  elbow  or  sometimes  in  the 
temporal  region.  The  condition  may  persist  for  years  without  causing 
any  trouble.  Pulsation,  a  loud  thrill,  and  a  continuous  humming  murmur 
are  usually  present. 

Congenital  Aneueism,  oe  Peeiaeteeitis  IsTodosa. 

A  series  of  eases  has  been  described  in  which  the  lesions  are  small 
aneurisms  on  the  arteries  of  the  muscles  and  viscera.  The  first  case  was 
reported  by  Kussmaul  and  Maier,  and  three  others  have  been  described. 
A  fifth  case,  agreeing  clinically  with  the  others,  has  occurred  in  m}'  wards. 
Xo  autopsy  was  permitted,  but  the  nodules  were  felt  in  the  abdominal  wall 
before  death.  The  case  is  reported  by  Sabin  (J.  H.  H.  Bull.,  1901).  There 
are  marked  thickening  of  the  intima  and  infiltration  of  the  other  coats, 
with  a  nuclear  growth  almost  sarcomatous.  There  are  two  theories:  one 
that  the  nodules  are  aneurisms  due  to  syphilis  or  to  congenital  weak- 
ening of  the  arteries;  the  other  that  they  are  aneurisms  secondary  to  an 
inflammatory  process  like  the  infectious  granulomata. 

The  cases  have  occurred  about  equally  in  men  and  women  between 
the  ages  of  twenty-seven  and  fifty-two;  the  course  is  from  eight  to 
twelve  weeks.  The  patients  complain  of  weakness.  The  symptoms 
correspond  with  the  situation  of  the  lesions;  thus,  their  presence  in 
the  muscles  is  associated  with  pain,  weakness,  and  sometimes  paralysis 
and  atrophy.  The  nodules  are  abundant  in  the  alimentary  tract. 
The  severest  symptom  is  epigastric  pain;  there  is  loss  of  appetite,  thirst, 
vomiting,  constipation,  or  diarrhoea.  The  disease  is  febrile  at  first, 
but  the  temperature  sinks  to  subnormal,  while  the  pulse  remains 
rapid.  The  anaemia  is  extreme.  In  our  case  the  haemoglobin  was  21 
per  cent,  the  red  blood-cells  1,704,000.  The  leucoc3d:es  rose  from  50,000 
to  116,000,  of  which  91  per  cent  were  polymorphonuclear  forms.  -  The  urine 
is  scanty,  of  low  specific  gravity,  with  albumin  and  casts.  Urea  is  excreted 
in  small  quantities,  but  the  mind  is  clear. 


SECTION   VIII. 

DISEASES  OF  THE  BLOOD  AE"D  DUCTLESS 

GLANDS. 


I.    ANEMIA. 

Anemia  may  be  defined  as  a  reduction  in  the  amount  of  the  blood  as 
a  whole  or  of  its  corpuscles,  or  of  certain  of  its  more  important  constitu- 
ents, such  as  albumin  and  haemoglobin.  The  condition  may  be  general 
or  local.  The  former  alone  we  are  here  considering.  It  is  interesting  to 
note,  however,  that  the  pallor,  particularly  of  the  face,  which  is  one  of  the 
most  striking  symptoms  of  angemia,  is  just  as  characteristic  of  local  anaemia 
due  to  fright  or  to  nausea.  There  are  persons  persistently  pale  without 
actual  anaemia  in  whom  the  condition  may  be  due  to  inherited  peculiarities. 

Our  knowledge  is  not  yet  sufficiently  advanced  to  classify  satisfactorily 
the  various  forms  of  anaemia.  The  following  provisional  grouping  may 
be  made:  (1)  Secondary  or  symptomatic  anaemia;  (2)  primary,  essential, 
or  cytogenic  anaemia. 

Secondaet  Anemia. 

Under  this  division  comes  a  large  proportion  of  all  cases.  The  follow- 
ing are  the  most  important  groups,  based  on  the  etiology: 

(1)  Ancemia  from  hcemorrhage,  either  traumatic  or  spontaneous.  The 
loss  of  blood  may  be  rapid,  as  in  lesions  of  large  vessels,  in  injury  or  in 
rupture  of  aneurisms,  in  cases  of  ulcer  of  the  stomach  or  duodenum,  or 
in  post-partum  haemorrhage.  If  the  loss  is  excessive,  death  results  from 
lowering  of  the  arterial  pressure.  In  sudden  profuse  haemorrhage  the 
loss  of  3  or  4  pounds  of  blood  may  prove  fatal.  In  the  rupture  of 
an  aneurism  into  the  pleura  the  loss  of  blood  may  amount  to  7^  pounds, 
the  largest  quantity  I  have  known  to  be  shed  into  one  cavity.  In 
a  case  of  haematemesis  the  patient  lost  over  10  pounds  by  measurement 
in  one  week  and  yet  recovered  from  the  immediate  effects.  Even  after  very 
severe  haemorrhage  the  number  of  red  blood-corpuscles  is  not  reduced  so 
greatly  as  in  forms  of  idiopathic  anaemia.  Thus  in  one  case  just  mentioned, 
at  the  termination  of  the  week  of  bleeding  there  were  nearly  1,390,000  red 
blood-corpuscles  to  the  cubic  millimetre.  The  process  of  regeneration  goes 
on  with  great  rapidity,  and  in  some  "  bleeders  "  a  week  or  ten  days  suffice 

789  • 


790 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


to  re-establish  the  normal  amount.  The  watery  and  saline  constituents  of 
the  blood  are  readily  restored  by  absorption  from  the  gastro-intestinal 
tract.  The  albuminous  elements  also  are  quickly  renewed,  but  it  may 
take  weeks  or  months  for  the  corpuscles  to  reach  the  normal  standard.    The 


APRIL.                                       M 

AY.                                                   JUNE.                                  JULY. 

S§SSSS~*o<»22;S 

2SSSSSS-»ior-ij.::2St;sssSS^ou=K 

110^ 

f 

100^ 

5,000,000 

90^ 

80^ 

4,000,000 

■^I" 

"" 

y'' 

10% 

""  ":;^^ 

^^^ 

60^ 

3,000,000         ^                /        ""-^ 

\       / 

50^ 

N    / 

40^ 

2,000,000 

• 

30^ 

-* — & -k—  '•£-  -S:-  -  k-  -  -r-  -•%■  -  -i. 

" 

- 

'■!■  - 

-   ••.--  - 

-  is-  -  i 

14,000 

12,000        ?■    .. 

10,000      ; 

8,000     \ 

6,000                                                   :------. 

4,000 

2,000 

-» 

1 

BLACK,  JiED  CORPUSCLES, 


BED,  HAEMOGLOBIN. 


MEAN  NORM. 
NUMBER  OF 

WHITE 
CORPUSCLES 


BLUE.  COLORLESS  CORPUSCLES. 


Chart  XVII. — Illustrates  the  rapidity  with  which  ansmia  is  produced  in  purpura 
hsemorrhagiea  and  the  gradual  recovery.* 

haemoglobin  is  restored  more  slowly  than  the  corpuscles.  The  accompany- 
ing chart  illustrates  the  rapid  fall  and  gradual  restitution  in  a  case  of  severe 
purpura  hasmorrhagica. 

The  microscopical  characters  of  the  blood  after  severe  haemorrhage  may 
not  be  greatly  changed.  The  red  corpuscles  show,  usually,  rather  more 
marked  differences  in  size  than  normally,  while  the  average  size  may  be  a 
trifle  reduced;  there  may  be  a  moderate  poikilocytosis.  The  corpuscles 
are  paler  than  normally.  Nucleated  red  corpuscles  appear,  almost  always, 
soon  after  the  haemorrhage;  they  are,  however,  not  numerous.  These  are 
small  bodies  of  about  the  same  size  as  a  normal  red  corpuscle  with  a  small, 


*  On  September  27th  the  patient  returned  from  the  oountry,  where  she  had  spent 
the  summer.  The  blood-count  was  then :  Red  corpuscles,  5,350,000 ;  white  corpuscles, 
5,500 ;  haemoglobin,  94  per  cent. 


ANEMIA.  791 

round,  deeply  staining  nucleus.  Free  nuclei  may  be  found.  The  color- 
less corpuscles  are,  at  first,  increased  in  number.  There  is  a  moderate 
leucocytosis,  the  differential  count  showing  an  increase  in  the  multinuclear 
neutrophiles  with  a  diminution  in  the  small  mononuclear  elements.  Dur- 
ing recovery  the  leucocytosis  diminishes. 

The  reduction  in  haemoglobin  is  always  proportionately  greater  than 
that  in  the  corpuscles. 

In  some  instances  a  rapidly  fatal  angemia  may  follow  a  single  severe 
haemorrhage,  or  repeated  small  haemorrhages  as  in  purpura.  Here  the 
appearances  of  the  red  corpuscles  are  much  the  same,  except  in  the  total 
absence  of  nucleated  red  corpuscles. 

The  leucocytes  in  these  cases  are  usually  reduced  in  number;  the  poly- 
nuclear  elements  are  present  in  a  relatively  diminished  proportion,  while 
the  small  mononuclear  forms  are  numerous.  The  autopsy,  in  these  cases, 
reveals  usually  a  total  absence  of  any  regenerative  activity  on  the  part  of 
the  bone-marrow. 

(2)  Anaemia  is  frequently  produced  by  long-continued  drain  on  the 
albimiinous  materials  of  the  blood,  as  in  chronic  suppuration  and  Bright's 
disease.  Prolonged  lactation  acts  in  the  same  way.  Eapidly  growing 
tumors  may  cause  a  profound  ansemia,  as  in  gastric  cancer.  The  charac- 
ters of  the  blood  here  may  be  much  the  same  as  in  the  acute  cases.  Usu- 
ally, though,  the  poikilocytosis  is  much  more  marked;  in  severe  cases  it 
may  be  excessive.  The  presence,  however,  of  the  very  large  corpuscles, 
such  as  one  sees  in  pernicious  anaemia,  is  not  noted,  the  average  size  ap- 
pearing to  be  rather  smaller  than  normal. 

Xucleated  red  corpuscles  are  usually  scanty.  In  long-continued  chronic 
secondary  anaemias  occasional  larger  nucleated  red  corpuscles  may  be  seen, 
bodies  with  larger  palely  staining  nuclei;  in  some  of  these  cells  karyo- 
kinetic  figures  occur.  Nucleated  red  corpuscles  with  fragmentary  nuclei 
may  also  be  seen. 

The  leucocytes  may  be  increased  in  number,  though  in  some  severe 
chronic  cases  there  may  be  a  diminution. 

(3)  Ancemia  from  Inanition. — This  may  be  brought  about  by  defective 
food  supply,  or  by  conditions  which  interfere  with  the  proper  reception 
and  preparation  of  the  food,  as  in  cancer  of  the  oesophagus  and  chronic 
dyspepsia.  The  reduction  of  the  blood  mass  may  be  extreme,  but  the 
plasma  suffers  proportionately  more  than  the  corpuscles,  which,  even  in  the 
wasting  of  cancer  of  the  oesophagus,  may  not  be  reduced  more  than  one 
half  or  three  fourths.  In  some  instances  the  reduction  in  the  plasma  may 
be  so  great  that  the  corpuscles  show  an  apparent  increase. 

(4)  Toxic  ancemia,  induced  by  the  action  of  certain  poisons  on  the 
blood,  such  as  lead,  mercury,  and  arsenic,  among  inorganic  substances, 
and  the  virus  of  sypbilis  and  malaria  among  organic  poisons.  They  act 
either  by  directly  destroying  the  red  blood-corpuscles,  as  in  malaria,  or  by 
increasing  the  rate  of  ordinary  consumption.  .  The  anaemia  of  pyrexia 
may  in  part  be  due  to  a  toxic  action,  but  is  also  caused  in  part  by  the  dis- 
turbance of  digestion  and  interference  with  the  function  of  the  blood- 
making  organs. 


'^•92  DISEASES   OF  THE  BLOOD  AND  DUCTLESS   GLANDS. 

Peimaet  oe  Essential  Ax^mia. 
1.  Chlorosis. 

Definition. — An  ansemia  of  unknown  cause,  occurring  in  young  girls, 
characterized  by  a  marked  relative  diminution  of  the  haemoglobin. 

Etiology. — It  is  a  disease  of  girls,  more  often  of  blondes  than  of 
brunettes.  It  is  doubtful  if  males  are  ever  affected.  I  have  never  seen  true 
chlorosis  in  a  boy.  The  age  of  onset  is  between  the  fourteenth  and  seven- 
teenth years;  under  the  age  of  twelve  cases  are  rare.  Eecurrences,  which 
are  common,  may  extend  into  the  third  decade.  Of  the  essential  cause  of 
the  disease  we  know  nothing.  There  exists  a  lowered  energy  in  the  blood- 
making  organs,  associated  in  some  obscure  way  with  the  evolution  of  the 
sexual  apparatus  in  women.  Hereditary  influences,  particularly  chlorosis 
and  tuberculosis,  play  a  part  in  some  cases.  Sometimes,  as  Yirchow  pointed 
out,  the  condition  exists  with  a  defective  development  (hypoplasia)  of  the 
circulatory  and  generative  organs. 

The  disease  is  most  common  among  the  ill-fed,  overworked  girls  of 
large  towns,  who  are  confined  all  day  in  close,  badly  lighted  rooms,  or 
have  to  do  much  stair-climbing.  Cases  are  frequent,  however,  under  the 
most  favorable  conditions  of  life.  Lack  of  proper  exercise  and  of  fresh  air, 
and  the  use  of  improper  food  are  important  factors.  Emotional  and  nerv- 
ous disturbances  may  be  prominent — so  prominent  that  certain  writers  have 
regarded  the  disease  as  a  neurosis.  De  Sauvages  speaks  of  a  cMorose  par 
amour.  Xewly  arrived  Irish  girls  were  very  prone  to  the  disease  in  Mont- 
real. The  "  corset  and  chlorosis  "  expresses  0.  Eosenbach's  opinion.  Men- 
strual disturbances  are  not  uncommon,  but  are  probably  a  sequence,  not  a 
cause,  of  chlorosis.  Sir  Andrew  Clark  believed  that  constipation  plays  an 
important  role,  and  that  the  condition  is  in  reality  a  coprcemia  due  to  the 
absorption  of  poisons — leueomaines  and  ptomaines — from  the  large  bowel, 
a  view  which  always  appeared  to  me  baseless,  considering  the  great  fre- 
quency of  the  condition  in  women. 

Symptoms. — (a)  General. — The  symptoms  of  chlorosis  are  those  of 
aneemia.  The  subcutaneous  fat  is  well  retained  or  even  increased  in 
amount.  The  complexion  is  peculiar;  neither  the  blanched  aspect  of  haem- 
orrhage nor  the  muddy  pallor  of  grave  antemia,  but  a  curious  yellow-green 
tinge,  which  has  given  to  the  disease  its  name,  and  its  popular  designation, 
the  green  sickness.  Occasionally  the  skin  shows  areas  of  pigmentation, 
particularly  about  the  joints.  In  cases  of  moderate  grade  the  color  may 
be  deceptive,  as  the  cheeks  have  a  reddish  tint,  particularly  on  exertion, 
(chlorosis  rubra).  The  subjects  complain  of  breathlessness  and  palpita- 
tion, and  there  may  be  a  tendency  to  fainting — symptoms  which  often 
lead  to  the  suspicion  of  heart  or  lung  disease.  Puffiness  of  the  face  and 
swelling  of  the  ankles  may  suggest  nephritis.  The  disposition  often 
changes,  and  the  girl  becomes  low-spirited  and  irritable.  The  eyes  have 
a  peculiar  brilliancy  and  the  sclerotics  are  of  a  bluish  color. 

(b)  Special  Features. — Blood. — The  drop  as  expressed  looks  pale. 
Johann  Duncan,  in  1867,  first  called  attention  to  the  fact  that  the  essen-- 


ANEMIA. 


793 


tial  feature  was  not  a  great  reduction  in  the  number  of  the  corpuscles,  but 
a  quantitative  change  in  the  haemoglobin.  The  corpuscles  themselves  look 
pale.  In  63  consecutive  cases  examined  at  my  clinic  by  Thayer,  the  average 
number  per  cubic  millimetre  of  the  red  blood-corpuscles  was  4,096,544, 
or  over  80  per  cent,  whereas  the  percentage  of  haemoglobin  for  the  total 
number  was  42.3  per  cent.  The  accompanying  chart  illustrates  well  these 
striking  differences.  There  may,  however,  be  well-marked  actual  anemia. 
The  lowest  blood-count  in  the  series  of  cases  referred  to  above  was  1,932,000. 
There  may  be  all  the  physical  characteristics  and  symptoms  of  a  profound 
anaemia  with  the  number  of  the  blood-corpuscles  nearly  at  the  normal 


JANUARY.                                         FEBRUARY.                                          MARCH. 

oo^«.r2:i::f:«SSSs»c»<oo22r^5SSSSSc»fflo??2:;2SS3g 

120^ 

6,000,000                                                                     /\ 

/    ^^ 

110^ 

\      Jr- 

100% 

5,000,000                                                          /                         \     / 

/               V 

90^ 

It 

/ 

80^ 

4,000,000                                        / 

^^X^^/ 

10% 

Q0% 

3,000,000 

zon. 

4=0^ 

2,000,000 

30^ 

20^ 

1,000,000 

.-^^-.-.:-.:-.:-.:-..-.-v-.-.:-i-v:-.-^Y -..-.- 

14,000 

12,000 

30,000                                   /"  - 

8,000                       ^--'''              ',                                        r * 

' 

6,000             "'                                     ^"■■-••■-..^              / 
4,000                                                                            ^"-'' 

2,000 

BLACK,  RED  CORPUSCLES. 


RED,  HAEMOGLOBIN. 

Chart  XVIII. — Chlorosis. 


MEAN  NORM. 

NUMBER  OF 

WHITE 

CORPUSCLES 


BLUE,   COLORLESS  CORPUSCLES. 


standard.  Thus  in  one  instance  the  globular  richness  was  over  85  per 
cent,  with  the  haemoglobin  about  35.  No  other  form  of  anaemia  presents 
this  feature,  at  least  with  the  same  constancy  and  in  the  same  degree.  The 
importance  of  the  reduction  in  the  haemoglobin  depends  upon  the  fact  that 


794  DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 

it  is  the  iron-containing  elements  of  the  blood  with  which  in  respiration 
the  oxygen  enters  into  combination.  This  marked  diminution  in  the  iron 
has  also  been  determined  by  chemical  analysis  of  the  blood.  The  micro- 
scopical characteristics  of  the  blood  are  as  follows:  In  severe  cases  the 
corpuscles  may  be  extremely  irregular  in  size  and  shape — poikilocytosis, 
which  may  occasionally  be  as  marked  as  in  some  cases  of  pernicious  ansemia. 
The  large  forms  of  red  blood-cells  are  not  as  common,  and  the  average 
size  is  stated  to  be  below  normal.  The  color  of  the  corpuscles  is  noticeably 
pale  and  the  deficiency  may  be  seen  either  in  individual  corpuscles  or  in 
the  blood  mixture  prepared  for  counting.  Nucleated  red  corpuscles  (normo- 
blasts) are  not  very  uncommon,  and  may  vary  greatly  in  numbers  in  the 
same  case  at  different  periods.  The  leucocytes  may  show  a  slight  increase; 
the  average  in  the  63  cases  above  referred  to  was  8,467  per  cubic  millimetre. 

(c)  Gastro-intestinal  Symptoms. — The  appetite  is  capricious,  and  pa- 
tients often  have  a  longing  for  unusual  articles,  particularly  acids.  In 
some  instances  they  eat  all  sorts  of  indigestible  things,  such  as  chalk  or 
even  earth.  Superacidity  of  the  gastric  juice  is  commonly  associated  with 
chlorosis.  In  19  out  of  21  cases  in  Eiegel's  clinic  this  condition  was  found 
to  exist.  In  the  other  two  instances  the  acidity  was  normal  or  a  trifle  in- 
creased. Distress  after  eating  and  even  cardialgic  attacks  may  be  associ- 
ated with  it.  Constipation  is  a  common  symptom,  and,  as  already  men- 
tioned, has  been  regarded  as  an  important  element  in  causing  the  disease. 
A  majority  of  chlorotic  girls  who  wear  corsets  have  gastroptosis,  and  on 
inflation  the  stomach  will  be  found  vertically  placed;  sometimes  the  organ 
is  very  much  dilated.  The  motor  power  is  usually  well  retained.  Enter- 
optosis  with  palpable  right  kidney  is  not  uncommon. 

(d)  Circulatory  Symptoms. — Palpitation  of  the  heart  occurs  on  exer- 
tion, and  may  be  the  most  distressing  symptom  of  which  the  patient  com- 
plains. Percussion  may  show  slight  increase  in  the  transverse  dulness.  A 
systolic  murmur  is  heard  at  the  apex  or  at  the  base;  more  commonly  at 
the  latter,  but  in  extreme  cases  at  both.  A  diastolic  murmur  is  rarely 
heard.  The  systolic  murmur  is  usually  loudest  in  the  second  left  inter- 
costal space,  where  there  is  sometimes  a  distinct  pulsation.  The  exact 
mode  of  production  is  still  in  dispute.  Balfour  holds  that  it  is  produced 
at  the  mitral  orifice  by  relative  insufficiency  of  the  valves  in  the  dilated 
condition  of  the  ventricle.  On  the  right  side  of  the  neck  over  the  jugular 
vein  a  continuous  murmur  is  heard,  the  hruit  de  diahle,  or  humming-top 
murmur. 

The  pulse  is  usually  full  and  soft.  Pulsation  in  the  peripheral  veins  is 
sometimes  seen.  There  is  a  tendency  to  thrombosis  in  the  veins;  most 
commonly  in  the  femoral,  but  in  other  instances  in  the  longitudinal  sinus; 
or  the  thrombosis  may  be  multiple.  Leichtenstern  has  found  that  of  86 
cases  of  thrombosis  in  chlorosis  the  veins  of  the  lower  extremities  were 
affected  48  times  and  the  cerebral  sinuses  29  times.  The  chief  danger  in 
thrombosis  of  the  extremities  is  pulmonary  embolism,  which  occurred  in  13 
of  52  cases  collected  by  Welch. 

As  in  all  forms  of  essential  anaemia,  fever  is  not  uncommon.  Especial 
attention  has  of  late  been  directed  to  this  by  French  writers.     Chlorotic 


ANEMIA.  795 

patients  suffer  frequently  from  headache  and  neuralgia,  which  may  be 
paroxysmal.  The  hands  and  feet  are  often  cold.  Dermatographia  is  com- 
mon. Hysterical  manifestations  are  not  infrequent.  Menstrual  disturb- 
ances are  very  common — amenorrhoea  or  dysmenorrhoea.  With  the  im- 
provement in  the  blood  condition  this  function  is  usually  restored. 

Diagnosis. — The  green  sickness,  as  it  is  sometimes  called,  is  in  many 
instances  recognized  at  a  glance.  The  well-nourished  condition  of  the 
girl,  the  peculiar  complexion,  which  is  most  marked  in  brunettes,  and  the 
white  or  bluish  sclerotics  are  very  characteristic.  A  special  danger  exists 
in  mistaking  the  apparent  anaemia  of  the  early  stage  of  pulmonary  tuber- 
culosis for  chlorosis.  Mistakes  of  this  sort  may  often  be  avoided  by  the  very 
simple  test  furnished  by  allowing  a  drop  of  blood  to  fall  on  a  white  towel 
or  a  piece  of  blotting  paper — a  deficiency  in  haemoglobin  is  readily  appre- 
ciated. The  palpitation  of  the  heart  and  shortness  of  breath  frequently 
suggest  heart-disease,  and  the  oedema  of  the  feet  and  general  pallor  cause 
the  cases  to  be  mistaken  for  Bright's  disease.  In  the  great  majority  of 
cases  the  characters  of  the  blood  readily  separate  chlorosis  from  other 
forms  of  anaemia. 


2.  Idiopathic  or  Progressive  Pernicious  AnsBinia. 

The  disease  was  first  clearly  described  by  Addison,  who  called  it  idio- 
pathic anaemia.  Channing  and  Gusserow  described  the  cases  occurring 
post  partum,  but  to  Biermer  we  owe  a  revival  of  interest  in  the  subject. 

Etiology. — The  existence  of  a  separate  disease  worthy  of  the  term  pro- 
gressive pernicious  anaemia  has  been  doubted,  but  there  are  unquestionably 
cases  in  which,  as  Addison  says,  there  exist  none  of  the  usual  causes  or 
concomitants  of  anaemia.  Clinically  there  are  several  different  groups 
which  present  the  characters  of  a  progressive  and  pernicious  anaemia  and 
are  etiologically  different.  Thus,  a  fatal  anaemia  may  be  due  to  the  pres- 
ence of  parasites,  or  may  follow  haemorrhage,  or  be  associated  with  chronic 
atrophy  of  the  stomach;  but  when  we  have  excluded  all  these  causes  there 
remains  a  group  which,  in  the  words  of  Addison,  is  characterized  by  a 
"  general  anaemia  occurring  without  any  discoverable  cause  whatever,  cases 
in  which  there  had  been  no  previous  loss  of  blood,  no  exhausting  diarrhoea, 
no  chlorosis,  no  purpura,  no  renal,  splenic,  miasmatic,  glandular,  strumous, 
or  malignant  disease." 

Idiopathic  ansemia  is  widely  distributed.  It  is  of  frequent  occurrence 
in  the  Swiss  cantons,  and  it  is  not  uncommon  in  this  country.  It  affects 
middle-aged  persons,  but  instances  in  children  have  been  described.  Griffith 
mentions  about  10  cases  occurring  under  twelve  years  of  age.  The  youngest 
patient  I  have  seen  was  a  boy  of  ten.  Males  are  more  frequently  affected 
than  females.  Of  40  cases  in  my  wards,  32  were  males  and  8  were  females. 
Two  were  colored.  Of  550  cases  collected  by  Colman,  323  were  in  men  and 
227  in  women.  Sinkler  and  Eshner  give  3  cases  in  one  family,  the  father 
and  two  girls. 

With  the  following  conditions  may  be  associated  a  profound  anaemia 
not  to  be  distinguished  clinically  from  Addison's  idiopathic  form: 


fjgQ  DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 

(a)  Pregnancy  and  Parturition. — The  symptoms  may  develop  during 
pregnancy,  as  in  19  of  29  cases  of  tliis  group  in  Eichhorst's  table.  More 
commonly,  in  my  experience,  the  condition  has  been  post  partum;  thus, 
of  my  27  cases,  5  followed  delivery. 

(h)  Atrophy  of  the  Stomach. — This  condition,  early  recognized  by  Flint 
and  Fenwick,  may  certainly  cause  a  progressive  pernicious  anasmia.  By 
modern  methods  it  may  now  be  possible  to  exclude  this  extreme  gastric 
atrophy. 

(c)  Parasites. — The  most  severe  form  may  be  due  to  the  presence  of 
parasites,  and  the  accounts  of  cases  depending  upon  the  anchylostoma  and 
the  bothriocephalus  describe  a  progressive  and  often  pernicious  anasmia. 

After  the  exclusion  of  these  forms  there  remains  a  large  proportion, 
numbering  18  cases  in  my  series,  which  correspond  to  Addison^s  descrip- 
tion. The  etiology  of  these  cases  is  still  dark.  The  researches  of  Quincke 
and  his  student  Peters  showed  that  there  was  an  enormous  increase  in  the 
iron  in  the  liver,  and  they  suggested  that  the  affection  was  probably  due  to 
increased  hgemolysis.  This  has  been  strongly  supported  by  the  extensive 
observations  of  Hunter,  who  has  also  shown  that  the  urine  excreted  is 
darker  in  color  and  contains  pathological  urobilin.  The  lemon  tint  of  the 
skin  or  the  actual  jaundice  is  attributed,  on  this  view,  to  an  overproduction. 
To  explain  the  haemolysis,  it  has  been  thought  that  in  the  condition  of 
faulty  gastro-intestinal  digestion,  which  is  so  commonly  associated  with 
these  cases,  poisonous  materials  are  developed,  which  when  absorbed  cause 
destruction  of  the  corpuscles.  Certainly  the  evidence  for  haemolysis  is 
very  strong,  but  we  are  still  far  away  from  a  full  knowledge  of  the  condi- 
tions under  which  it  is  produced. 

Stockman  suggests  that  repeated  small  capillary  haemorrhages — chiefly 
internal — play  an  important  role  in  the  causation  of  the  disease,  Avhich 
also  explains,  he  holds,  the  existence  of  a  great  excess  of  iron  in  the  liver. 

On  the  other  hand,  F.  P.  Henry,  Stephen  Mackenzie,  Eindflcisch,  and 
other  authorities  incline  to  the  belief  that  the  essence  of  the  disease  is  in 
defective  hasmogenesis,  in  consequence  of  which  the  red  blood-corpuscles 
are  abnormally  vulnerable.  William  Hunter  has  advanced  the  view  that  it 
is  a  special  infective  disease  associated  often  with  infection  of  the  ali- 
mentary tract  and  frequently  with  oral  sepsis. 

Morbid  Anatomy. — The  body  is  rarely  emaciated.  A  lemon  tint 
of  the  skin  is  present  in  a  majority  of  the  cases.  The  muscles  often  are 
intensely  red  in  color,  like  horse-flesh,  while  the  fat  is  light  yellow.  Haem- 
orrhages are  common  on  the  skin  and  serous  surfaces.  The  heart  is  usu- 
ally large,  flabby,  and  empty.  In  one  instance  I  obtained  only  2  drachms 
of  blood  from  the  right  heart,  and  between  3  and  4  from  the  left.  The 
muscle  substance  of  the  heart  is  intensely  fatty,  and  of  a  pale,  light-yellow 
color.  In  no  affection  do  we  see  more  extreme  fatty  degeneration.  The 
lungs  show  no  special  changes.  The  stomach  in  many  instances  is  normal, 
but  in  some  cases  of  fatal  anaemia  the  mucosa  has  been  extensively  atro- 
phied. In  the  case  described  by  Henry  and  myself  the  mucous  membrane 
had  a  smooth,  cuticular  appearance,  and  there  was  complete  atrophy  of 


ANEMIA.  797 

the  secreting  tubules.  The  liver  may  be  enlarged  and  fatty.  In  most  of 
my  autopsies  it  was  normal  in  size,  but  usually  fatty.  The  iron  is 
in  excess,  a  striking  contrast  to  the  condition  in  cases  of  secondary  anaemia. 
It  is  deposited  in  the  outer  and  middle  zones  of  the  lobules,  and  in  two 
specimens,  which  I  examined,  seemed  to  have  such  a  distribution  that  the 
bile  capillaries  were  distinctly  outlined.  This,  Hunter  states,  is  a  special 
and  characteristic  lesion,  possibly  peculiar  to  pernicious  anasmia.  A.  J. 
Scott  examined  for  me  the  livers  in  45  consecutive  autopsies  without  finding 
(except  in  pernicious  anaemia)  this  special  distribution  of  pigment. 

The  spleen  shows  no  important  changes.  In  one  of  Palmer  Howard's 
cases  the  organ  weighed  only  1  ounce  and  5  drachms.  The  iron  pigment 
is  usually  in  excess.  The  lymph-glands  may  be  of  a  deep  red  color.  The 
amount  of  iron  pigment  is  increased  in  the  kidneys,  chiefly  in  the  convo- 
luted tubules.  The  bone  marrow,  as  pointed  out  by  H.  C.  Wood,  is  usually 
red,  lymphoid  in  character,  showing  great  numbers  of  nucleated  red  cor- 
puscles, especially  the  larger  forms  called  by  Ehrlich  gigantoblasts.  Changes 
in  the  ganglion  cells  of  the  sympathetic  have  been  reported  on  several  oc- 
casions. Lichtheim  has  found  sclerosis  in  the  posterior  columns  of  the 
cord.  Burr  described  a  series  of  cases.  The  subject  is  referred  to  again 
under  diseases  of  the  spinal  cord  (University  Med.  Magazine,  1895). 

Symptoms. — The  patient  may  have  been  in  previous  good  health, 
but  in  many  cases  there  is  a  history  of  gastro-intestinal  disturbance,  mental 
shock,  or  worry.  The  description  given  by  Addison  presents  the  chief 
features  of  the  disease  in  a  masterly  way.  "  It  makes  its  approach  in  so 
slow  and  insidious  a  manner  that  the  patient  can  hardly  fix  a  date  to  the 
earliest  feeling  of  that  languor  which  is  shortly  to  become  so  extreme. 
♦The  countenance  gets  pale,  the  whites  of  the  eyes  become  pearly,  the  gen- 
eral frame  flabby  rather  than  wasted,  the  pulse  perhaps  large,  but  remark- 
ably soft  and  compressible,  and  occasionally  with  a  slight  jerk,  especially 
under  the  slightest  excitement.  There  is  an  increasing  indisposition  to 
exertion,  with  an  uncomfortable  feeling  of  faintness  or  breathlessness  in 
attempting  it;  the  heart  is  readily  made  to  palpitate;  the  whole  surface 
of  the  body  presents  a  blanched,  smooth,  and  waxy  appearance;  the  lips, 
gums,  and  tongue  seem  bloodless,  the  flabbiness  of  the  solids  increases,  the 
appetite  fails,  extreme  languor  and  faintness  supervene,  breathlessness 
and  palpitations  are  produced  by  the  most  trifling  exertion  or  emotion; 
some  slight  oedema  is  probably  perceived  about  the  ankles;  the  debility 
becomes  extreme — the  patient  can  no  longer  rise  from  bed;  the  mind  oc- 
casionally wanders;  he  falls  into  a  prostrate  and  half-torpid  state,  and  at 
length  expires;  nevertheless,  to  the  very  last,  and  after  a  sickness  of  several 
months'  duration,  the  bulkiness  of  the  general  frame  and  the  amount  of 
obesity  often  present  a  most  striking  contrast  to  the  failure  and  exhaustion 
observable  in  every  other  respect." 

The  Blood. — The  red  corpuscles  may  fall  to  one  fifth  or  less  of  the  nor- 
mal number.  The  average  count  in  my  40  hospital  cases  was  1,500,000 
per  cubic  millimetre,  and  the  haemoglobin  was  about  30  per  cent.  The 
haemoglobin  is  relatively  increased,  so  that  the  individual  globular  rich- 
ness is  plus,  a  condition  exactly  the   opposite  to   that  which   occurs  in 


798 


DISEASES  OP  THE  BLOOD  AND  DUCTLESS   GLANDS, 


chlorosis  and  the  secondary  anaemia,  in  which  the  corpuscular  richness  in 
coloring  matter  is  minus.  The  relative  increase  in  the  hsemoglohin  is 
probably  associated  with  the  average  increase  in  the  size  of  the  red  blood- 
corpuscles.  The  accompanying  chart  illustrates  these  points.  Microscop- 
ically the  red  blood-corpuscles  present  a  great  variation  in  size,  and  there 
can  be  seen  large  giant  forms,  megalocytes,  which  are  often  ovoid  in  form, 


FEB. 

MAR. 

APR. 

MAY 

JUNE 

JULY 

AUG. 

SEPT.                 OCT. 

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BLACK,   RED  CORPUSCLES. 


RED,  HAEMOGLOBIN. 


MEAN   NORM. 
NUMBER  OP 

WHITE 
CORPUSCLES 


BLUE,   COLORLESS  CORPUSCLES. 


110^ 

100^ 

90^ 

80!« 

m% 

Mi% 
SOU 
20^ 
10^ 


Chart  XIX. — Pernicious  anteraia. 


measuring  8,  11,  or  even  15  /x  in  diameter — a  circumstance  which  Henry 
regards  as  indicating  a  reversion  to  a  loAver  type.  Laache  thinks  these 
pathognomonic,  and  they  certainly  form  a  constant  feature.  There  are 
also  small  round  cells,  microcytes,  from  2  to  6  yu.  in  diameter,  and  of  a 
deep  red  color.  The  corpuscles  show  a  remarkable  irregularity  in  form; 
they  are  elongated  and  rodlike  or  pyriform;  one  end  of  a  corpuscle' may 


ANEMIA.  Y99 

retain  its  shape  while  the  other  is  narrow  and  extended.  To  this  condition 
of  irregularity  Quincke  gave  the  name  poikilocytosis. 

Nucleated  red  blood-corpuscles  are  almost  always  present,  as  pointed 
out  by  Ehrlieh.  It  may  require  a  long  search  to  find  them.  There  are 
two  types,  normoblasts  and  megaloblasts,  which  Ehrlieh  regards  as  almost 
distinctive  of  this  anaemia.  There  are  frequently  forms  intermediate  be- 
tween these  two  groups  which  often  have  irregular  nuclei.  A  relatively 
large  number  of  megaloblasts  usually  indicates  a  grave  outlook.  Though 
these  large  forms  are  most  characteristic,  occasionally  forms  closely  similar 
to  them  may  be  found  in  the  graver  secondary  ansemias — e.  g.,  bothrio- 
cephalus  anaemia,  anchylostomiasis — and  in  leuksemia.  Karyokinetic  fig- 
ures may  be  seen  in  these  bodies.  Eed  corpuscles  with  fragmenting  nuclei 
are  common  in  pernicious  ansemia.  The  leucocytes  are  generally  normal 
or  diminished  in  number;  and  a  marked  relative  increase  in  the  small  mono- 
nuclear forms,  with  a  diminution  in  the  polynuclear  leucocytes,  is  often 
noted.     The  blood-plates  are  either  absent  or  very  scanty. 

The  cardio-vascular  symptoms  are  important  and  are  noted  in  the  de- 
scription given  above.  Hsemic  murmurs  are  usually  present.  The  larger 
arteries  pulsate  visibly  and  the  throbbing  in  them  may  be  distressing  to  the 
patient.  The  pulse  is  full  and  frequently  suggests  the  water-hammer  beat 
of  aortic  insufficiency.  The  capillary  pulse  is  frequently  to  be  seen.  The 
superficial  veins  are  often  prominent,  and  I  have  seen  well-marked  pulsa- 
tion in  them.  Haemorrhages  occurred,  either  in  the  skin  or  from  the 
mucous  surfaces,  in  12  cases  of  my  series.  Eetinal  haemorrhages  are  com- 
mon.    There  are  rarely  symptoms  in  the  respiratory  organs. 

Gastro-intestinal  symptoms,  such  as  dyspepsia,  nausea,  and  vomiting, 
may  be  present  throughout  the  disease.  Diarrhoea  is  not  infrequent.  The 
urine  is  usually  of  a  low  specific  gravity  and  sometimes  pale,  but  in  other 
instances  it  is  of  a  deep  sherry  color,  shown  by  Hunter  and  Mott  to  be 
due  to  great  excess  of  urobilin.  Fever  was  present  in  three  fourths  of 
my  cases.  Nervous  symptoms  were  found  in  14  out  of  40  cases.  The 
commonest  were  sensory  disturbances  with  a  spastic  condition.  Pigmenta- 
tion of  the  skin  was  present  in  8  cases.  It  is  often  patchy  and  associated 
with  leucoderma. 

Diagnosis.— From  chlorosis  the  disease  is  readily  distinguished.  Sev- 
eral points  in  the  blood  examination  are  of  especial  importance,  namely, 
the  relative  increase  in  the  haemoglobin  and  the  presence  of  megalocytes 
and  of  the  large  forms  of  nucleated  red  blood-corpuscles,  the  gigantoblasts 
of  Ehrlieh.  Poikilocytosis  may  occur  in  any  severe  ana?mia.  The  marked 
secondary  anaemia  of  cancer  of  the  stomach  may  give  difficulty.  In  this 
there  are  usually  the  features  of  a  secondary  anaemia:  the  red  count  is 
rarely  so  low  and  the  gastric  findings  are  of  help.  The  lower  red  count 
of  pernicious  anaemia,  the  high  color  index,  higher  percentage  of  small 
mononuclears,  and  especially  the  finding  of  megaloblasts,  are  all  important 
points. 

Prognosis. — In  the  true  Addisonian  cases  the  outlook  is  bad,  though 
of  late  years  on  the  arsenic  treatment  the  proportion  of  recoverv  has  in- 
creased.   Of  the  40  cases  from  my  wards,  death  occurred  in  1 7  while  under 


800  DISEASES  OF  THE  BLOOD   AND  DUCTLESS   GLANDS. 

observation.  The  average  duration  of  these  was  one  year.  In  8  the  course 
^\as  less  than  six  months.  The  average  duration  of  22  cases,  the  majority 
of  which  were  discharged  improved  or  well,  had  been  sixteen  months.  One 
patient  recovered  completely.  He  was  admitted  in  1890  with  a  history  of 
one  year,  was  discharged  well,  and  returned  in  1896  with  cancer  of  the 
stomach.  One  patient  is  in  good  health  six  years  and  another  four  years 
after  the  onset.  In  Pye-Smith's  article  in  the  Guy's  Hospital  Eeports  he 
mentions  20  cases  of  recovery.  Colman,  in  a  recent  article,  states  that 
one  of  these  cases  treated  with  arsenic  in  1880  was  alive  and  well  in  March, 
1900.  The  history  is  usually  not  one  of  progressive  advance  but  of  alter- 
nate periods  of  gain  and  loss.  Yet  in  6  of  my  cases  the  course  was  practically 
progressive  throughout,  and  in  2  it  might  be  termed  acute.  In  my  series 
a  red  count  below  one  million  has  been  a  bad  omen.  Of  16  such  only  4 
recovered.  The  presence  of  many  megaloblasts  is  unfavorable.  They  were 
relatively  eleven  times  more  numerous  in  the  fatal  cases  of  my  series  than 
in  those  that  recovered.  That  a  large  relative  percentage  of  small  mono- 
nuclears was  of  bad  import  is  not  supported  by  my  cases.  Those  that  recov- 
ered had  a  slightly  higher  average  percentage  than  the  fatal  cases.  Pa- 
tients who  do  not  take  arsenic  will  usually  do  badly.  Gastro-intestinal 
disturbances  are  serious.  Only  4  of  my  cases  reached  a  red  count  of  over 
four  million. 

Treatment  of  AnSBinia. — Secondary  Ancemia. — The  traumatic 
cases  do  best,  and  with  plenty  of  good  food  and  fresh  air  the  blood  is 
readily  restored.  The  extraordinary  rapidity  with  which  the  normal  per- 
centage of  red  blood-corpuscles  is  reached  without  any  medication  what- 
ever is  an  important  lesson.  The  cause  of  the  hsemorrhage  should  be 
sought  and  the  necessary  indications  met.  The  large  group  depending 
on  the  drain  on  the  albuminous  materials  of  the  blood,  as  in  Bright's  dis- 
ease, suppuration,  and  fever,  is  difficult  to  treat  successfully,  and  so  long 
as  the  cause  keeps  up  it  is  impossible  to  restore  the  normal  blood  condition. 
The  anaemia  of  inanition  requires  plenty  of  nourishing  food.  "When  de- 
pendent on  organic  changes  in  the  gastro-intestinal  mucosa  not  much 
can  be  expected  from  either  food  or  medicine.  In  the  toxic  cases  due  to 
mercury  and  lead,  the  poison  must  be  eliminated  and  a  nutritious  diet 
given  with  full  doses  of  iron.  In  a  great  majority  of  these  cases  there  is 
deficient  blood  formation,  and  the  indications  are  briefly  three:  plenty  of 
food,  an  open-air  life,  and  iron.  As  a  rule  it  makes  but  little  difference 
what  form  of  the  drug  is  administered. 

The  treatment  of  chlorosis  affords  one  of  the  most  brilliant  instances — 
of  which  we  have  but  three  or  four — of  the  specific  action  of  a  remedy. 
Apart  from  the  action  of  quinine  in  malarial  fever,  and  of  mercury  and 
iodide  of  potassium  in  syphilis,  there  is  no  other  drug  the  beneficial  efEects 
of  which  we  can  trace  with  the  accuracy  of  a  scientific  experiment.  It 
is  a  minor  matter  liow  the  iron  cures  chlorosis.  In  a  week  we  give  to  a 
case  as  much  iron  as  is  contained  in  the  entire  blood,  as  even  in  the  worst 
case  of  chlorosis  there  is  rarely  more  than  a  deficit  of  2  grammes  of  this 
metal.  Iron  is  present  in  the  faeces  of  chlorotic  patients  before  they  are 
placed  upon  any  treatment,  so  that  the  disease  does  not  result  from  any 


ANJEMIA.  801 

deficiency  of  available  iron  in  the  food.  Bunge  believes  that  it  is  the  sul- 
phur which  interferes  with  the  digestion  and  assimilation  of  this  natural 
iron.  The  sulphides  are  produced  in  the  process  of  fermentation  and 
decomposition  in  the  fseces,  and  interfere  with  the  assimilation  of  the 
normal  iron  contained  in  the  food.  By  the  administration  of  an  inorganic 
preparation  of  iron,  with  which  these  sulphides  unite,  the  natural  organic 
combinations  in  the  food  are  spared.  In  studying  a  number  of  charts  of 
chlorosis,  it  is  seen  that  there  is  an  increase  in  the  red  blood-corpuscles 
under  the  infliTcnce  of  the  iron,  and  in  some  instances  the  globular  rich- 
ness rises  above  normal.  The  increase  in  the  hemoglobin  is  slower  and 
the  jnaximum  percentage  may  not  be  reached  for  a  long  time.  I  have  for 
years  in  the  treatment  of  chlorosis  used  with  the  greatest  success  Blaud's 
pills,  made  and  given  according  to  the  formula  in  Niemeyer's  text-book, 
in  which  each  pill  contains  2  grains  of  the  sulphate  of  iron.  During  the 
first  week  one  pill  is  given  three  times  a  day;  in  the  second  week,  two 
pills;  in  the  third  week,  three  pills,  three  times  a  day.  This  dose  should 
be  continued  for  four  or  five  weeks  at  least  before  reduction.  An  impor- 
tant feature  in  the  treatment  of  chlorosis  is  to  persist  in  the  use  of  the 
iron  for  at  least  three  months,  and,  if  necessary,  subsequently  to  resume 
it  in  smaller  doses,  as  recurrences  are  so  common.  The  diet  should  con- 
sist of  good,  easily  digested  food.  Special  care  should  be  directed  to  the 
bowels,  and  if  constipation  is  present  a  saline  purge  should  be  given  each 
morning.  Such  stress  did  Sir  Andrew  Clark  lay  on  the  importance  of  con- 
stipation in  chlorosis,  that  he  stated  that  if  limited  to  the  choice  of  one 
drug  in  the  treatment  of  the  disease  he  would  choose  a  purgative.  The 
good  influence  of  alkaline  waters  in  association  with  the  treatment  by  iron 
has  been  noted  by  von  Jaksch.  In  many  instances  the  dyspeptic  symptoms 
may  be  relieved  by  alkalies.  Dilute  hydrochloric  acid,  manganese,  phos- 
phorus, and  oxygen  have  been  recommended.  Rest  in  bed  is  important  in 
severe  cases. 

Treatment  of  Pernicious  Ancemia. — Since  the  introduction  by  Byrom 
Bramwell  of  arsenic  in  this  affection  a  large  number  of  cases  have  been 
temporarily,  a  few  permanently,  cured  by  it.  It  should  be  given  as  Fowler's 
solution  in  increasing  doses.  It  is  usually  well  borne,  and  patients,  as  a 
rule,  take  up  to  20  minims  three  times  a  day  without  any  disturbance. 
I  usually  begin  with  3  minims  and  increase  to  5  at  the  end  of  the  first 
week,  to  10  at  the  end  of  the  second  week,  to  15  at  the  end  of  the  third 
week,  and,  if  necessary,  go  up  to  20  or  25.  Symptoms  of  an  over-dose  are 
rare;  vomiting  and  diarrhoea  occasionally  occur.  The  drug  should  be  dis- 
continued for  a  few  days.  Acting  on  Hunter's  suggestion  that  the  disease 
is  a  septic  infection,  oral  and  intestinal  antiseptics  may  be  used.  Anti- 
streptococcic scrum  has  been  given  in  some  instances. 

Eest  in  bed  and  a  light  but  nutritious  diet  (giving  the  food  in  small 
amounts  and  at  fixed  intervals)  are  the  first  indications.  I  always  prefer 
to  begin  the  treatment  of  a  case  of  pernicious  anaemia,  whatever  the  grade 
may  be,  with  rest  in  bed  as  one  of  the  essential  elements.  The  patient 
should  be  out  of  doors  if  possible.  The  bonoficial  effect  of  massage  has 
been  shown  by  J.  K.  Mitchell.    I  have  abandoned  the  use  of  rectal  injections 


802  DISEASES  OP  THE  BLOOD  AND  DUCTLESS   GLANDS. 

of  dried  blood.  Iron  rarely  acts  well  in  this  form,  iDut  in  a  case  in  which 
the  arsenic  disagrees  it  may  be  tried.  Bone  marrow  has  been  recommended. 
It  is  best  given  as  a  glycerin  extract.  I  have  not  seen  any  benefit  follow 
its  administration.    Inlialations  of  oxygen  may  be  tried. 


II.    LEUKEMIA. 

Definition. — An  affection  characterized  by  persistent  increase  in  the 
white  blood-corpuscles,  associated  with  changes,  either  alone  or  together, 
in  the  spleen,  lymphatic  glands,  or  bone  marrow. 

The  disease  was  described  almost  simultaneously  by  Virchow  and  by 
Bennett,  who  gave  to  it  the  name  leucocythasmia.  It  is  ordinarily  seen  in 
two  main  types,  though  combinations  and  variations  may  occur: 

(1)  Spleno-meduUary  leukgemia,  in  which  the  changes  are  especially 
localized  in  the  spleen  and  the  bone  marrow,  while  the  blood  shows  a  great 
increase  in  elements  which  are  derived  especially  from  the  latter  tissue, 
a  condition  which  Miiller  has  termed  "  myelgemia."  Ehrlich  prefers  to 
call  this  type  of  the  disease  "  myelogenous  leukemia,"  believing  the  part 
played  by  the  spleen  in  the  process  to  be  purely  passive. 

(3)  Lymphatic  leukaemia,  in  which  the  changes  are  chiefly  localized  in 
the  lymphatic  apparatus,  the  blood  showing  an  especial  increase  in  those 
elements  derived  from  the  lymph-glands. 

Etiology. — We  know  nothing  of  the  conditions  under  which  the  dis- 
ease develops.  It  is  not  uncommon  on  this  continent.  There  have  been 
24  cases  in  my  wards,  of  which  15  were  of  the  spleno-myelogenous  and  9 
of  the  lymphatic  type.  There  were  13  males  and  11  females.  Three  were 
colored.  There  were  18  below  the  age  of  forty  years.  It  does  not  seem 
more  frequent  in  the  southern  parts  of  the  country.  The  disease  is  most 
common  in  the  middle  period  of  life.  The  youngest  of  my  patients  was 
a  child  of  eight  months,  and  cases  are  on  record  of  the  disease  as  early 
as  the  eighth  or  tenth  week.  It  may  occur  as  late  as  the  seventieth  year. 
Males  are  more  prone  to  the  affection  than  females.  Birch-Hirschfeld 
states  that  of  200  cases  collected  from  the  literature,  135  were  males  and 
65  females. 

A  tendency  to  haemorrhage  has  been  noted  in  many  cases,  and  some 
of  the  patients  have  suffered  repeatedly  from  nose-bleeding.  In  women 
the  disease  is  most  common  at  the  climacteric.  There  are  instances  in 
which  it  has  developed  during  pregnancy.  The  case  described  by  J.  Chal- 
mers Cameron,  of  Montreal,  is  in  this  respect  remarkable,  as  the  patient 
passed  through  three  pregnancies,  bearing  on  each  occasion  non-leukfemic 
children.  The  case  is  interesting,  too,  as  showing  the  hereditary  character 
of  the  affection,  as  the  grandmother  and  mother,  as  well  as  a  brother,  suf- 
fered from  symptoms  strongly  suggestive  of  leukaemia.  One  of  the  pa- 
tient's children  had  leukaemia  before  the  mother  showed  any  signs,  and  a 
second  died  of  the  disease.  At  the  last  report  this  patient  had  gradually 
recovered  from  the  third  confinement,  and  the  red  blood-corpuscles  had 
risen  to  4,000,000  per  cubic  millimetre,  and  the  ratio  of  white  to  red  was  1 


LEUKEMIA.  803 

to  200.     Sanger  has  reported  a  case  in  which,  a  healthy  mother  bore  a 
leukajmic  child. 

Malaria  is  believed  by  some  to  be  an  etiological  factor.  Of  150  cases 
analyzed  by  Gowers,  there  was  a  history  of  malaria  in  30;  of  my  hospital 
cases  7  gave  a  history  of  it.  The  disease  has  followed  injury  or  a  blow. 
The  lower  animals  are  subject  to  the  affection,  and  cases  have  been  de- 
scribed in  horses,  dogs,  ozen,  cats,  swine,  and  mice.  Lowit  has  described  a 
parasite  which  he  terms  Hcemamceba  leukcemice.  He  describes  two  varie- 
ties.    His  views  have  met  with  little  acceptance. 

Morbid  Anatomy. — The  wasting  may  be  extreme,  and  dropsy  is 
sometimes  present.  There  is  in  many  cases  a  remarkable  condition  of 
polysmia;  the  heart  and  veins  are  distended  with  large  blood-clots.  In 
Case  XI  of  my  geries  the  weight  of  blood  in  the  heart  chambers  alone  was  ■ 
620  grammes.  There  may  be  remarkable  distention  of  the  portal,  cerebral, 
pulmonary,  and  subcutaneous  veins.  The  blood  is  usually  clotted,  and 
the  enormous  increase  in  the  leucocytes  gives  a  pus-like  appearance  to  the 
coagula,  so  that  it  has  happened  more  than  once,  as  in  Virchow's  memor- 
able case,  that  on  opening  the  right  auricle  the  observer  at  first  thought 
he  had  cut  into  an  abscess.  The  coagula  have  a  peculiar  greenish  color, 
somewhat  like  the  fat  of  a  turtle.  The  alkalinity  of  the  blood  is  dimin- 
ished. The  fibrin  is  increased.  The  character  of  the  corpuscles  will  be 
described  under  the  symptoms.  Charcot's  octohedral  crystals  may  separate 
from  the  blood  after  death.  The  specific  gravity  of  the  blood  is  some- 
what lowered.     There  may  be  pericardial  ecchymoses. 

In  the  spleno-meduUary  form  the  spleen  is  greatly  enlarged.  Strong 
adhesions  may  unite  it  to  the  abdominal  wall,  the  diaphragm,  or  the  stom- 
ach. The  capsule  may  be  thickened.  The  vessels  at  the  hilus  are  enlarged; 
the  weight  may  range  from  2  to  18  pounds.  The  organ  is  in  a  condition 
of  chronic  hyperplasia.  It  cuts  with  resistance,  has  a  uniformly  reddish- 
brown  color,  and  the  Malpighian  bodies  are  invisible.  Grayish-white,  cir- 
cumscribed, lymphoid  tumors  may  occur  throughout  the  organ,  contrasting 
strongly  with  the  reddish-brown  matrix.  In  the  early  stage  the  swollen 
spleen  pulp  is  softer,  and  it  is  stated  that  rupture  has  occurred  from  the 
intense  hyperaemia. 

In  association  with  these  changes  in  the  spleen,  the  bone  marrow  is 
involved,  the  lieno-medullary  form  of  the  Germans.  The  essential  change, 
indeed,  in  the  disease  appears  to  be  the  extraordinary  hyperplasia  of  the 
red  marrow,  and  the  appearance  of  an  hyperplastic  cellular  tissue  in  regions 
where  in  the  adults  the  marrow  is  fatty.  Instead  of  a  fatty  tissue,  the 
medulla  of  the  long  bones  may  resemble  the  consistent  matter  which 
forms  the  core  of  an  abscess,  or  it  may  be  dark  brown  in  color.  In  Pon- 
fick's  ease  there  were  hagmorrhagic  infarctions.  There  may  be  much  ex- 
pansion of  the  shell  of  bone,  and  localized  swellings  which  are  tender  and 
may  even  yield  to  firm  pressure.  Histologically,  there  are  found  in  the 
medulla  large  numbers  of  nucleated  red  corpuscles  in  all  stages  of  develop- 
ment, numerous  cells  with  eosinophilic  granules,  both  small  polynuclear 
forms  and  large  almost  giant  mononuclear  elements.  There  are  also  many 
large  cells  with  single  large  nuclei  and  neutrophilic  granules — the  cellules 


804  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

medullaires  of  Cornil — the  myelocytes  which  are  found  in  the  hlood.  Great 
numbers  of  polynuclear  leucocytes  are  also  present,  as  well  as  a  certain 
number  of  small  mononuclear  elements. 

In  the  lymphatic  forms  of  the  disease  there  is  a  general  lymphatic  en- 
largement, which  is  usually  associated  with  a  certain  amount  of  enlarge- 
ment of  the  spleen.  In  only  one  of  my  cases  was  the  splenic  enlargement 
notable.  In  the  cases  of  lymphatic  leukaemia  the  cervical,  axillary,  mesen- 
teric, and  inguinal  groups  may  be  much  enlarged,  but  the  glands  are  usu- 
ally soft,  isolated,  and  movable.  They  may  vary  considerably  in  size  dur- 
ing the  course  of  the  disease.  The  tonsils  and  the  lymph  follicles  of  the 
tongue,  pharynx,  and  mouth  may  be  enlarged.  Numerous  mitoses  may  be 
found  in  the  small  cells  of  the  lymphatic  tissue. 

In  some  instances  there  are  leukgemic  enlargements  in  .the  solitary  and 
agminated  glands  of  Peyer.  In  a  case  of  Willcocks'  there  were  growths 
on  the  surface  of  the  stomach  and  gastro-splenic  omentum.  The  thymus 
is  rarely  involved,  though  it  has  been  enlarged  in  some  of  the  cases  of  acute 
lymphatic  leukemia.  The  bone  marrow  in  these  cases  may  be  replaced  by 
a  lymphoid  tissue.  Nucleated  red  corpuscles  and  the  normal  granular 
marrow  elements  may  be  greatly  reduced  in  number. 

The  liver  may  be  enlarged,  and  in  a  case  described  by  Welch  it  weighed 
over  13  pounds.  The  enlargement  is  usually  due  to  a  diffuse  leukgemic 
infiltration.  The  columns  of  liver  cells  are  widely  separated  by  leucocytes, 
which  are  partly  within  and  partly  outside  the  lobular  capillaries.  There 
may  be  definite  leukemic  growths. 

There  are  rarely  changes  of  importance  in  the  lungs.  The  kidneys  are 
often  enlarged  and  pale,  the  capillaries  may  be  distended  with  leucocytes, 
and  leuksemic  tumors  may  occur.  The  skin  may  be  involved,  as  in  a  case 
described  by  Kaposi. 

Leuksemic  tumors  in  the  organs  are  not  common.  They  were  present 
in  only  1  of  the  12  autopsies  in  my  series.  In  159  cases  collected  by  Gowers 
there  were  only  13  instances  of  leuksemic  nodules  in  the  liver  and  10  in 
the  kidneys.  These  new  growths  probably  develop  from  leucocytes  which 
leave  the  capillaries.  Bizzozero  has  shown  that  the  cells  which  compose 
them  are  in  active  fission. 

Symptoms. — The  onset  is  insidious,  and,  as  a  rule,  the  patient  seeks 
advice  for  progressive  enlargement  of  the  abdomen  and  shortness  of  breath, 
or  for  the  enlarged  glands  or  the  pallor,  palpitation,  and  other  symptoms 
of  anaemia.  Bleeding  at  the  nose  is  common.  Gastro-intestinal  symptoms 
may  precede  the  onset.  Occasionally  the  first  symptoms  are  of  a  very  seri- 
ous nature.  In  one  of  the  cases  of  my  series  the  boy  played  lacrosse  two 
days  before  the  onset  of  the  final  hsematemesis;  and  in  another  case  a 
girl,  who  had,  it  was  supposed,  only  a  slight  chlorosis,  died  of  fatal  hsem- 
orrhage  from  the  stomach  before  any  suspicion  had  been  aroused  as  to 
the  true  condition. 

Ansemia  is  not  a  necessary  accompaniment  of  all  stages  of  the  disease;' 
the  subjects  may  look  very  healthy  and  well. 

As  has  been  stated,  the  disease  is  most  commonly  seen  in  two  main 
types,  though  combinations  may  occur. 


LEUKEMIA.  805 

(1)  Spleno-medullary  Leukaemia. 

This  is  much  the  commonest  type  of  the  disease.  The  gradual  in- 
crease in  the  volume  of  the  spleen  is  the  most  prominent  symptom  in  a 
majority  of  the  cases.  Pain  and  tenderness  are  common,  though  the  pro- 
gressive enlargement  may  he  painless.  A  creaking  fremitus  may  be  felt 
on  palpation.  The  enlarged  organ  extends  downward  to  the  right,  and 
may  be  felt  just  at  the  costal  edge,  or  when  large  it  may  extend  as  far 
over  as  the  navel.  In  many  cases  it  occupies  fully  one  half  of  the  abdo- 
men, reaching  to  the  pubes  below  and  extending  beyond  the  middle  line. 
As  a  rule,  the  edge,  in  some  the  notch  or  notches,  can  be  felt  distinctly. 
Its  size  varies  greatly  from  time  to  time.  It  may  be  perceptibly  larger 
after  meals.  A  hsemorrhage  or  free  diarrhoea  may  reduce  the  size.  The 
pressure  of  the  enlarged  organ  may  cause  distress  after  eating;  in  one  case 
it  caused  fatal  obstruction  of  the  bowels.  *A  murmur  may  sometimes  be 
heard  over  the  spleen,  and  Gerhardt  has  described  a  pulsation  in  it. 

The  pulse  is  usually  rapid,  soft,  compressible,  but  often  full  in  volume. 
There  are  rarely  any  cardiac  symptoms.  The  apex  beat  may  be  lifted  an 
interspace  by  the  enlarged  spleen.  Toward  the  close  oedema  may  occur  in 
the  feet  or  general  anasarca.  Haemorrhage  is  common.  There  may  be  most 
extensive  purpura,  or  hsemorrhagic  exudate  into  pleura  or  peritonaeum. 
Epistaxis  is  the  most  frequent  form.  Haemoptysis  and  haematuria  are  rare. 
Bleeding  from  the  gums  may  be  present.  Hsmatemesis  proved  fatal  in 
two  of  my  cases,  and  in  a  third  a  large  cerebral  haemorrhage  rapidly  killed. 
The  leukaemic  retinitis  is  a  part  of  the  hsemorrhagic  manifestations.  Sud- 
den death,  without  obvious  cause,  may  occur,  as  in  Bennett's  first  case. 

Local  gangrene  may  develop,  with  signs  of  intense  infection  and  high 
fever.  There  are  very  few  pulmonary  symptoms.  The  shortness  of  breath 
is  due,  as  a  rule,  to  the  anaemia.  Toward  the  end  there  may  be  oedema  of 
the  lungs,  or  pneumonia  may  carry  off  the  patient.  The  gastro-intestinal 
symptoms  are  rarely  absent.  Nausea  and  vomiting  are  early  features  in 
some  cases.  Diarrhoea  may  be  very  troublesome,  even  fatal.  Intestinal 
haemorrhage  is  not  common.  There  may  be  a  dysenteric  process  in  the 
colon.  Jaundice  rarely  occurs,  though  in  one  case  of  my  series  there  were 
recurrent  attacks.  Ascites  may  be  a  prominent  symptom,  probably  due  to 
the  .presence  of  the  splenic  tumor.  A  leukaemic  peritonitis  also  may  be 
present,  due  to  new  growths  in  the  membranes. 

The  nervous  system  is  not  often  involved.  Facial  paralysis  has  been 
noted.  Headache,  dizziness,  and  fainting  spells  are  due  to  anaemia.  The 
patients  are  usually  tranquil.    Coma  may  follow  cerebral  haemorrhage. 

The  special  senses  are  often  affected.  There  is  a  peculiar  retinitis,  due 
chiefly  to  the  extravasation  of  blood,  but  there  may  be  aggregations  of 
leucocytes,  forming  small  leukaemic  growths.  Optic  neuritis  is  rare.  Deaf- 
ness has  frequently  been  observed;  it  may  appear  early  and  possibly  is  due 
to  haemorrhage.  Features  suggestive  of  Meniere's  disease  may  come  on 
quite  suddenly,  due  to  leukaemic  infiltration  or  haemorrhage  into  the  semi- 
circular canal. 

The  urine  presents  no  constant  changes.     The  uric  acid  excreted  is 
always  in  excess. 
50 


806  mSEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

Priapism  is  a  curious  symptom  which  has  been  present  in  a  large  num- 
ber of  cases.  It  may,  as  in  one  of  our  cases,  be  the  first  symptom.  Pea- 
body  reports  a  case  in  which  it  persisted  for  six  weeks.  The  cause  is  not 
known. 

Fever  was  present  in  two  thirds  of  my  series.  Periods  of  pyrexia  may 
alternate  with  prolonged  intervals  of  freedom.  The  temperature  may 
range  from  102°  to  103°. 

Blood. — In  all  forms  of  the  disease  the  diagnosis  must  be  made  by  the 
examination  of  the  blood,  as  it  alone  ofl'ers  distinctive  features. 

The  most  striking  change  in  the  more  common  form,  the  spleno-myelog- 
enous,  is  the  increase  in  the  colorless  corpuscles.  The  average  of  my  hos- 
pital cases  was  298,700  per  cubic  millimetre,  and  the  average  ratio  to  the 
red  cells  was  as  1  to  10.  The  proportion  may  be  1  to  5,  or  may  even  reach 
1  to  1.  There  are  instances  on  record  in  which  the  number  of  leucocytes 
has  exceeded  that  of  the  red  corpuscles.  The  leucocytes  may  vary  greatly 
within  short  intervals. 

The  character  of  the  cells  in  splenic  myelogenous  leukaemia  is  as  fol- 
lows: The  small  mononuclear  forms  are  little  if  at  all  increased;  relatively 
they  are  greatly  diminished.  The  eosinophiles  are  present  in  normal  or 
increased  relative  proportion,  so  that  there  is  a  great  total  increase,  and 
their  presence  is  a  striking  feature  in  the  stained  blood-slide.  The  poly- 
nuclear  neutrophiles  may  be  in  normal  proportion;  more  frequently  they 
are  relatively  diminished,  and  in  the  later  stages  they  may  form  but  a 
small  proportion  of  the  colorless  elements.  Marked  differences  in  size  be- 
tween individual  polynuclear  leucocytes  may  be  noted;  the  same  is  true 
of  the  eosinophiles.  The  most  characteristic  features  of  the  blood  in  this 
form  of  leukgemia  is  th^  presence  of  cells  which  do  not  occur  in  normal 
blood.  They  appear  to  be  derived  from  the  marrow,  and  are  called  by 
Ehrlich  myelocytes.  They  are  large  mononuclear  neutrophilic  cells,  which' 
may  vary  much  in  size.  They  comprise  about  30  per  cent  of  the  colorless 
cells.  Nicked  nuclei  are  common.  Miiller  has  recently  found  many  large 
mononuclear  elements  with  karyokinetic  figures  in  leukaemic  blood  and  in 
the  marrow.  These  probably  correspond  to  the  myelocytes  of  Ehrlich  as 
well  as  to  the  "  cellules  medullaires  "  of  Cornil.  Polynuclear  cells  with 
coarse  basophilic  granules,  "  Mastzellen,"  are  always  present  in  this  form 
of  leukgemia  in  considerable  numbers.  The  granules  do  not  stain  in  Ehr- 
lich's  triacid  mixture,  and  the  cells  may  be  recognized  as  polynuclear  non- 
granular elements.  These  cells,  which  form  only  about  0.28  per  cent  of 
the  leucocytes  of  normal  blood,  may  be  even  more  numerous  than  the 
eosinophiles. 

Nucleated  red  blood-corpuscles  are  present  in  considerable  numbers. 
These  are  usually  "  normoblasts,"  but  cells  with  larger  paler  nuclei,  some 
showing  evidences  of  mitosis,  may  be  seen.  Eed  cells  with  fragmented 
nuclei  are  common,  while  true  megaloblasts  may  be  found.  The  average 
number  of  red  cells  in  my  hospital  series  was  2,850,000  per  cubic  milli- 
metre. In  no  case  was  the  count  below  two  million.  The  average  haemo- 
globin was  42  per  cent.  The  accompanying  blood  chart  is  from  a  case  of 
leukaemia  with  an  enormously  enlarged  spleen.    Among  other  points  about 


LEUKEMIA. 


807 


leuksemic  blood  may  be  mentioned  the  feebleness  of  the  amoeboid  movement, 
as  noted  by  Cavafy,  which  may  be  accounted  for  by  the  large  number  of 
mononuclear  elements  present,  the  polynuclear  alone  possessing  this  power. 
The  blood-plates  exist  in  variable  numbers;  they  may  be  remarkably  abun- 
dant.    The  fibrin  network  between  the  corpuscles  is  usually  thick  and 


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CORPUSCLES 


BLACK,  RED  CORPUSCLES. 


RED,   HAEMOGLOBIN. 

Chart  XX. — Leukaemia. 


BLUE,  COLORLESS  CORPUSCLES. 


dense.  In  blood-slides  which  are  kept  for  a  short  time,  Charcot's  octohedral 
crystals  separate,  and  in  the  blood  of  leukaemia  the  haemoglobin  shows  a 
remarkable  tendency  to  crystallize. 


808  DISEASES  OF   THE  BLOOD  AND  DUCTLESS  GLANDS. 

2.  Lympliatic  Leuksemia. 

This  form  of  leukaemia  is  rare.  There  were  9  out  of  26  in  my  hospital 
series.  The  superficial  glands  are  usually  most  involved,  but  even  when 
affected  it  is  rare  to  see  such  large  bunches  as  in  Hodgkin's  disease.  Ex- 
ternal lymph  tumors  are  rare.  Lymphatic  leukgemia  is  often  more  rapid 
and  fatal  in  its  course,  though  chronic  cases  may  occur.  It  is  more  com- 
mon in  young  subjects. 

The  histological  characters  of  the  hlood  in  lymphatic  leukaemia  differ 
materially  from  those  in  the  spleno-meduUary  form.  The  increase  in  the 
colorless  elements  is  never  so  great  as  in  the  preceding  form;  a  proportion 
of  1  to  10  would  be  extreme.  The  number  of  both  white  and  red  cells 
showed  great  variations  in  my  series.  The  average  haemoglobin  percentage 
was  37,  the  red  cells  2,294,000  and  the  white  cells  144,800  per  cubic  milli- 
metre— a  ratio  of  1  to  16.  This  increase  takes  place  solely  in  the  lympho- 
cytes, all  other  forms  of  leucocytes  being  present  in  greatly  diminished 
relative  proportion.  In  one  of  my  cases  over  99  per  cent  of  all  the  leuco- 
cytes were  lymphocytes.  In  some  cases,  as  Cabot  has  pointed  out,  this 
increase  takes  place  largely  in  the  smaller  forms,  while  in  others  the  large 
lymphocytes — cells  nearly  as  large  as  polynuclear  leucocytes — predominate. 
Eosinophiles  and  nucleated  red  corpuscles  are  rare.  Myelocytes  are  not 
present. 

Combined  forms  of  leukaemia  are  not  common.  One  such  instance  oc- 
curred at  the  Johns  Hopkins  Hospital.  Here  the  spleen,  marrow,  and 
lymphatic  glands  all  showed  marked  changes.  The  blood  in  this  instance 
showed,  besides  a  large  proportion  of  lymphocytes  and  myelocytes,  a  con- 
siderable number  of  large  mononuclear  leucocytes. 

Acute  Leukcemia. — This  is  usually  of  the  lymphatic  type,  and  in  young 
persons.  Three  of  my  cases  ran  a  course  of  less  than  two  months.  They 
were  all  young.  In  this  type  the  large  lymphocytes  are  frequently  present 
in  considerable  percentage.  In  the  more  chronic  cases  the  small  forms 
usually  predominate. 

Diagnosis. — The  recognition  of  leukaemia  can  be  determined  only 
by  microscopical  examination  of  the  blood.  The  clinical  features  may  be 
identical  with  those  of  ordinary  splenic  anaemia,  or  of  Hodgkin's  disease. 
An  interesting  question  arises  whether  real  increase  in  the  leucocytes  is 
the  only  criterion  of  the  existence  of  the  disease.  Thus,  for  instance,  in 
the  case  whose  chart  is  given  on  page  807,  the  patient  came  under  observa- 
tion in  September,  1890,  with  2,000,000  red  blood-corpuscles  per  cubic  mil- 
limetre, 30  per  cent  of  haemoglobin,  and  500,000  white  blood-corpuscles  per 
cubic  millimetre — a  proportion  of  1  to  4.  As  shown  by  the  chart,  through- 
out September,  October,  November,  and  December,  this  ratio  was  main- 
tained. Early  in  January,  under  treatment  with  arsenic,  the  white  cor- 
puscles began  to  decrease,  and  gradually,  as  shown  in  the  chart,  the  normal 
ratio  was  reached.  At  this  time  could  it  be  said  that  the  case  was  one  of 
leukaemia  without  increase  in  the  number  of  leucocytes?  The  blood  exam- 
ination showed  that  nucleated  red  corpuscles  in  large  numbers  as  well  as 
myelocytes,  elements  which  are  but  rarely  found  in  normal  blood,  were 
still  present  in  numbers  sufficient  to  suggest,  if  the  patient  had  come  under 


HODGKIN'S  DISEASE.  809 

observation  for  the  first  time,  that  leukaemia  might  occur.  In  another  case 
the  blood  became  perfectly  normal  and  the  spleen  tumor  disappeared  twice 
in  one  year.  A  characteristic  leukaemic  condition  returned  subsequently, 
with  a  fatal  termination.  An  intercurrent  infection  usually  causes  a 
marked  diminution  in  the  number  of  leucocytes,  which  may  even  fall  to 
normal.  This  is  often  seen  in  terminal  infections.  It  is,  however,  not 
invariable,  as  in  a  recent  case  with  streptococcus  infection  the  leucocytes 
were  unaltered  until  death. 

The  remarkable  "  green  cancer  "  or  chloroma  is,  according  to  Dock,  "  a 
lymphomatous  process  similar  in  its  classical  features  to  leukaemia  and 
pseudo-leukaemia.^' 

Prognosis. — Eecovery  occasionally  occurs.  A  great  majority  of  the 
cases  prove  fatal  within  two  or  three  years.  Unfavorable  signs  are  a  tend- 
ency to  haemorrhage,  persistent  diarrhoea,  early  dropsy,  and  high  fever. 
Eemarkable  variations  are  displayed  in  the  course,  and  a  transient  im- 
provement may  take  place  for  weeks  or  even  months.  The  pure  lymphatic 
form  seems  to  be  of  particular  malignancy,  some  cases  proving  fatal  in 
from  six  to  eight  weeks;  but  there  are  exceptions,  and  I  have  recently  seen 
a  case  in  which  the  diagnosis  was  made  ten  years  ago  by  W.  H.  Draper. 
The  patient  has  had  enlarged  glands  ever  since,  and,  though  not  anemic, 
the  leucocytes  were  242,000  per  cubic  millimetre,  above  90  per  cent  of 
them  being  lymphocytes.  The  longest  course  of  my  hospital  series  of  the 
lymphatic  type  was  three  years,  and  of  the  spleno-myelogenous  about  the 
same  duration. 

Treatment. — Fresh  air,  good  diet,  and  abstention  from  mental  worry 
and  care,  are  the  important  general  indications.  The  indicatio  morhi  can 
not  be  met.  There  are  certain  remedies  which  have  an  influence  upon  the 
disease.  Of  these,  arsenic,  given  in  large  doses,  is  the  best.  I  have  re- 
peatedly seen  improvement  under  its  use.  On  the  other  hand,  there  are 
curious  remissions  in  the  disease,  as  mentioned  above,  which  render  thera- 
peutical deductions  very  fallacious. 

Quinine  may  be  given  in  cases  with  a  malarial  history.  Iron  may  be 
of  value  in  some  cases,  as  may  also  inhalations  of  oxygen. 

Excision  of  the  leukaemic  spleen  has  been  performed  43  times,  with  5 
recoveries  (J.  C.  Warren). 

III.    HODGKIN'S    DISEASE. 

Definition. — An  affection  characterized  by  progressive  enlargement  of 
the  lymphatic  glands  (beginning  usually  on  one  side  of  the  neck)  and 
spleen,  with  the  formation  in  the  liver,  spleen,  and  other  organs  of  nodu- 
lar growths,  associated  with  a  secondary  anaemia,  without  leukfemia. 

Hodgkin,  in  1832,  recorded  a  series  of  cases  of  enlargement  of  the  lym- 
phatic glands  and  spleen.  As  with  Addison's  disease,  to  Wilks  we  owe  a 
clear  conception  of  the  affection  with  which  he  associated  the  name  of 
the  distinguished  morbid  anatomist  of  Guy's  Hospital.* 

*  Students  have  now  easy  access  to  the  original  account  (which  appeared  in  the  Trans- 
actions of  the  Royal  Med.  and  Chirur.  Society,  1832),  New  Sydenham  Society  Memoirs,  1902. 


810  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

Clinically  the  cases  resemble  certain  forms  of  leukeemia,  lympho-sar- 
coma^,  and  lymphatic  tuberculosis;  some  recent  writers  even  deny  the  exist- 
ence of  a  separate  malady,  Hodgkin's  disease. 

Many  names  have  been  given  to  the  condition — anaemia  lymphatica 
(Wilks),  adenie  (Trousseau),  pseudo-leukgemia  (Cohnheim),  and  generalized 
lymphadenoma. 

The  names  malignant  lymphoma  (Billroth)  and  lympho-sarcoma  have 
also  been  given  to  a  form  of  progressive  enlargement  of  the  lymph  glands, 
but  they  should  be  restricted  to  primary  sarcoma  of  these  structures,  a  very 
different  affection  anatomically,  though  clinically  it  may  resemble  Hodg- 
kin's  disease. 

Etiology. — A  majority  of  the  cases  occur  in  young  persons.  Of  43 
recent  cases  collected  by  Mitchell  Clarke,  37  were  in  males.  Ten  occurred 
below  ten  years  of  age  and  33  below  the  fortieth  year.  Heredity,  syphilis, 
and  tuberculosis  are  doubtful  factors.  Local  irritation  about  the  throat 
and  mouth — regions  draining  into  the  cervical  glands — often  precedes  the 
onset  of  the  swelling  (Trousseau).  The  true  nature  of  the  disease  is  un- 
known. Certain  features  suggest  that  it  may  be  an  acute  infection — the 
rapidly  fatal  course  of  some  cases,  the  frequency  with  which  the  disease 
starts  in  the  cervical  glands,  and  the  not  infrequent  preliminary  involve- 
ment of  the  tonsils,  the  gradual  extension  from  one  gland-group  to  an- 
other, and  the  recurring  exacerbations  of  fever.  A  possible  instance  of 
direct  infection  is  quoted  by  Murray  in  AUbutt's  system.  The  results  of 
bacteriological  study  are  as  yet  uncertain. 

Relation  to  Malignant  Disease. — Much  confusion  has  come  from  the  use 
of  the  terms  lympho-sarcoma  and  malignant  lymphoma  to  designate  cases 
of  Hodgkin's  disease.  The  two  conditions  are  quite  different.  We  know  of 
no  malignant  growth  the  metastases  of  which  occur  in  one  form  of  tissue 
only.  Sarcoma  invades  the  capsule  of  the  gland  and  the  adjacent  textures, 
and  does  not  limit  its  extension  from  one  gland-group  to  another.  Histo- 
logically there  are  radical  differences  between  lympho-sarcoma  and  Hodg- 
kin's disease. 

Relation  to  Tuberculosis. — Of  late  the  view  has  been  advanced  that  Hodg- 
kin's disease  is  only  a  peculiar  form  of  lymphatic  tuberculosis,  a  view  sup- 
ported by  Sternberg,  Crowder,  Musser,  Sailer,  and  others.  There  is  an 
acute  tuberculous  adenitis  and  a  chronic  form  (see  p.  282),  either  of 
which  may  closely  resemble  Hodgkin's  disease.  The  statement  of  the  re- 
lationship is  based  upon  (1)  the  presence  of  tubercle  bacilli  in  the  glands 
in  a  certain  number  of  cases  of  Hodgkin's  disease,  and  (2)  the  successful 
inoculation  of  animals,  even  when  the  glands  did  not  show  tubercle  bacilli 
microscopically.  Opposed  to  this  are  the  facts  that  (1)  in  a  large  majority 
of  all  cases  bacilli  are  not  present  in  the  glands,  and  the  inoculation  ex- 
periments are  negative  (Westphal);  (2)  the  histological  changes  in  the 
glands  in  Hodgkin's  disease  are  specific  and  distinctive  (Reed);  (3)  the 
tuberculin  test  in  typical  cases  of  the  disease  is  negative  (Eeed);  and  (4) 
the  tuberculosis  when  present  is  in  many  cases,  at  least,  a  terminal  infection. 

Morbid  Anatomy. — The  superficial  lymph  glands  are  found  most 
extensively  involved,  and  from  the  cervical  groups  they  form  continuous 


HODGKIN'S  DISEASE.  811 

chains  uniting  the  mediastinal  and  axillary  glands.  The  masses  may 
pass  beneath  the  pectoral  muscles  and  even  beneath  the  scapulae.  Of 
the  internal  glands^,  those  of  the  thorax  are  most  often  affected,  and  the 
tracheal  and  bronchial  groups  may  form  large  masses.  The  trachea  and 
the  aorta  with  its  branches  may  be  completely  surrounded;  the  veins  may 
be  compressed,  rarely  the  aorta  itself.  The  masses  do  not  perforate  the 
sternum  or  invade  the  lung,  as  is  sometimes  seen  in  lympho-sarcoma.  The 
retroperitoneal  glands  may  form  a  continuous  chain  from  the  diaphragm 
to  the  inguinal  canals.  They  may  compress  the  ureters,  the  lumbar  and 
sacral  nerves,  and  the  iliac  veins.  They  may  adhere  to  the  broad  liga- 
ment and  the  uterus  and  simulate  fibroids.  At  an  early  stage  the  glands 
are  soft  and  elastic;  later  they  may  become  firm  and  hard.  Fusion  of 
contiguous  glaifeds  does  not  often  occur,  and  they  tend  to  remain  discrete, 
even  after  attaining  a  large  size.  The  capsule  is  not  infiltrated,  nor  are 
adjacent  tissues  invaded.  On  section  the  gland  presents  a  grayish-white 
semi-translucent  appearance,  broken  by  intersecting  strands  of  fibrous 
tissue;  there  is  no  caseation  or  necrosis  unless  a  secondary  infection  has 
occurred. 

The  spleen  is  enlarged  in  75  per  cent  of  the  cases;  in  young  children  the 
enlargement  may  be  great,  but  the  organ  rarely  reaches  the  size  of  the 
spleen  in  ordinary  leukaemia.  In  more  than  half  of  the  cases  lymphoid 
growths  are  present. 

The  marrow  of  the  long  bones  may  be  converted  into  a  rich  lymphoid 
tissue.  The  lymphatic  structures  of  the  tonsillar  ring  and  of  the  intestines 
may  show  marked  hyperplasia.  The  liver  is  often  enlarged,  and  may  pre- 
sent scattered  nodular  tumors,  which  may  also  occur  in  the  kidneys. 

Histology. — The  recent  study  of  D.  M.  Eeed,*  from  the  laboratory  of 
my  colleague,  Dr.  Welch,  suggests  that  there  is  a  specific  histological  pic- 
ture in  Hodgkin's  disease  characterized  by  (1)  proliferation  of  the  endo- 
thelial and  reticular  cells;  (2)  the  formation  of  lymphoid  cells  (uniform  in 
size  and  shape)  from  the  mother  cells  of  the  lymph-nodes  and  from  the 
endothelial  cells  of  the  reticulum;  (3)  characteristic  giant  cells,  formed 
from  proliferating  endothelial  cells,  which  differ  from  the  giant  cells  of 
tuberculosis;  (4)  great  proliferation  of  the  connective-tissue  stroma  leading 
to  fibrosis;  and,  lastly,  eosinophile  cells,  which  form  a  marked  feature  in  a 
large  proportion  of  the  cases.  The  metastatic  nodules  present  the  same 
structure  as  the  glandular  growths. 

Wlien  tuberculosis  occurs  as  a  secondaiy  infection  the  two  processes 
may  be  readily  differentiated  in  sections  of  the  glands. 

Symptoms. — Enlargement  of  the  glands  on  one  side  of  the  neck  is 
usually  the  first  symptom.  It  is  rare  that  other  superficial  groups  or  the 
deeper  glands  are  first  attacked.  A  chronic  tonsillitis  may  precede  the 
onset.  Months,  or  even  several  years,  may  elapse  before  the  glands  on 
the  other  side  of  the  neck  or  in  the  axilla  are  involved.  Usually  there  is 
a  progressive  growth,  until  quite  large  groups  are  formed,  in  which,  how- 
ever, the  individual  glands  may  be  felt.    There  is  not  often  any  pain.    The 

*  Johns  Hopkins  Hospital  Reports,  vol.  x,  1902. 


812  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

inguinal  glands  may  soon  be  involved  and  grow  rapidly,  but  in  many  cases 
they  do  not  reach  the  size  of  the  cervical  groups.  During  what  may  be 
called  the  first  stage  of  the  disease  the  patient's  general  condition  is  good. 
It  may  be  many  months  before  the  internal  lymph  glands  become  involved, 
and  they  may  never  enlarge  sufficiently  to  cause  symptoms.  The  spleen 
enlarges  in  a  majority  of  cases.  In  rare  instances  the  lymphoid  tumors  may 
be  felt  on  the  surface  of  the  enlarged  liver  and  spleen. 

As  the  disease  advances  the  symptoms  fall  into  two  groups — those  due 
to  pressure  of  the  enlarged  glands,  and  the  progressive  cachexia.  The  axil- 
lary groups  may  cause  swelling  and  pain  in  the  hands  and  arms.  The  ingui- 
nal glands  may  press  on  the  nerves  and  cause  great  pain,  with  swelling  of  the 
feet.  Involvement  of  the  mediastinal  glands  is  indicated  by  paroxysmal 
cough,  attacks  of  pain,  dyspnoea,  and  sometimes  most  intense  cyanosis  of 
the  upper  part  of  the  body.  Pleural  effusion,  disturbed  heart  action,  and 
pupillary  changes  are  rarer  events.  The  cases  with  paraplegia  from  inva- 
sion of  the  spine  and  the  cord  are  lympho-sarcoma. 

The  general  symptoms  of  the  disease  are: 

Ancemia  of  a  secondary  type,  not  marked  at  first,  and  even  in  the  later 
stages  the  red  corpuscles  rarely  fall  below  2,000,000  per  cubic  millimetre. 
The  leucocytes  may  be  normal  in  number  or  there  may  be  an  early  leucocy- 
tosis,  or  at  any  time  during  the  course  there  may  be  a  transient  increase. 
The  small  mononuclear  forms  may  be  relatively  increased.  In  very  rare 
instances  a  terminal  leukeemia  occurs,  but,  as  C.  F.  Martin  suggests,  these 
cases  may  be  true  leuksemia  from  the  start. 

Fever. — A  majority  of  the  cases  present  (1)  a  slight  irregular  fever; 
(2)  later  in  the  disease  there  may  be  a  daily  rise  of  three  or  four  degrees, 
sometimes  with  a  chill  and  sweat;  (3)  in  a  few  rare  instances  Pel  has  de- 
scribed remarkable  periods  of  fever  of  ten  to  fourteen  days'  duration,  alter- 
nating with  intervals  of  complete  apyrexia.  They  occurred  in  one  of  my 
cases.  Ebstein  described  it  as  a  form  of  chronic  recurring  fever.  It  is 
probably  due  to  an  intercurrent  infection. 

Cachexia. — A  remarkable  grade  of  emaciation  ultimately  follows,  associ- 
ated with  great  asthenia,  and  sometimes  anasarca  from  the  anaemia. 

Bronzing  of  the  skin  may  occur,  apart  from  the  use  of  arsenic.  An 
obstinate  pruritus  and  recurring  boils  may  add  to  the  patient's  distress. 

Diagnosis. — (a)  Tuberculosis. — It  is  not  sufficiently  recognized  that 
there  are  both  acute  and  chronic  forms  of  general  tuberculous  adenitis  (see 
p.  282),  but  such  cases  do  not  often  present  difficulty  in  diagnosis.  In  the 
case  of  enlargement  of  the  glands  on  one  side  of  the  neck  beginning  in  a 
young  person,  it  is  often  not  at  ail  easy  to  determine  whether  the  disease 
is  tuberculosis  or  beginning  Hodgkin's  disease.  Two  points  should  be 
decided.  First,  under  cocaine  one  of  the  small  glands  of  the  affected  side 
should  be  excised  and  the  structure  carefully  studied  in  the  light  of  Dr. 
Eeed's  recent  observations.  The  histological  changes  differ  markedly  in 
Hodgkin's  disease  from  those  in  tuberculosis.  Secondly,  tuberculin  should 
be  used  if  the  patient  is  afebrile.  In  early  tuberculosis  of  the  glands  of 
the  neck  the  reaction  is  prompt  and  decisive.  The  large  experience  on  this 
point  in  the  wards  of  my  colleague,  Dr.  Halsted,  is  conclusive  as  to  the 


HODG  KIN'S  DISEASE.  813 

efficiency  (and  the  harmlessness)  of  the  method.  In  the  later  stages,  when 
many  groups  of  glands  are  involved  and  the  cachexia  is  well  advanced,  the 
tuberculin  reaction  may  be  present  in  Hodgkin's  disease,  but  even  then  the 
histological  changes  are  distinctive.  Other  points  to  be  noted  are  the 
tendency  in  the  tuberculous  adenitis  to  coalescence  of  the  glands,  adhesion 
to  the  skin,  with  suppuration,  etc.,  and  the  liability  to  tuberculosis  of 
the  lung  or  pleura. 

(&)  Leukmmia. — As  a  rule,  the  blood  examination  gives  the  diagnosis  at 
a  glance,  as  Hodgkin's  disease  presents  only  a  slight  leucocytosis.  A  dif- 
ficulty arises  only  in  those  rare  instances  of  leukaemia,  usually  the  acute 
lymphatic  form,  in  which  the  leucocytes  gradually  decrease  or  in  which 
the  number  for  a  time  may  become  normal.  Histologically  there  are  strik- 
ing differences  between  the  structure  of  the  glands  in  the  two  conditions. 

(c)  Lymphosarcoma. — Clinically  the  cases  may  resemble  Hodgkin's  dis- 
ease very  closely,  and  in  the  literature  the  two  diseases  have  been  con- 
founded. The  glands,  as  a  rule,  form  larger  masses,  the  capsules  are  in- 
volved, and  adjacent  structures  are  attacked.  Pressure  signs  in  the  chest 
and  abdomen  are  much  more  common  in  lym'pho-sarcoma.  But  the  easiest 
and  most  satisfactory  mode  of  diagnosis  is  examination  of  sections  of  a 
gland,  as  the  structure  is  very  different  from  that  seen  in  Hodgkin's  disease. 
The  blood  condition,  the  type  of  fever,  etc.,  need  a  more  careful  study  in 
this  group  of  cases. 

Course. — There  are  acute  cases  in  which  the  enlargements  spread 
rapidly  and  death  follows  in  three  or  four  months.  As  a  rule,  the  disease 
lasts  for  two  or  three  years.  Eemarkable  periods  of  quiescence  may  occur, 
in  which  the  glands  diminish  in  size,  the  fever  disappears,  and  the  general 
condition  improves.  Even  a  large  group  of  glands  may  almost  completely 
disappear,  or  a  tumor  mass  on  one  side  of  the  neck  may  subside  while  the 
inguinal  glands  are  enlarging.  Usually  a  cachexia  with  ansemia  and  swell- 
ing of  the  feet  precedes  death.  A  fatal  event  may  occur  early  from  great 
enlargement  of  the  mediastinal  glands. 

Treatment. — When  the  glands  are  small  and  limited  to  one  side  of 
the  neck,  operation  should  be  advised;  even  when  both  sides  of  the  neck 
are  involved,  if  there  are  no  signs  of  mediastinal  growth,  operation  is 
justifiable.  The  course  of  the  disease  may  be  delayed,  even  if  cure  does 
not  follow. 

There  is  a  possibility  that  the  X-rays  may  do  good  in  selected  cases. 
Certainly  the  glands  have  been  reduced  in  size,  but  I  know  of  no  case  in 
which  complete  cure  has  been  reported.  Local  treatment  of  the  glands 
seems  to  do  but  little  good. 

Arsenic  is  the  only  drug  which  has  a  positive  value  in  the  disease.  In 
some  cases  the  effects  on  the  glands  are  striking.  It  may  be  given  in  the 
form  of  Fowler's  solution  in  increasing  doses.  Eecoveries  have  been  re- 
ported (?).  Ill  effects  from  the  larger  doses  are  rare.  Peripheral  neuritis 
followed  the  use  of  f,iv,  3j,  mxviij  during  a  period  of  less  than  three 
months.  Phosphorus  is  recommended  by  Cowers  and  Broadbent,  and  may 
be  tried  if  arsenic  is  not  well  borne.  Quinine,  iron,  and  cod-liver  oil  are 
useful  as  tonics.    For  the  pressure  pains  morphia  should  be  given. 


814  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


IV.   PURPURA.' 

Strictly  speaking,  purpura  is  a  symptom,  not  a  disease;  but  under  this 
term  are  conveniently  arranged  a  number  of  affections  characterized  by 
extravasations  of  the  blood  into  the  skin.  In  the  present  state  of  our 
knowledge  a  satisfactory  classification  cannot  be  made.  Excluding  symp- 
tomatic purpura,  W.  Koch  groups  all  forms,  including  hsemophiha,  under 
the  designation  hcemorrhagic  diathesis,  believing  that  intermediate  forms 
link  the  mild  purpura  simplex  and  the  most  intense  purpura  hsemorrhagica; 
while  F.  A.  Hoffmann  considers  them  all  (except  haemophilia)  under  the 
heading  morbus  maculosus.  The  purpuric  spots  vary  from  1  to  3  or  4  mm. 
in  diameter.  When  small  and  pin-point-like  they  are  called  petechias; 
when  large,  they  are  known  as  ecchymoses.  At  first  bright  red  in  color, 
they  become  darker,  and  gradually  fade  to  brownish  stains.  They  do  not 
disappear  on  pressure. 

In  all  cases  of  purpura  the  coagulation  time  of  the  blood  should  be  esti- 
mated (Wright);  the  coagulometer  is  a  useful  clinical  instrument  for  the 
purpose.  Normal  blood  clots  in  the  tubes  in  from  three  to  five  minutes.  In 
some  forms  of  purpura  the  coagulation  time  is  retarded  to  ten  or  fifteen 
minutes,  and  in  haemophilia  it  has  been  delayed  to  fifty  minutes. 

The  following  is  a  provisional  grouping  of  the  cases: 

Symptomatic  Purpura. — [a)  Infectious. — In  pyaemia,  septicaemia, 
and  malignant  endocarditis  (particularly  in  the  last  affection),  ecchymoses 
may  be  very  abundant.  In  typhus  fever  the  rash  is  always  purpuric. 
Measles,  scarlet  fever,  and  more  particularly  small-pox,  have  each  a  variety 
characterized  by  an  extensive  purpuric  rash. 

(b)  Toxic. — The  virus  of  snakes  produces  with  great  rapidity  extrava- 
sation of  blood — a  condition  which  has  been  very  carefully  studied  by 
Weir  Mitchell.  Certain  medicines,  particularly  copaiba,  quinine,  bella- 
donna, mercury,  ergot,  and  the  iodides  occasionally,  are  followed  by  a 
petechial  rash.  Purpura  may  follow  the  use  of  comparatively  small  doses 
of  iodide  of  potassium.  It  is  not  a  very  common  occurrence,  considering 
the  great  frequency  with  which  the  drug  is  employed.  A  fatal  event  may 
be  caused  by  a  small  amount,  as  in  a  case  reported  by  Stephen  Mackenzie 
of  a  child  which  died  after  a  dose  of  2^  grains.  An  erythema  may  precede 
the  haemorrhage.  It  is  not  always  a  simple  purpura,  but  may  be  an  acute 
febrile  eruption  of  great  intensity.  In  September,  1894,  a  man  aged  forty- 
eight  was  admitted  under  my  care  with  arterio-sclerosis  and*  dropsy.  The 
latter  yielded  rapidly  to  digitalis  and  diuretin.  When  convalescent  he  was 
ordered  iodide  of  potassium  in  10-grain  doses  three  times  a  day,  and  took 
in  fourteen  days  420  grains.  He  had  high  fever,  coryza,  swelling  of  the 
throat,  and  the  most  extensive  purpura  over  the  whole  body.  Under  this 
division,  too,  comes  the  purpura  so  often  associated  with  jaundice. 

(c)  Cachectic. — Under  this  heading  are  best  described  the  instances  of 
purpura  which  develop  in  the  constitutional  disturbance  of  cancer,  tuber- 
culosis, Hodgkin's  disease,  Bright's  disease,  scurvy,  and  in  the  debility  of 
old  age.    In  these  cases  the  spots  are  usually  confined  to  the  extremities. 


PURPURA.  815 

They  may  be  very  abundant  on  the  lower  limbs  and  about  the  wrists 
and  hands.  This  constitutes,  probably,  the  commonest  variety  of  the 
disease,  and  many  examples  of  it  can  be  seen  in  the  wards  of  any  large 
hospital. 

(d)  Neurotic. — One  variety  is  met  with  in  cases  of  organic  disease.  It 
is  the  so-called  myelopathic  purpura,  which  is  seen  occasionally  in  loco- 
motor ataxia,  particularly  following  attacks  of  the  lightning  pains  and, 
as  a  rule,  involving  the  area  of  the  skin  in  which  the  pains  have  been  most 
intense.  Cases  have  been  met  with  also  in  acute  myelitis  and  in  transverse 
myelitis,  and  occasionally  in  severe  neuralgia.  Another  form  is  the  re- 
markable hysterical  condition  in  which  stigmata,  or  bleeding  points,  appear 
upon  the  skin. 

(e)  Mechanical. — This  variety  is  most  frequently  seen  in  venous  stasis 
of  any  form,  as  in  the  paroxysms  of  whooping-cough  and  in  epilepsy. 

Arthritic. — This  form  is  characterized  by  involvement  of  the  joints. 
It  is  usually  known,  therefore,  as  rheumatic,  though  in  reality  the  evidence 
upon  which  this  view  is  based  is  not  conclusive.  Of  200  cases  of  purpura 
analyzed  by  Stephen  Mackenzie,  61  had  a  history  of  rheumatism.  For  the 
present  it  seems  more  satisfactory  to  use  the  designation  arthritic.  Three 
groups  of  cases  may  be  recognized: 

(a)  A  mild  form,  often  known  as  Purpura  simplex,  seen  most  com- 
monly in  children,  in  whom,  with  or  without  articular  pain,  a  crop  of 
purpuric  spots  appears  upon  the  legs,  less  commonly  upon  the  trunk  and 
arms.  As  pointed  out  by  Graves,  this  form  is  not  infrequently  associated 
with  diarrhoea.  The  disease  is  seldom  severe.  There  may  be  loss  of  ap- 
petite, and  slight  anaemia.  Fever  is  not,  as  a  rule,  present,  and  the  pa- 
tients get  well  in  a  week  or  ten  days.  These  cases  are  usually  regarded 
as  rheumatic,  and  are  certainly  associated,  in  some  instances,  with  un- 
doubted rheumatic  manifestations;  yet  in  a  majority  of  the  patients  which 
I  have  seen  the  arthritis  was  slighter  than  in  the  ordinary  rheumatism  of 
children,  and  no  other  manifestations  were  present. 

(&)  Purpura  (Peliosis)  rheumatica  (Schonlein's  Disease). — This  remark- 
able affection  is  characterized  by  multiple  arthritis,  and  an  eruption 
which  varies  greatly  in  character,  sometimes  purpuric,  more  commonly 
associated  with  urticaria  or  with  erythema  exudativum.  The  disease  is  most 
common  in  males  between  the  ages  of  twenty  and  thirty.  It  not  infre- 
quently sets  in  with  sore  throat,  a  fever  from  101°  to  103°,  and  articular 
pains.  The  rash,  which  makes  its  appearance  first  on  the  legs  or  about  the 
affected  joints,  may  be  a  simple  purpura  or  may  show  ordinary  urticarial 
wheals.  In  other  instances  there  are  nodular  infiltrations,  not  to  be  distin- 
guished from  erythema  nodosum.  The  combination  of  wheals  and  purpura, 
the  purpura  urticans,  is  very  distinctive.  Much  more  rarely  vesication  is 
met  with,  the  so-called  pemphigoid  purpura.  The  amount  of  oedema  is  vari- 
able; occasionally  it  is  excessive.  In  one  case,  which  I  saw  in  Montreal 
with  Molson,  the  chin  and  lower  lip  were  enormously  swollen,  tense,  glazed, 
and  deeply  ecchymotic.  The  eyelids  were  swollen  and  purpuric,  while 
scattered  over  the  cheeks  and  about  the  joints  were  numerous  spots  of 
purpura  urticans.    These  are  the  cases  which  have  been  described  as  fchrile 


816  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

purpuric  oedema.     The  temperature  range,  in  mild  cases,  is  not  high,  hut 
may  reach  102°  or  103°. 

The  urine  is  sometimes  reduced  in  amount  and  may  be  albuminous. 
The  joint  affections  are  usually  slight,  though  associated  with  much  pain, 
particularly  as  the  rash  comes  out.  Eelapses  may  occur  and  the  disease 
may  return  at  the  same  time  for  several  years  in  succession. 

The  diagnosis  of  Schonlein's  disease  offers  no  difficulty.  The  associa- 
tion of  multiple  arthritis  with  purpura  and  urticaria  is  very  characteristic. 
In  a  case  which  I  saw  with  Musser  there  was  endo-pericarditis,  and  the 
question  at  first  arose  whether  the  patient  had  malignant  endocarditis 
with  extensive  cutaneous  infarcts. 

Schonlein's  peliosis  is  thought  by  most  writers  to  be  of  rheumatic 
origin,  and  certainly  many  of  the  cases  have  the  characters  of  ordinary 
rheumatic  fever,  plus  purpura.  By  many,  however,  it  is  regarded  as  a 
special  affection,  of  which  the  arthritis  is  a  manifestation  analogous  to 
that  which  occurs  in  haemophilia  and  in  scurvy.  The  frequency  with 
which  sore  throat  precedes  the  attack,  and  the  occasional  occurrence  of  en- 
docarditis or  pericarditis,  are  certainly  very  suggestive  of  true  rheumatism. 

The  cases  usually  do  well,  and  a  fatal  event  is  extremely  rare.  The 
throat  symptoms  may  persist  and  give  trouble.  In  two  instances  I  have 
seen  necrosis  and  sloughing  of  a  portion  of  the  uvula. 

(c)  Henoch's  Purpura. — This  variety,  seen  chiefly  in  children,  is  char- 
acterized by  (1)  relapses  or  recurrences,  often  extending  over  several  years; 
(3)  cutaneous  lesions,  which  are  those  of  erythema  multiforme  rather  than 
of  simple  purpura;  (3)  gastro-intestinal  crises — pain,  vomiting,  and  diar- 
rhcea;  (4)  Joint  pains  or  swelling,  often  trifling;  (5)  heemorrhages  from 
the  mucous  membranes.  When  from  the  kidney,  an  intense  hgemorrhagic 
nephritis  may  supervene,  which  proved  fatal,  with  the  symptoms  of  acute 
Bright's  disease,  in  one  of  my  cases,  and  became  chronic  in  a  case  under 
D.  W.  Prentiss.  Any  one  or  two  of  the  above  symptoms  may  be  absent;  the 
intestinal  crises  with  enlargement  of  the  spleen  may  be  present  and  recur 
for  months  before  the  true  nature  of  the  trouble  becomes  manifest.  This 
form  has  an  interesting  connection  with  the  angio-neurotic  oedema,  which 
is  also  characterized  by  severe  gastro-intestinal  crises.  The  prognosis  is,  as 
a  rule,  good.    I  have  reported  a  series  of  18  cases.* 

Purpura  Haemorrhagica. — Under  this  heading  may  be  consid- 
ered the  cases  of  very  severe  purpura  with  haemorrhages  from  the  mucous 
membranes.  The  affection,  known  as  the  morbus  maculosus  of  Werlhof, 
is  most  commonly  met  with  in  young  and  delicate  individuals,  particu- 
larly in  girls;  but  cases  are  described  in  which  the  disease  has  attacked 
adults  in  full  vigor.  After  a  few  days  of  weakness  and  debility,  purpuric 
spots  appear  on  the  skin  and  rapidly  increase  in  numbers  and  size.  Bleed- 
ing from  the  mucous  surfaces  sets  in,  and  the  epistaxis,  hsematuria,  and 
haemoptysis  may  cause  profound  anaemia.  Chart  XXI  illustrates  the  rapid- 
ity with  which  anemia  is  produced  and  the  gradual  recovery.  Death  may 
take  place  from  loss  of  blood,  or  from  haemorrhage  into  the  brain.    Slight 

*  Jacobi,  Festschrift,  1900. 


PURPURA. 


817 


fever  usually  accompanies  the  disease.  In  favorable  cases  the  affection 
terminates  in  from  ten  days  to  two  weeks.  There  are  instances  of  purpura 
haemorrhagica  of  great  malignancy,  which  may  prove  fatal  within  twenty- 
four  hours — purpura  fulminans.  This  form  is  most  commonly  met  with 
in  children,  and  is  characterized  by  cutaneous  hsemorrhages,  which  develop 
with  great  rapidity.  Death  may  occur  before  any  bleeding  takes  place 
from  the  mucous  membranes. 

In  the  diagnosis  of  purpura  hsemorrhagica  it  is  important  to  exclude 
scurvy,  which  may  be  done  by  the  consideration  of  the  previous  health, 


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Chart  XXI. — Illustrates  the  rapidity  with  which  anaemia  is  produced  in  purpura 
htemorrhagica  and  the  gradual  recovery. 


the  circumstances  under  which  the  disease  develops,  and  by  the  absence 
of  swelling  of  the  gums.  The  malignant  forms  of  the  fevers,  particularly 
small-pox  and  measles,  are  distinguished  by  the  prodromes  and  the  higher 
temperature. 

Treatment. — In  symptomatic  purpura  attention  should  be  paid  to 
the  conditions  under  which  it  develops,  and  measures  should  be  employed 
to  increase  the  strength  and  to  restore  a  normal  blood  condition.  Tonics, 
good  food,  and  fresh  air  meet  these  indications.    In  the  simple  purpura  of 


818  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

children,  or  that  associated  with  slight  articular  trouble,  arsenic  in  full 
doses  should  be  given.  ISTo  good  is  obtained  from  the  small  doses,  but  the 
Fowler's  solution  should  be  pushed  freely  until  physiological  effects  are 
obtained.  In  peliosis  rheumatica  the  sodium  salicylates  may  be  given,  but 
with  discretion.  I  confess  not  to  have  seen  any  special  control  of  the  haem- 
orrhages by  this  remedy. 

Aromatic  sulphuric  acid,  ergot,  turpentine,  acetate  of  lead,  or  tannic 
and  gallic  acids,  may  be  used,  and  in  some  instances  they  seem  to  check 
the  bleeding.  Oil  of  turpentine  is  perhaps  the  best  remedy,  in  10  or  15 
minims  doses  three  or  four  times  a  day.  Wright,  of  Netley,  advises  the 
use  of  calcium  chloride  in  20-grain  doses  four  times  a  day  (for  three  or 
four  days)  to  increase  the  coagulability  of  the  blood.  In  bleeding  from 
the  mouth,  gums,  and  nose,  the  inhalation  of  carbon  dioxide,  irrigations 
with  2-per-cent  gelatin  solution,  and  the  application  of  an  aqueous  solution 
of  suprarenal  extract  should  be  tried.  The  last  remedy  has  often  acted 
promptly. 

HEMORRHAGIC  DISEASES  OF  THE  NEW-BORN. 

1.  Syphilis  Haemorrhagica  Neonatorum. — The  child  may  be  born 
healthy,  or  there  may  be  signs  of  haemorrhage  at  birth.  Then  in  a  few 
days  there  are  extensive  cutaneous  extravasations  and  bleeding  from  the 
mucous  surfaces  and  from  the  navel.  The  child  may  become  deeply  jaun- 
diced. The  post  mortem  shows  numerous  extravasations  in  the  internal 
organs  and  extensive  syphilitic  changes  in  the  liver  and  other  organs. 

2.  Epidemic  Hsemoglobinuria  (WincJceTs  Disease). — Hgemoglobinuria  in 
the  new-born,  which  occasionally  develops  in  epidemic  form  in  lying-in 
institutions,  is  a  very  fatal  affection,  which  sets  in  usually  about  the  fourth 
day  of  life.  The  child  becomes  jaundiced,  and  there  are  marked  gastro- 
intestinal symptoms,  with  fever,  jaundice,  rapid  respiration,  and  sometimes 
cyanosis.  The  urine  contains  albumin  and  blood-coloring  matter — me- 
thasmoglobin.  The  disease  has  to  be  distinguished  from  the  simple  icterus 
neonatorum,  with  which  tiiere  may  sometimes  be  blood  or  blood-coloring 
matter  in  the  urine.  The  post  mortem  shows  an  absence  of  any  septic 
condition  of  the  umbilical  vessels,  but  the  spleen  is  swollen,  and  there  are 
punctiform  haemorrhages  in  different  parts.  Some  cases  have  shown  in 
a  marked  degree  acute  fatty  degeneration  of  the  internal  organs — ^the  so- 
called  Buhl's  disease. 

3.  Morbus  Maculosus  Neonatorum. — Apart  from  the  common  visceral 
haemorrhages,  the  result  of  injuries  at  birth,  bleeding  from  one  or  more 
of  the  surfaces  is  a  not  uncommon  event  in  the  new-born,  particularly  in 
hospital  practice.  Forty-five  cases  occurred  in  6,700  deliveries  (C.  W. 
Townsend).  The  bleeding  may  be  from  the  navel  alone,  but  more  com- 
monly it  is  general.  Of  Townsend's  50  cases,  in  20  the  blood  came  from 
the  bowels  (melcena  neonatorum),  in  14  from  the  stomach,  in  14  from  the 
mouth,  in  12  from  the  nose,  in  18  from  the  navel,  in  3  from  the  navel 
alone.  The  bleeding  begins  within  the  first  week,  but  in  rare  instances 
is  delayed  to  the  second  or  third.  Thirty-one  of  the  cases  died  and  19 
recovered.  The  disease  is  usually  of  brief  duration,  death  occurring  in 
from  one  to  seven  days.     The  temperature  is  often  elevated.     The  nature 


HEMOPHILIA.  819 

of  the  disease  is  unknown.  As  a  rule,  nothing  abnormal  is  found  post 
mortem.  The  general  and  not  local  nature  of  the  affection,  its  self -limited 
character,  the  presence  of  fever,  and  the  greater  prevalence  of  the  disease 
in  hospitals,  suggest  an  infectious  origin  (Townsend).  The  bleeding  may 
be  associated  with  intense  hgematogenous  jaundice.  Not  every  case  of 
bleeding  from  the  stomach  or  bowels  belongs  in  this  category.  Ulcers  of 
the  oesophagus,  stomach,  and  duodenum  have  been  found  in  the  new-born 
dead  of  melcena  neonatorum.  The  child  may  draw  the  blood  from  the  breast 
and  subsequently  vomit  it.  In  the  treatment  the  external  warmth  must  be 
maintained,  and  in  feeble  infants  the  couveuse  may  be  used.  Camphor  is 
recommended,  ergotin  hypodermically,  and  the  suprarenal  extract. 

V.    H>EMOPHILIA. 

Definition. — A  constitutional  fault,  hereditary  or  acquired,  charac- 
terized by  a  tendency  to  uncontrollable  bleeding,  either  spontaneous  or 
from  slight  wounds,  sometimes  associated  with  a  form  of  arthritis.  The 
coagulation  time  of  the  blood  is  usually  much  retarded. 

The  fact  that  fatal  hsemorrhage  might  occur  from  slight,  trifling  wounds 
had  been  known  for  centuries.  Fordyce,  in  1784,  recognized  the  hereditary 
nature,  and  early  in  the  last  century  described  the  American  bleeder  fami- 
lies. Buel,  Otto,  Hay,  Coates,  and  others  in  this  country  published  similar 
reports.  The  disease  is  considered  at  length  in  the  monographs  of  Legg 
and  Grandidier,  and  recently  by  Stempel. 

Etiology. — In  a  majority  of  cases  the  disposition  is  hereditary.  In 
the  Appleton-Swain  family,  of  Heading,  Mass.,  there  have  been  cases  for 
nearly  two  centuries;  and  F.  F.  Brown,  of  that  town,  tells  me  that  in- 
stances have  already  occurred  in  the  seventh  generation.  Atavism  through 
the  female  alone  is  almost  the  rule,  and  the  daughters  of  a  bleeder,  though 
healthy  and  free  from  any  tendency,  are  almost  certain  to  transmit  the 
disposition  to  the  male  offspring.  The  affection  is  much  more  common 
in  males  than  in  females — 11:1,  Legg;  4:1,  Stempel.  The  tendency  usually 
appears  within  the  first  two  years  of  life.  It  is  rare  for  manifestations  to 
be  delayed  until  the  tenth  or  twelfth  year.  Families  in  all  conditions  of 
life  are  affected.  The  bleeder  families  are  usually  large.  The  members 
are  healthy-looking,  and  have  fine,  soft  skins.  The  Anglo-German  races 
are  chiefly  attacked;  of  209  cases  collected  within  the  ten  years  1890-1900 
by  Stempel,  96  were  German,  95  English  or  American,  only  16  French, 
Hungarian,  or  Russian.  Steiner  has  reported  from  my  clinic  instances  oc- 
curring in  a  negro  family. 

Morbid  Anatomy. — No  special  peculiarities  have  been  described. 
In  some  instances  changes  have  been  found  in  the  smaller  vessels;  but 
in  others  careful  studies  have  been  negative.  An  unusual  thinness  of  the 
vessels  has  been  noted.  Haemorrhages  have  been  found  in  and  about  the 
capsules  of  the  joints,  and  in  a  few  instances  inflammation  of  the  synovial 
surfaces.  The  nature  of  the  disease  is  unknown.  An  increase  in  the  num- 
ber of  the  red  blood-corpuscles — erythrocytha^ia — with  a  peculiar  frailty 
of  the  blood-vessels,  has  been  supposed.    A  deficiency  of  the  leucocytes  and 


820  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

a  diminution  of  the  blood-plates  have  been  noted,  though  in  a  case  from  my 
clinic,  studied  by  Steiner,  these  structures  were  normal.  Wright  has  found 
the  coagulation  time  much  retarded,  as  long  as  twenty-three  and  forty-five 
minutes. 

Symptoms. — Usually  haemophilia  is  not  noted  in  the  child  until  a 
trifling  cut  is  followed  by  serious  or  uncontrollable  haemorrhage,  or  spon- 
taneous bleeding  occurs  and  presents  insuperable  difficulties  in  its  arrest. 
The  symptoms  may  be  grouped  under  three  divisions:  external  bleedings, 
spontaneous  and  traumatic;  interstitial  bleedings,  petechige  and  ecchy- 
moses;  and  the  joint  affections.  The  external  bleedings  may  be  spon- 
taneous, but  more  commonly  they  follow  cuts  and  wounds.  In  334  cases 
(Grandidier)  the  chief  bleedings  were  epistaxis,  169;  from  the  mouth,  43; 
stomach,  15;  bowels,  36;  urethra^  16;  lungs,  17;  and  in  a  few  instances 
bleeding  from  the  skin  of  the  head,  the  tongue,  finger-tips,  tear-papilla, 
eyelids,  external  ear,  vulva,  navel,  and  scrotum. 

Traumatic  bleeding  may  result  from  blows,  cuts,  scratches,  etc.,  and 
the  blood  may  be  diffused  into  the  tissues  or  discharged  externally.  Trivial 
operations  have  proved  fatal,  such  as  the  extraction  of  teeth,  circumcision, 
or  venesection.  It  is  possible  that  there  may  be  local  defects  which  make 
bleeding  from  certain  parts  of  the  body  more  dangerous.  D.  Hayes  Agnew 
mentioned  to  me  the  case  of  a  bleeder  who  had  always  bled  from  cuts  and 
bruises  above  the  neck,  never  from  those  below.  The  bleeding  is  a  capil- 
lary oozing.  It  may  last  for  hours,  or  even  many  days.  Epistaxis  may 
prove  fatal  in  twenty-four  hours.  In  the  slow  bleeding  from  the  mucous 
surfaces  large  blood  tumors  may  form  ami  project  from  the  nose  or  mouth, 
forming  remarkable-looking  structures,  and  showing  that  the  blood  has 
the  power  of  coagulation.  The  interstitial  hgemorrhages  may  be  spon- 
taneous, or  may  result  from  injury.  Petechias  or  large  extravasations — 
hasmatomata — may  occur,  the  latter  usually  following  blows. 

Joint  Affections. — The  knees  and  elbows  are  chiefly  involved,  but  the 
small  joints  may  be  attacked.  The  onset  is  usually  acute,  with  slight  fever 
and  swelling  and  pain,  and  sometimes  redness.  In  other  instances  there  is 
haemorrhagic  elfusion  without  fever.  Konig  recognizes  three  stages:  first, 
haemarthrosis;  secondly,  an  inflammatory  process,  with  fever  and  spindle- 
formed  swelling,  which  is  apt  to  be  mistaken  for  tuberculosis;  and,  lastly, 
there  may  be  extensive  organic  changes,  which  may  even  resemble  those 
of  arthritis  deformans. 

Diagnosis. — In  the  diagnosis  of  the  condition  the  family  tendency 
is  important.  A  single  uncontrollable  haemorrhage  in  child  or  adult  is  not 
to  be  ranked  as  haemophilia;  but  it  is  only  when  a  person  shows  a  marked 
tendency  to  multiple  haemorrhages,  spontaneous  or  traumatic,  which  tend- 
ency is  not  transitory  but  persists,  and  particularly  if  there  have  been  joint 
affections,  that  we  may  consider  the  condition  haemophilia.  Such  condi- 
tions as  epistaxis,  recurring  for  years — if  no  other  haemorrhage  occurs — 
or  recurring  haematuria  from  one  kidney,  which  has  been  spoken  of  as 
unilateral  renal  hajmophilia,  have  no  association  with  the  true  disease. 
Peliosis  rheumatica  is  an  affection  which  touches  haemophilia  very  closely, 
particularly  in  the  relation  of  the  joint  swellings.    It  may  also  show  itself 


SCURVY.  821 

in  several  members  of  a  family.     The  diagnosis  from  the  various  forms 
of  purpura  is  usually  easy. 

Prognosis. — The  patients  rarely  die  in  the  first  bleeding.  The 
younger  the  individual  the  worse  is  the  outlook,  though  children  rarely  die 
in  the  first  year.  Grandidier  states  that  of  153  boy  subjects,  81  died  before 
the  termination  of  the  seventh  year.  The  longer  the  bleeder  survives  the 
greater  the  chance  of  his  outliving  the  tendency;  but  it  may  persist  to 
old  age,  as  shown  in  the  case  of  Oliver  Appleton,  the  first  reported  Ameri- 
can bleeder,  who  died  at  an  advanced  age  of  haemorrhage  from  a  bed-sore 
and  from  the  urethra.  The  prognosis  is  graver  in  a  boy  than  in  a  girl. 
In  the  latter  menstruation  is  sometimes  early  and  excessive,  but  fortunately, 
in  the  female  members  of  hsemophilic  families,  neither  this  function  nor 
the  act  of  parturition  brings  with  it  special  dangers. 

Treatment. — Members  of  a  bleeder's  family,  particularly  the  boys, 
should  be  guarded  from  injury,  and  operations  of  all  sorts  should  be 
avoided.  The  daughters  should  not  marry,  as  it  is  through  them  that  the 
tendency  is  propagated. 

When  an  injury  or  wound  has  occurred,  absolute  rest  and  compression 
should  first  be  tried,  and  if  these  fail  the  styptics  may  be  used.  In  epis- 
taxis  ice,  tannic  and  gallic  acid  may  be  tried  before  resorting  to  plug- 
ging. Internally  ergot  seems  to  have  done  good  in  several  cases.  Legg 
advises  the  perchloride  of  iron  in  half-drachm  doses  every  two  hours  with 
a  purge  of  sulphate  of  soda.  For  the  epistaxis  the  inhalation  of  carbon 
dioxide  through  the  nostrils  is  recommended  by  A.  E.  Wright.  He  also 
advises  a  solution  of  fibrin  ferment  and  chloride  of  calcium  as  a  styptic. 
Dried  suprarenal  gland,  1  part  to  10  of  water,  freshly  prepared,  may  be 
applied  to  the  part,  or  the  active  principle,  epinephrin  or  adrenalin,  may 
be  tried.  Gelatin  in  5-per-cent  solution  is  warmly  recommended.  Vene- 
section has  been  tried  in  several  cases.  Transfusion  has  been  employed, 
but  without  success.  During  convalescence,  iron  and  arsenic  should  be 
freely  used. 


VI.  SCURVY  (Scorhutus). 

Definition. — A  constitutional  disease  characterized  by  great  debility, 
with  angemia,  a  spongy  condition  of  the  gums,  and  a  tendency  to  h£emor- 
rhages. 

Etiology. — The  disease  has  been  known  from  the  earliest  times,  and 
has  prevailed  particularly  in  armies  in  the  field  and  among  sailors  on  long 
voyages.    It  has  been  well  called  "  the  calamity  of  sailors." 

From  the  early  part  of  the  last  century,  owing  largely  to  the  efforts 
of  Lind  and  to  a  knowledge  of  the  conditions  upon  which  the  disease  de- 
pends, scurvy  has  gradually  disappeared  from  the  naval  service.  In  the 
mercantile  marine,  cases  still  occasionally  occur,  owing  to  the  lack  of  proper 
and  suitable  food. 

In  parts  of  Eussia  scurvy  is  endemic,  at  certain  seasons  reaching  epi- 
demic proportions;  and  the  leading  authorities  upon  the  disorder,  now  in 


822  DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 

that  country,  are  almost  unanimous,  according  to  Hoffmann,*  in  regard- 
ing it  as  infectious. 

In  the  United  States  scurvy  has  become  a  very  rare  disease.  To  the 
hospitals  in  the  seaport  towns  sailors  are  now  and  then  admitted  with  it. 
In  large  almshouses  outbreaks  occasionally  occur.  A  very  great  increase 
of  foreign  population  of  a  low  grade  has  in  certain  districts  made  the  dis- 
ease not  at  all  uncommon.  In  the  mining  districts  of  Pennsylvania  the 
Hungarian,  Bohemian,  and  Italian  settlers  are  not  infrequently  attacked. 
McGsfijp-  has  recently  reported  42  cases  in  Chicago,  limited  entirely  to 
Poles.  He  ascertained  that  in  a  large  proportion  of  the  cases  the  diet  was 
composed  of  bread,  strong  coffee,  and  meat.  Occasionally  one  meets  with 
scurvy  among  quite  well-to-do  people.  One  of  the  most  characteristic  cases 
I  have  ever  seen  was  in  a  woman  with  chronic  dyspepsia,  who  had  lived 
for  many  months  chiefly  on  tea  and  bread.  Some  years  ago  scurvy  was 
not  infrequent  in  the  large  lumbering  camps  in  the  Ottawa  Valley.  Judg- 
ing from  the  Eeport  of  the  American  Paediatric  Society,  we  must  infer  that 
infantile  scurvy  is  on  the  increase  in  this  country.  In  Great  Britain  and 
Ireland  it  has  become  very  rare;  only  302  cases  were  admitted  to  the  Sea- 
man's Hospital  in  the  twenty-two  years  ending  1896  (Johnson  Smith). 

There  are  three  theories  of  the  disease: 

(a)  That  it  is  the  result  of  an  absence  of  those  ingredients  in  the  food 
which  are  supplied  by  fresh  vegetables.  What  these  constituents  are  has 
not  yet  been  definitely  determined.  Garrod  holds  that  the  defect  is  in  the 
absence  of  the  potassic  salts.  Others  believe  that  the  essential  factor  is 
the  absence  of  the  organic  salts  present  in  fruits  and  vegetables.  Ealfe, 
who  has  made  a  very  careful  study  of  the  subject,  believes  that  the  absence 
from  the  food  of  the  malates,  citrates,  and  lactates  reduces  the  alkalinity 
of  the  blood,  which  depends  upon  the  carbonates  directly  derived  from 
these  salts. 

(h)  That  it  is  due  to  toxic  materials  in  the  foods — some  unknown 
organic  poison  the  product  of  decomposition.  That  it  is  not  due  to  an 
absence  of  fresh  vegetables  or  the  salts  of  fruits  and  vegetables  seems  to 
have  been  settled  by  ISTansen  and  his  comrades,  who,  living  for  months  under 
the  most  unfavorable  hygienic  surroundings,  but  eating  fresh  bear's  meat 
and  bear's  blood,  escaped  scurvy.  The  experiments  of  Vaughan  Harley, 
and  Jackson,  who  have  produced  a  disease  analogous  to  scurvy  by  feeding 
monkeys  on  slightly  tainted  meat,  with  maize  and  rice,  support  this  view. 

(c)  In  opposition  to  these  chemical  views  it  is  urged  that  the  disease 
depends  upon  a  specific  (as  yet  unknown)  micro-organism. 

Other  factors  play  an  important  part  in  the  disease,  particularly  phys- 
ical and  moral  influences — overcrowding,  dwelling  in  cold,  damp  quarters, 
and  prolonged  fatigue  under  depressing  influences,  as  during  the  retreat 
of  an  army.  Among  prisoners,  mental  depression  plays  an  important  role. 
It  is  stated  that  epidemics  of  the  disease  have  broken  out  in  the  French 
convict-ships  en  route  to  ISTew  Caledonia  even  when  the  diet  was  amply 

*  Lehrbuch  der  Constitutionskrankheiten,  F.  A.  Hoffmann  (1893),  a  work  to  which  the 
student  is  referred  for  the  best  exposition  of  this  group  of  disorders. 


SCURVY.  823 

sufficient.  Nostalgia  is  sometimes  an  important  element.  It  is  an  inter- 
esting fact  that  prolonged  starvation  in  itself  does  not  necessarily  cause 
scurvy.  Not  one  of  the  professional  fasters  of  late  years  has  displayed  any 
scorbutic  symptom.  The  disease  attacks  all  ages,  but  the  old  are  more 
susceptible  to  it.  Sex  has  no  special  influence,  but  during  the  siege  of 
Paris  it  was  noted  that  the  males  attacked  were  greatly  in  excess  of  the 
females. 

Morbid  Anatomy. — The  anatomical  changes  are  marked,  though 
by  no  means  specific,  and  are  chiefly  those  associated  with  hsemorrhage. 
The  blood  is  dark  and  fluid.  The  microscopical  alterations  are  those  of  a 
severe  anaemia,  without  leucocytosis.  The  bacteriological  examination  has 
not  yielded  anything  very  positive.  Practically  there  are  no  changes  in 
the  blood,  either  anatomical  or  chemical,  which  can  be  regarded  as  pecul- 
iar to  the  disease.  The  skin  shows  the  ecchymoses  evident  during  life. 
There  are  haemorrhages  into  the  muscles,  and  occasionally  about  or  even 
into  the  joints.  Haemorrhages  occur  in  the  internal  organs,  particularly 
on  the  serous  membranes  and  in  the  kidneys  and  bladder.  The  gums  are 
swollen  and  sometimes  ulcerated,  so  that  in  advanced  cases  the  teeth  are 
loose  and  have  even  fallen  out.  Ulcers  are  occasionally  met  with  in  the 
ileum  and  colon.  Haemorrhages  into  the  mucous  membranes  are  extremely 
common.  The  spleen  is  enlarged  and  soft.  Parenchymatous  changes  are 
constant  in  the  liver,  kidneys,  and  heart. 

Symptoms. — The  disease  is  insidious  in  its  onset.  Early  symptoms 
are  loss  in  weight,  progressively  developing  weakness,  and  pallor.  Very 
soon  the  gums  are  noticed  to  be  swollen  and  spongy,  to  bleed  easily,  and 
in  extreme  cases  to  present  a  fungous  appearance.  These  changes,  re- 
garded as  characteristic,  are  sometimes  absent.  The  teeth  may  become 
loose  and  even  fall  out.  Actual  necrosis  of  the  jaw  is  not  common.  The 
breath  is  excessively  foul.  The  tongue  is  swollen,  but  may  be  red  and 
not  much  furred.  The  salivary  glands  are  occasionally  enlarged.  Haem- 
orrhages beneath  the  mucous  membranes  of  the  mouth  are  common.  The 
skin  becomes  dry  and  rough,  and  ecchymoses  soon  appear,  first  on  the  legs 
and  then  on  the  arms  and  trunk,  and  particularly  into  and  about  the  hair- 
follicles.  They  are  petechial,  but  may  become  larger,  and  when  subcu- 
taneous may  cause  distinct  swellings.  In  severe  cases,  particularly  in  the 
legs,  there  may  be  effusion  between  the  periosteum  and  the  bone,  forming 
irregular  nodes,  which,  in  the  case  of  a  sailor  from  a  whaling  vessel  who 
came  under  my  observation,  had  broken  down  and  formed  foul-looking 
sores.  The  slightest  bruise  or  injury  causes  haemorrhages  into  the  injured 
part.  (Edema  about  the  ankles  is  common.  The  "  scurvy  sclerosis,"  seen 
oftenest  in  the  legs,  is  a  remarkable  infiltration  of  the  subcutaneous  tissues 
and  muscles,  forming  a  brawny  induration,  the  skin  over  which  may  be 
blood-stained.  Haemorrhages  from  the  mucous  membranes  are  less  con- 
stant symptoms;  epistaxis  is,  however,  frequent.  Hemoptysis  and  haemate- 
mesis  are  uncommon.  Hsematuria  and  bleeding  from  the  bowels  may  be 
present  in  very  severe  cases. 

Palpitation  of  the  heart  and  feebleness  and  irregularity  of  the  impulse 
are  prominent  symptoms.     A  haemic  murmur  can  usually  be  heard  at  the 


824  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

base.  Hgemorrhagic  infarction  of  the  lungs  and  spleen  has  been  described. 
Eespiratory  symptoms  are  not  common.  The  appetite  is  impaired,  and 
owing  to  "the  soreness  of  the  gums  the  patient  is  unable  to  chew  the  food. 
Constipation  is  more  frequent  than  diarrhcea.  Pain,  tenderness,  or  swell- 
ing in  the  joints  were  present  in  13  of  McGrew's  42  eases.  The  urine  is 
often  albuminous.  The  changes  in  its  composition  are  not  constant;  the 
specific  gravity  is  high;  the  color  is  deeper.  The  statements  with  reference 
to  the  inorganic  constituents  are  contradictory.  Some  authorities  have 
found  the  phosphates  and  potassium  salts  to  be  deficient;  others  hold  that 
they  are  increased. 

There  are  mental  depression,  indifference,  in  some  cases  headache,  and 
in  the  later  stages  delirium.  Cases  of  convulsions,  of  hemiplegia,  and  of 
meningeal  haemorrhage  have  been  described.  Eemarkable  ocular  symp- 
toms are  occasionally  met  with,  such  as  night-blindness  or  day-blindness. 

In  advanced  cases  necrosis  of  the  bones  may  occur,  and  in  young  per- 
sons even  separation  of  the  epiphyses.  There  are  instances  in  which  the 
cartilages  have  separated  from  the  sternum.  The  callus  of  a  recently 
repaired  fracture  has  been  known  to  undergo  destruction.  Fever  is  not 
present,  except  in  the  later  stages,  or  when  secondary  inflammations  in  the 
internal  organs  appear.  The  temperature  may,  indeed,  be  sometimes  below- 
normal.    Acute  arthritis  is  an  occasional  complication. 

Diagnosis. — K"o  difficulty  is  met  in  the  recognition  of  scurvy  when 
a  number  of  persons  are  affected  together.  In  isolated  cases,  however,  the 
disease  is  distinguished  with  difficulty  from  certain  forms  of  purpura.  The 
association  with  manifest  insufficiency  in  diet,  and  the  rapid  ameliora- 
tion with  suitable  food,  are  points  by  which  the  diagnosis  can  be  readily 
settled. 

Prognosis.  — The  outlook  is  good,  unless  the  disease  is  far  advanced 
and  the  conditions  persist  which  lead  to  its  development.  The  mortality 
now  is  rarely  great.  Death  results  from  gradual  heart-failure,  occasionally 
from  sudden  syncope.  Meningeal  hsemorrhage,  extravasation  into  the 
serous  cavities,  entero-colitis,  and  other  intercurrent  affections  may  prove 
fatal. 

Propliylaxis. — The  regulations  of  the  Board  of  Trade  require  that  a 
sufficient  supply  of  antiscorbutic  articles  of  diet  be  taken  on  each  ship;  so 
that  now,  except  as  the  result  of  accident,  the  occurrence  of  scurvy  is  rare 
in  sailors. 

Treatment. — The  juice  of  two  or  three  lemons  daily  and  a  diet  of 
plenty  of  meat  and  fresh  vegetables  suffice  to  cure  all  cases  of  scurvy, 
unless  far  advanced.  When  the  stomach  is  much  disordered,  small  quan- 
tities of  scraped  meat  and  milk  should  be  given  at  short  intervals,  and  the 
lemon-juice  in  gradually  increasing  quantities.  A  bitter  tonic,  or  a  steel  and 
bark  mixture,  may  be  given.  As  the  patient  gains  in  strength,  the  diet  may 
be  more  liberal,  and  he  may  eat  freely  of  potatoes,  cabbage,  water-cresses, 
and  lettuce.  The  stomatitis  is  the  symptom  which  causes  the  greatest  dis- 
tress. The  permanganate  of  potash  or  dilute  carbolic  acid  forms  the  best 
mouth-wash.  Pencilling  the  swollen  gums  with  a  tolerably  strong  solution 
of  nitrate  of  silver  is  very  useful.   The  solution  is  better  than  the  solid  stick, 


SCURVY.  825 

as  it  reaches  to  the  crevices  between  the  granulations.  The  constipation 
which  is  so  common  is  best  treated  with  large  enemata.  For  other  con- 
ditions, such  as  hsemorrhages  and  ulcerations,  suitable  measures  must  be 
employed. 

INFANTILE  SCURVY  {Barlow's  Disease). 

As  in  adults,  scurvy  may  occur  in  children  in  consequence  of  imper- 
fect food  supply. 

W.  B.  Cheadle  and  Gee,  in  London,  have  described  in  very  young  chil- 
dren a  cachexia  associated  with  hemorrhage.  Cheadle  regarded  the  cases 
as  scurvy  ingrafted  on  a  rickety  stock.  Gee  called  his  cases  periosteal 
cachexia.    Cases  had  previously  been  regarded  as  acute  rickets. 

A  few  years  later  Barlow  made  an  exhaustive  study  of  the  condition 
with  careful  anatomical  observations.  The  affection  is  now  recognized  as 
infantile  scurvy,  and  in  Germany  is  called  Barlow's  Disease.  The  Ameri- 
can Pgediatric  Society  has  collected  (1898)  in  this  country  379  cases.  Of 
these,  the  hygienic  surroundings  were  good  in  303.  A  majority  of  the 
patients  were  under  twelve  months.  The  proprietary  foods,  particularly 
malted  milk  and  condensed  milk,  seem  to  be  the  most  important  factors  in 
producing  the  disease.  There  are  instances  in  which  it  has  developed  in 
breast-fed  infants,  and  in  others  fed  on  the  carefully  prepared  milk  of  the 
Walker-Gordon  laboratories. 

The  following  is  a  general  clinical  summary,  taken  from  Barlow's  Brad- 
shaw  Lecture,  1894: 

"  So  long  as  it  is  left  alone  the  child  is  tolerably  quiet;  the  lower  limbs 
are  kept  drawn  up  and  still;  but  when  placed  in  its  bath  or  otherwise 
moved  there  is  continuous  crying,  and  it  soon  becomes  clear  that  the  pain 
is  connected  with  the  lower  limbs.  At  this  period  the  upper  limbs  may 
be  touched  with  impunity,  but  any  attempt  to  move  the  legs  or  thighs 
gives  rise  to  screams.  Next,  some  obscure  swelling  may  be  detected,  first 
on  one  lower  limb,  then  on  the  other,  though  it  is  not  absolutely  symmet- 
rical. .  .  .  The  swelling  is  ill-defined,  but  is  suggestive  of  thickening 
round  the  shafts  of  the  bones,  beginning  above  the  epiphyseal  junctions. 
Gradually  the  bulk  of  the  limbs  affected  becomes  visibly  increased.  .  .  . 
The  position  of  the  limbs  becomes  somewhat  different  from  what  it  was  at 
the  outset.  Instead  of  being  flexed  they  lie  everted  and  immobile,  in  a 
state  of  pseudo-paralysis.  .  .  .  About  this  time,  if  not  before,  great  weak- 
ness of  the  back  becomes  manifest.  A  little  swelling  of  one  or  both  scap- 
ulae may  appear,  and  the  upper  limbs  may  show  changes.  These  are  rarely 
so  considerable  as  the  alterations  in  the  lower  limbs.  There  may  be  swell- 
ing above  the  wrists,  extending  for  a  short  distance  up  the  forearm,  and 
some  swelling  in  the  neighborhood  of  the  epiphyses  of  the  humerus.  There 
is  symmetry  of  lesions,  but  it  is  not  absolute;  and  the  limb  affection  is 
generally  consecutive,  though  the  involvement  of  one  limb  follows  very 
close  upon  another.  The  joints  are  free.  In  severe  cases  another  symp- 
tom may  now  be  found — namely,  crepitus  in  the  regions  adjacent  to  the 
junctions  of  the  shafts  with  the  epiphyses.  The  upper  and  lower  extremi- 
ties of  the  femur,  and  the  upper  extremity  of  the  tibia,  are  the  common 
51 


826  DISEASES  OF  THE  BLOOD  AND   DUCTLESS  GliANDS. 

sites  of  such  fractures;  but  the  upper  end  of  the  humerus  may  also  be  so 
affected.  ...  A  very  startling  appearance  may  be  observed  at  this  period 
in  the  front  of  the  chest.  The  sternum,  with  the  adjacent  costal  carti- 
lages and  a  small  portion  of  the  contiguous  ribs,  seems  to  have  sunk  bodily 
back,  en  Hoc,  as  though  it  had  been  subjected  to  some  violence  which  had 
fractured  several  ribs  in  the  front  and  driven  them  back.  Occasionally 
thickenings  of  varying  extent  may  be  found  on  the  exterior  of  the  vault 
of  the  skull,  or  even  on  some  of  the  bones  of  the  face.  .  .  .  Here  also  must 
be  mentioned  a  remarkable  eye  phenomenon.  There  develops  a  rather 
sudden  proptosis  of  one  eyeball,  with  puffiness  and  very  slight  staining  of 
the  upper  lid.  Within  a  day  or  two  the  other  eye  presents  similar  appear- 
ances, though  they  may  be  of  less  severity.  The  ocular  conjunctiva  may 
show  a  little  ecchymosis,  or  may  be  quite  free.  With  respect  to  the  con- 
stitutional symptoms  accompanying  the  above  series  of  events  the  most 
important  feature  is  the  profound  ansemia  which  is  developed.  .  .  .  The 
anaemia  is  proportional  to  the  amount  of  limb  involvement.  As  the  case 
proceeds,  there  is  a  certain  earthy-colored  or  sallow  tint,  which  is  note- 
worthy in  severe  cases,  and  when  once  this  is  established  bruise-like  ecchy- 
moses  may  appear,  and  more  rarely  small  purpurge.  Emaciation  is  not  a 
marked  feature,  but  asthenia  is  extreme  and  suggestive  of  muscular  failure. 
The  temperature  is  very  erratic;  it  is  often  raised  for  a  day  or  two,  when 
successive  limbs  are  involved,  especially  during  the  tense  stage,  but  is 
rarely  above  101°  or  103°.  At  other  times  it  may  be  normal  or  subnormal." 
If  the  teeth  have  appeared  the  gums  may  be  spongy. 

'The  condition  must  always  be  looked  for  in  young  children  with  diffi- 
culty in  moving  the  lower  limbs,  or  in  whom  paralysis  is  suspected.  What 
is  known  sometimes  as  Parrot's  disease,  or  syphilitic  pseudo-paralysis,  may 
be  confounded  with  it.  In  it  the  loss  of  motion  is  more  or  less  sudden  in 
the  upper  or  lower  limbs,  or  in  both,  due  to  a  solution  of  continuity  and 
separation  of  the  cartilage  at  the  end  of  the  diaphysis.  There  are  usually 
crepitation  and  much  pain  on  movement. 

The  essential  lesion  is  a  subperiosteal  blood  extravasation,  which  causes 
the  thickening  and  tenderness  in  the  shafts  of  the  bones.  In  some  in- 
stances there  is  haemorrhage  in  the  intramuscular  tissue. 

The  prophylaxis  is  most  important.  The  various  proprietary  forms  of 
condensed  milk  and  preserved  foods  for  infants  should  not  be  used.  The 
fresh  cow's  milk  should  be  substituted,  and  a  teaspoonful  of  meat-juice 
or  gravy  may  be  given  with  a  little  mashed  potato.  Orange-juice  or  lemon- 
juice  should  be  given  three  or  four  times  a  day.  Kecovery  is  usually  prompt 
and  satisfactory. 


VII.    STATUS    LYMPHATICUS.    LYMPHATISM. 

Much  attention  has  been  paid  lately  to  a  somewhat  rare  condition  met 
with  chiefly  in  children  and  young  persons,  in  which  the  lymphatic  glands 
and  lymph  tissues  throughout  tlie  body,  the  spleen,  the  thymus,  and  the 
lymphoid  bone  marrow  are  in  a  state  of  hyperplasia.    These  features  have 


STATUS  LYMPHATICUS.     LYMPHATISM.  827 

been  found  associated  with  rickets  and  with  hypoplasia  of  the  heart  and 
aorta.  The  special  interest  lies  in  the  fact  that  these  pathological  condi- 
tions have  been  met  with  frequently  in  cases  of  sudden  death.  Paltauf 
and  others  of  the  Vienna  school,  who  have  written  extensively  on  the  sub- 
ject, believe  that  individuals  with  this  hyperplasia  have  lowered  powers 
of  resistance,  and  are  particularly  liable  to  paralysis  of  the  heart.  The 
condition  has  not  received  much  attention  in  England  and  in  this  coun- 
try. An  excellent  account  of  it,  by  James  Ewing,  appeared  in  the  New 
York  Medical  Journal  of  July  10,  1897. 

Anatomical  Condition. — (a)  Lymph-glands. — The  pharyngeal,  J;horacic, 
and  abdominal  groups  are  most  frequently  affected.  The  cervical,  axil- 
lary, and  inguinal  are  less  commonly  involved,  but  these  glands  may  show 
slight  enlargement.  The  lymphatic  structures  of  the  alimentary  tract,  the 
tissues  of  the  tonsils,  the  adenoid  structures  in  the  upper  pharynx,  and 
the  solitary  and  agminated  follicles  of  the  small  and  large  intestines  are 
usually  much  enlarged.  The  hyperplasia  of  the  intestinal  lymphatic  struc- 
tures may  be  the  most  remarkable,  the  individual  glands  standing  out  like 
peas. 

(b)  8pleen. — Enlargement  of  this  organ  is  usually  moderate  in  degree. 
The  Malpighian  bodies  may  show  very  prominently,  and  when  anaemic  may 
look  like  large  tubercles.    The  organ  is  usually  soft  and  hyperasmic. 

(c)  The  thymus  is  enlarged,  and  may  measure  as  much  as  10  cm.  in 
length.  It  looks  swollen  and  soft,  and  on  section  may  exude  a  milky  white 
fluid. 

{d)  The  lone  marrow  has  been  found  in  a  state  of  hyperplasia,  and  the 
yellow  marrow  of  the  long  bones  in  young  adults,  and  even  in  persons 
between  the  ages  of  twenty  and  thirty,  has  been  found  replaced  by  red 
marrow.  Among  other  associated  conditions  of  this  constitutio  lymphatica, 
as  it  has  been  called,  are  hypoplasia  of  the  heart  and  aorta  and  enlargement 
of  the  thyroid  gland.  In  a  large  number  of  the  cases  in  children  rickets  is 
coincident. 

The  diagiiosis  of  the  lymphatic  constitution  is  not  always  easy.  En- 
largement of  the  superficial  glands,  with  hypertrophy  of  the  tonsils,  signs 
of  slight  swelling  of  the  thyroid,  dulness  over  the  sternum,  with  signs  of 
enlargement  of  the  mesenteric  glands,  are  among  the  most  important  fea- 
tures. Signs  of  hypoplasia  of  the  vascular  system  are  still  more  uncertain, 
though  Quincke  believes  that  in  such  instances  the  left  ventricle  is  dilated 
and  the  peripheral  arteries  may  be  much  smaller  than  normal.  The  sub- 
jects are  usually  ill-developed  and  infantile  in  conformation. 

Sudden  Death  in  the  status  lymphaticus. — What  has  directed  the  at- 
tention of  writers  more  particularly  to  this  condition  is  the  frequency  with 
which  it  has  been  found  in  cases  of  unexpected  death  from  very  trifling 
and  inadequate  causes.  A  good  deal  of  attention  was  directed  to  the  sub- 
ject by  the  death  of  the  son  of  Professor  Langerhans,  of  Berlin,  immedi- 
ately after  the  preventive  inoculation  with  the  antitoxine  of  diphtheria. 
In  another  child  death  occurred  under  similar  circumstances.  The  condi- 
tion has  also  been  met  with  in  a  number  of  cases  of  sudden  death  under 
anesthetics,  and  I  know  of  one  instance  during  anaesthesia  for  adenoid 


828      '       DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 

growths.  Cases  of  sudden  death  of  persons  in  the  water,  who  have  fallen 
in  and,  though  immediately  recovered,  were  dead,  or  who  have  died  sud- 
denly while  bathing,  are  referred  by  Paltauf  to  this  condition.  And,  lastly, 
there  is  the  large  group  of  cases  of  sudden  death  in  children  without  recog- 
nizable cause,  in  whom  post  mortem  the  thymus  has  been  found  enlarged — • 
the  so-called  "  Thymus  Tod "  (see  under  Thymus  Gland).  It  has  also 
been  suggested  that  certain  of  the  sudden  deaths  during  convalescence 
from  the  infectious  fevers  are  to  be  referred  to  this  status  lymphaticus. 
Escherich  thinks  that  certain  measures  usually  harmless,  such  as  hydro- 
therapy, naay  have  an  untoward  effect  in  children  in  this  condition  of  lym- 
phatism,  and  adds  that  tetany  and  laryngismus  may  be  associated  with  it. 
The  whole  question  is  one  which  deserves  the  most  careful  study.  The 
anatomical  features  appear  fairly  well  defined.  The  clinical  features  are 
by  no  means  so  clear,  nor  is  it  at  all  certain  in  what  way  sudden  death  is 
caused  in  these  cases.  The  students  of  the  question  have,  however,  in  the 
past  few  years  brought  forward  evidence  enough  to  show  that  the  subjects 
of  this  lymphatic  constitution  have  a  diminished  vital  resistance,  and  are 
especially  prone  to  fatal  collapse  under  ordinarily  very  inadequate  exciting 
causes. 


VIII.    DISEASES    OF   THE   SUPRARENAL   BODIES, 

1.  Addison's  Disease. 

Definition. — A  constitutional  affection  characterized  by  asthenia,  de- 
pressed circulation,  irritability  of  the  stomach,  and  pigmentation  of  the 
skin.  Tuberculosis  of  the  adrenals  is  the  common  anatomical  change. 
Eecent  observations  indicate  that  the  symptoms  are  due  to  loss  of  function 
of  the  suprarenal  bodies. 

The  recognition  of  the  disease  is  due  to  Addison,  of  Guy's  Hospital, 
whose  monograph  on  The  Constitutional  and  Local  Effects  of  Disease  of 
the  Suprarenal  Capsules  was  published  in  1855. 

Etiology. — Males  are  more  frequently  attacked  than  females.  In 
Greenhow's  analysis  of  183  eases  119  were  males  and  61:  females.  A  ma- 
jority of  the  cases  occur  between  the  twentieth  and  the  fortieth  year.  A 
congenital  case  has  been  described  in  which  the  skin  had  a  yellow-gray 
tint.  The  child  lived  for  eight  weeks,  and  post  mortem  the  adrenals  were 
found  to  be  large  and  cystic.  Injury  such  as  a  blow  upon  the  abdomen 
or  back,  and  caries  of  the  spine,  have  in  many  cases  preceded  the  attack. 
The  disease  is  rare  in  America.  The  number  of  deaths  during  the  census 
year  1890  was  99 — 59  males  and  4©  females.  Twelve  cases  have  come 
under  my  personal  observation,  9  in  men.     One  case  was  in  a  negro. 

Morbid  Anatomy  and  Pathology. — There  is  rarely  emaciation 
or  anasmia.  Rolleston  *  thus  summarizes  the  condition  of  the  suprarenal 
bodies  in  Addison's  disease: 

*  Goulstouian  Lectures,  Royal  College  of  Physicians,  British  Medical  Journal,  1895, 
i,  to  which  the  student  is  referred  for  an  exhaustive  consideration  of  the  entire  question. 


DISEASES  OF  THE  SUPRARENAL  BODIES.  829 

"  1.  The  fibro-caseous  lesion  due  to  tuberculosis — far  the  commonest 
condition  found.  2.  Simple  atrophy.  3.  Chronic  interstitial  inflamma- 
tion leading  to  atrophy.  4.  Malignant  disease  invading  the  capsules,  in- 
cluding Addison's  case  of  malignant  nodule  compressing  the  suprarenal 
vein.  5.  Blood  extra vasated  into  the  suprarenal  bodies.  6.  No  lesion  of 
the  suprarenal  bodies  themselves,  but  pressure  or  inflammation  involving 
the  semilunar  ganglia. 

"  The  first  is  the  only  common  cause  of  Addison's  disease.  The  others, 
with  the  exception  of  simple  atrophy,  may  be  considered  as  very  rare.'^ 

Among  other  anatomical  features  the  condition  of  the  abdominal  sym- 
pathetic has  been  specially  studied.  The  nerve-cells  of  the  semilunar 
ganglia  have  been  described  as  degenerated  and  deeply  pigmented, 
and  the  nerves  sclerotic.  The  ganglia  are  not  uncommonly  entangled  in 
the  cicatricial  tissue  about  the  adrenals.  The  spleen  has  occasionally 
been  found  enlarged;  the  thymus  may  have  persisted  and  be  larger  than 
normal. 

It  is  difficult  to  explain  satisfactorily  all  the  symptoms  of  this  remark- 
able disease.  The  two  chief  theories  which  have  been  advanced  are  briefly 
as  follows:  (a)  That  the  disease  depended  upon  the  loss  of  function  of 
the  adrenals.  This  was  the  view  of  Addison.  The  balance  of  experimental 
evidence  is  in  favor  of  the  view  that  the  adrenals  are  functional  glands, 
which  furnish  an  internal  secretion  essential  to  the  normal  metabolism. 
Schafer  and  Oliver  have  shown  that  the  human  adrenals  contain  a  very 
powerful  extract,  which  is  not  to  be  obtained  in  cases  of  Addison's  dis- 
ease; they  have  also  studied  the  toxic  effects  on  animals  of  the  extracts  of 
the  glands.  In  the  cases  in  which  the  adrenals  have  been  found  involved 
without  the  symptoms  of  Addison's  disease,  accessory  glands  may  have 
been  present;  while  in  the  rare  cases  in  which  the  symptoms  of  the  disease 
have  been  present  with  healthy  adrenals  the  semilunar  ganglia  and  adjacent 
tissues  have  been  involved  in  dense  adhesions,  which  may  have  interfered 
readily  with  the  vessels  or  lymphatics  of  the  glands.  On  this  view  Addi- 
son's disease  is  due  to  an  inadequate  supply  of  the  adrenal  secretion,  just 
as  myxoedema  is  caused  by  loss  of  function  of  the  thyroid  gland.  "  Wliether 
the  deficiency  in  this  internal  secretion  leads  to  a  toxic  condition  of  the 
blood  or  to  a  general  atony  and  apathy  is  a  question  which  must  remain 
open  "  (Rolleston).  (b)  That  it  is  an  affection  of  the  abdominal  sympa- 
thetic system,  induced  most  commonly  by  disease  of  the  adrenals,  but  also 
by  other  chronic  disorders  which  involve  the  solar  plexus  and  its  ganglia. 
According  to  this  view,  it  is  an  affection  of  the  nervous  system,  and  the 
pigmentation  has  its  origin  in  changes  induced  through  the  trophic  nerves. 
The  pronounced  debility  is  the  outcome  of  disturbed  tissue  metabolism, 
and  the  circulatory,  respiratory,  and  digestive  symptoms  are  due  to  im- 
plication of  the  pneumogastric.  The  changes  found  in  the  abdominal 
sympathetic  are  held  to  support  this  view,  and  its  advocates  urge  the  occur- 
rence of  pigmentation  of  the  skin  in  tuberculosis  of  the  peritonaeum,  cancer 
of  the  pancreas,  or  aneurism  of  the  abdominal  aorta.  Bramwell  thinks 
that  the  symptoms  may  be  in  part  due  to  irritation  of  the  sympathetic  and 
in  part  to  adrenal  inadequacy. 


830  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

Symptoms. — In  the  words  of  Addison,  the  characteristic  symptoms 
are  "  anaemia,  general  languor  or  debility,  remarkable  feebleness  of  the 
heart's  action,  irritability  of  the  stomach,  and  a  peculiar  change  of  color 
in  the  skin." 

The  onset  is,  as  a  rule,  insidious.  The  feelings  of  weakness,  as  a  rule, 
precede  the  pigmentation.  In  other  instances  the  gastro-intestinal  symp- 
toms, the  weakness,  and  the  pigmentation  come  on  together.  There  are 
a  few  cases  in  the  literature  in  which  the  whole  process  has  been  acute, 
following  a  shock  or  some  special  depression.  There  are  three  important 
symptoms  of  the  disease: 

(1)  Pigmentation  of  the  Skin. — This,  as  a  rule,  first  attracts  the  atten- 
tion of  the  patient's  friends.  The  grade  of  coloration  ranges  from  a  light 
yellow  to  a  deep  brown,  or  even  black.  In  typical  cases  it  is  diffuse,  but 
always  deeper  on  the  exposed  parts  and  in  the  regions  where  the  normal 
pigmentation  is  more  intense,  as  the  areolae  of  the  nipples  and  about  the 
genitals;  also  wherever  the  skin  is  compressed  or  irritated,  as  by  the  waist- 
band. At  first  it  may  be  confined  to  the  face  and  hands.  Occasionally  it 
is  absent.  Patches  showing  atrophy  of  pigment,  leucoderma,  may  occur. 
The  pigmentation  is  found  on  the  mucous  membranes  of  the  mouth,  con- 
junctivge,  and  vagina.  Pigmentation  of  the  mucous  membrane  is  not  dis- 
tinctive. It  has  been  found  in  chronic  stomach  troubles,  etc.  (Fr.  Schultze), 
and  is  common  in  the  negro.  A  patchy  pigmentation  of  the  serous  mem- 
branes has  often  been  found.  Over  the  diffusely  pigmented  skin  there 
may  be  little  mole-like  spots  of  deeper  pigmentation. 

(2)  Gastro-intestinal  Symptoms. — The  disease  may  set  in  with  attacks 
of  nausea  and  vomiting,  spontaneous  in  character.  Toward  the  close  there 
may  be  pain  with  retraction  of  the  abdomen,  and  even  features  suggestive 
of  peritonitis  (Ebstein).  A  marked  anorexia  may  be  present.  The  gas- 
tric symptoms  are  variable  throughout  the  course;  occasionally  they  are 
absent.  Attacks  of  diarrhoea  are  frequent  and  come  on  without  obvious 
cause. 

(3)  Asthenia. — This  is  perhaps  the  most  characteristic  feature  of  the 
disease.  It  may  be  manifested  early  as  a  feeling  of  inability  to  carry  on 
the  ordinary  occupation,  and  the  patient  complains  constantly  of  feeling 
tired.  The  weakness  is  specially  marked  in  the  muscular  and  cardio- 
vascular systems.  There  may  be  an  extreme  degree  of  muscular  prostra- 
tion in  an  individual  apparently  well  nourished  and  whose  muscles  feel 
firm  and  hard.  The  cardio-vascular  asthenia  is  manifest  in  a  feeble,  irregu- 
lar action  of  the  heart,  which  may  come  on  in  paroxysms,  in  attacks  of 
vertigo,  or  of  syncope,  in  one  of  which  the  disease  may  prove  fatal.  Head- 
ache is  a  frequent  symptom;  convulsions  occasionally  occur.  McMunn 
has  described  an  increase  in  the  urinary  pigments,  and  a  pigment  has  been 
isolated  of  very  much  the  same  character  as  the  melanin  of  the  skin. 

Antemia  was  a  symptom  specially  referred  to  by  Addison,  but  it  has 
been  present  in  a  marked  degree  in  only  one  of  my  cases.  I  saw  an  in- 
stance, in  Philadelphia,  with  J.  C.  Wilson,  in  which  the  diagnosis  at  first 
was  not  at  all  clear  between  Addison's  disease  and  pernicious  anaemia. 

The  mode  of  termination  is  either  by  syncope,  which  may  occur  even 


DISEASES  OP  THE  SUPRARENAL  BODIES.  831 

early  in  the  disease,  by  gradual  progressive  asthenia,  or  by  the  development 
of  tuberculous  lesions.  In  two  cases  I  have  known  a  noisy  delirium  with 
urgent  dyspnoea  to  precede  the  fatal  event. 

Diagnosis. — Pigmentation  of  the  skin  is  not  confined  to  Addison's 
disease.  The  following  are  the  conditions  which  may  give  rise  to  an  in- 
crease in  the  pigment: 

(1)  Abdominal  growths — tubercle,  cancer,  or  lymphoma.  In  tubercu- 
losis of  the  peritonaeum  pigmentation  is  not  uncommon. 

(2)  Pregnancy,  in  which  the  discoloration  is  usually  limited  to  the  face, 
the  so-called  masque  des  femmes  engeintes.  Uterine  disease  is  a  common 
cause  of  a  patchy  melasma. 

(3)  Hcemochromatosis,  associated  with  hypertrophic  cirrhosis,  pigmenta- 
tion of  the  skin,  and  diabetes.  More  commonly  in  overworked  persons  of 
constipated  habit  and  with  sluggish  livers  there  is  a  patchy  staining  about 
the  face  and  forehead. 

(4)  The  vagabond's  discoloration,  caused  by  the  irritation  of  lice  and 
dirt,  which  may  reach  a  very  high  grade,  and  has  sometimes  been  mis- 
taken for  Addison's  disease. 

(5)  In  rare  instances  there  is  deep  discoloration  of  the  skin  in  mela- 
notic cancer,  so  deep  and  general  that  it  has  been  confounded  with  melasma 
suprarenale. 

(6)  In  certain  cases  of  exophthalmic  goitre  abnormal  pigmentation 
occurs,  as  noted  by  Drummond  and  others. 

(7)  In  a  few  rare  instances  the  pigmentation  common  in  scleroderma 
may  be  general  and  deep. 

(8)  In  the  face  there  may  be  an  extraordinary  degree  of  pigmentation 
due  to  innumerable  small  black  comedones.  If  not  seen  in  a  very  good 
light,  the  face  may  suggest  argyria.  Pigmentation  of  an  advanced  grade 
may  occur  in  chronic  ulcer  of  the  stomach  and  in  dilatation  of  the  organ. 

(9)  Argyria  could  scarcely  be  mistaken,  and  yet  I  was  consulted  in  a 
case  in  which  the  diagnosis  of  Addison's  disease  had  been  made  by  several 
good  observers. 

(10)  Arsenic  when  taken  for  many  months  may  cause  a  most  intense 
pigmentation  of  the  skin. 

(11)  Lastly,  with  arterio-sclerosis  and  chronic  heart-disease  there  may 
be  marked  melanoderma. 

In  any  case  of  unusual  pigmentation  these  various  conditions  must  be 
sought  for;  the  diagnosis  of  Addison's  disease  is  scarcely  Justifiable  with- 
out the  asthenia.  In  many  instances  it  is  difficult  early  in  the  disease  to 
arrive  at  a  definite  conclusion.  The  occurrence  of  fainting  fits,  of  nausea, 
and  gastric  irritability  are  important  indications.  As  the  lesion  of  the 
capsules  is  almost  always  tuberculous,  in  doubtful  cases  the  tuberculin 
test  may  be  used.  In  a  recent  case,  a  robust,  healthy-looking  man  with 
symptoms  of  Addison's  disease,  the  characteristic  reaction  was  obtained. 

Prognosis. — The  disease  is  usually  fatal.  The  cases  in  which  the 
bronzing  is  slight  or  does  not  occur  run  a  more  rapid  course.  There  are 
occasionally  acute  cases  which,  with  great  weakness,  vomiting,  and  diar- 
rhoea, prove  fatal  in  a  few  weeks.    In  a  few  cases  the  disease  is  much  pro- 


832  -DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

longed,  even  to  six  or  ten  years.  In  rare  instances  recovery  has  taken  place, 
and  periods  of  improvement,  lasting  many  months,  may  occur. 

Treatment. — The  causal  indications  cannot  be  met.  When  there  is 
"profound  asthenia  the  patient  should  be  confined  to  bed,  as  fatal  syncope 
may  at  any  time  occur.  In  three  of  my  cases  death  was  sudden.  When 
anaemia  is  present  iron  may  be  given  in  full  doses.  Arsenic  and  strychnia 
are  useful  tonics.  For  the  diarrhoea  large  doses  of  bismuth  should  be 
given;  for  the  irritability  of  the  stomach,  creasote,  hydrocyanic  acid,  ice, 
and  champagne.  The  diet  should  be  light  and  nutritious.  Many  patients 
thrive  best  on  a  strict  milk  diet. 

Treatment  hy  Suprarenal  Extract. — Following  the  researches  of  Schafer 
and  Oliver,  the  latter  used  the  gland  in  the  treatment  of  the  disease.  Kinni- 
cutt  has  collected  48  cases  treated  with  adrenal  preparations.  Of  these, 
6  were  reported  as  cured  and  22  as  improved.  I  have  used  it  in  a  number 
of  cases  within  the  past  five  years.  One  patient  was  greatly  benefited, 
gained  19  pounds,  the  symptoms  of  asthenia  disappeared,  and  he  was  alive 
two  years  subsequently,  but  was  still  pigmented.  The  other  cases  were 
not  benefited  in  the  slightest  degree.  The  gland  may  be  given  raw  or  par- 
tially cooked  or  in  a  glycerin  extract.  Tabloids  of  the  dried  extract  are 
used,  one  grain  of  which  corresponds  to  fifteen  of  the  gland.  Three  of  the 
tabloids  may  be  given  daily.  Operation  has  been  suggested,  but  has  not 
been  carried  out  on  any  undoubted  case. 

2.  Othee  Diseases  of  the  Supeaeenal  Capsules. 

HcemorrJiage  into  the  gland  is  not  uncommon,  particularly  in  new-born 
children  (Spencer).  Tuberculosis  may  occur  without  the  symptoms  of  Ad- 
dison's disease.  Among  157  cases  of  tuberculous  disease  in  various  parts 
of  the  body,  caseous  tuberculous  foci  were  found  in  20  in  the  suprarenals 
without  signs  of  Addison's  disease  (Eolleston). 

Tumors  of  the  Suprarenals. — Adenomata  are  common,  particularly  the 
small  yellowish  nodules.    Fibromata  and  fatty  tumors  occur,  but  are  rare. 

Of  malignant  growths  secondary  tumors  are  not  uncommon.  In  63  cases 
of  secondary  carcinoma,  in  7  the  suprarenal  bodies  were  the  seat  of  growths 
(Eolleston).  Of  the  primary  growths,  both  sarcoma  and  carcinoma  may 
occur.  Afiieck  and  Leith  have  collected  20  cases  of  primary  sarcoma. 
Eamsay  informs  me  that  we  have  had  3  cases  of  primary  tumor  of  the 
suprarenals  at  the  Johns  Hopkins  Hospital — 2  in  females  and  1  in  a  male. 
Two  were  sarcomata  and  1  a  carcinoma.  The  diagnosis  in  all  was  malig- 
nant tumor  of  the  kidney.  The  cases  were  operated  upon,  1  with  com- 
plete recovery. 


IX.    DISEASES    OF    THE    SPLEEN.* 

Apart  from  the  acute  swelling  in  fever,  the  chronic  enlargement  of  the 
organ  in  paludism,  leukaemia,  cirrhosis  of  the  liver,  and  heart-disease,  we 

*  For  a  good  discussion  of  the  general  pathology  of  the  spleen,  see  Rolleston  in 
Allbutt's  System  of  Medicine. 


DISEASES  OF  THE  SPLEEN.  833 

see  very  few  instances  of  disease  of  the  spleen.  These  affections  have  been 
fully  described,  but  there  remain  several  conditions  to  which  brief  reference 
may  be  made. 

1.  Movable  Spleen. 

Movable  or  wandering  spleen  is  seen  most  frequently  in  women  the 
subjects  of  enteroptosis.  It  is  occasionally  met  with  without  signs  of  dis- 
placement of  other  organs.  It  may  be  found  accidentally  in  individuals 
who  present  no  symptoms  whatever.  In  other  cases  there  are  dragging, 
uneasy  feelings  in  the  back  and  side.  All  grades  are  met  with,  from  a 
spleen  that  can  be  felt  completely  below  the  margin  of  the  ribs  to  a  condi- 
tion in  which  the  tumor-mass  impinges  upon  the  pelvis;  indeed,  the  organ 
has  been  found  in  an  inguinal  hernia!  In  the  large  majority  of  all  cases  the 
spleen  is  enlarged.  Sometimes  it  appears  that  the  enlargement  has  caused 
relaxation  of  the  ligaments;  in  other  instances  the  relaxation  seems  con- 
genital, as  movable  spleens  have  been  found  in  different  members  of  the 
same  family.  Possibly  traumatism  may  account  for  some  of  the  cases. 
Apart  from  the  dragging,  uneasy  sensations  and  the  worry  in  nervous  pa- 
tients, wandering  spleen  causes  very  few  serious  symptoms.  Torsion  of 
the  pedicle  may  produce  a  very  alarming  and  serious  condition,  leading 
to  great  swelling  of  the  organ,  high  fever,  or  even  to  necrosis.  A  young 
woman  was  admitted  to  my  colleague  Kelly's  ward  with  a  tumor  supposed 
to  be  ovarian,  but  which  proved  to  be  a  wandering,  moderately  enlarged 
spleen.  She  was  transferred  to  the  medical  ward,  where  she  developed 
suddenly  very  great  pain  in  the  abdomen,  a  large  swelling  in  the  left  flank, 
and  much  tenderness.  Halsted  operated  and  found  an  enormously  enlarged 
spleen  in  a  condition  of  necrosis,  adherent  to  the  adjacent  parts  and  to 
the  abdominal  wall.  He  laid  it  open  freely,  and  large  necrotic  masses  of 
spleen  tissue  discharged  for  some  time.    She  made  a  good  recovery. 

The  diagnosis  of  a  wandering  spleen  is  usually  easy  unless  the  organ 
becomes  fixed  and  is  deformed  by  adhesions  and  perisplenitis.  The  shape 
of  the  organ  and  the  sharp  margin  with  the  notches  are  the  points  to  be 
specially  noted. 

The  treatment  of  the  condition  is  important.  Occasionally  the  organ 
may  be  kept  in  position  by  a  properly  adapted  belt  and  a  pad  under  the  left 
costal  margin.  Eemoval  of  the  displaced  organ  has  been  advised  and  car- 
ried out  in  many  cases,  and  nowadays  it  is  not  a  very  serious  operation.  It 
is,  however,  as  a  rule  unnecessary.  In  2  cases  of  enlarged  spleen  under  my 
care,  with  great  mobility,  causing  much  discomfort  and  uneasiness,  Halsted 
completely  relieved  the  condition  by  replacing  the  spleen,  packing  it  in 
position  with  gauze,  and  allowing  firm  adhesions  to  take  place.  Both  these 
patients  were  seen  more  than  eighteen  months  after  the  operation  and  the 
organ  had  remained  in  position. 

2.  Rupture  of  the  Spleen. 

This  is  of  interest  medically  in  connection  with  the  spontaneous  rup- 
ture in  cases  of  acute  enlargement  during  typhoid  fever  or  malaria.  The 
condition  seems  very  rare  in  this  country.    We  have  had  instances  of  rup- 


834  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

ture  of  a  malarial  spleen  following  a  blow,  but  neither  in  this  disease  nor 
in  typhoid  have  we  had  an  instance  of  spontaneous  rupture.  In  India  and 
in  Mauritius  rupture  of  the  spleen  is  stated  to  be  very  common.  Fatal 
hsemorrhage  may  follow  puncture  of  a  swollen  spleen  with  a  hypodermic 
needle.  Occasionally  the  rupture  results  from  the  breaking  of  an  infarct 
or  of  an  abscess.  The  symptoms  are  those  of  hgemorrhage  into  the  peri- 
tonseum,  and  the  condition  demands  immediate  laparotomy. 

3.  Infakct  and  Abscess  of  the  Spleen. 

Emboli  in  the  splenic  arteries  causing  infarcts  may  be  either  infective 
or  simple.  They  are  seen  most  frequently  in  ulcerative  endocarditis  and 
in  septic  conditions.  Infarcts  may  also  follow  the  formation  of  thrombi 
in  the  branches  of  the  splenic  artery  in  cases  of  fever.  They  are  not  very 
infrequent  in  typhoid.  In  a  few  instances  the  infarcts  have  followed 
thrombosis  in  the  splenic  veins.  They  are  chiefly  of  pathological  interest. 
The  infarct  of  the  spleen  may  be  suspected  in  cases  of  septicseniia  or  pyee- 
mia  when  there  is  pain  in  the  splenic  region,  tenderness  on  pressure,  and 
slight  swelling  of  the  organ;  on  several  occasions  I  have  heard  a  well-marked 
peritoneal  friction  rub.  Occasionally  in  the  infective  infarcts  large  ab- 
scesses are  formed,  and  in  rare  instances  the  whole  organ  may  be  converted 
into  a  sac  of  pus. 

Tumors  of  the  spleen,  hydatid  and  other  cysts  of  the  organ,  and  gummata 
are  rare  conditions  of  anatomical  interest,  for  an  account  of  which  the 
reader  is  referred  to  Eolleston's  article  and  to  the  section  on  the  spleen, 
by  Gr.  E.  Lockwood,  in  Loomis  and  Thompson's  System  of  Medicine. 

4.  Splenic  Anemia. 

Under  this  head  are  grouped  cases  characterized  by  idiopathic  enlarge- 
ment of  the  spleen  with  angemia.  Whether  the  anaemia  is  secondary  to  the 
splenic  condition  or  both  are  secondary  to  some  unknown  cause  we  do  not 
know.  Perhaps  several  different  conditions  are  classed  together  under  the 
term.  Attention  was  first  called  to  it  in  this  country  by  H.  C.  Wood,  in 
1871.  Formerly  regarded  as  the  splenic  form  of  Hodgkin's  disease,  it  is 
generally  now  held  to  be  separate  from  it.  It  is  sometimes  termed  'primitive 
splenomegaly.  To  a  group  with  enlarged  spleen  and  cirrhosis  of  the  liver 
Banti  has  drawn  special  attention.  Pathologically  the  spleen  shows  atrophy 
and  sclerosis  of  the  Malpighian  corpuscles.  The  majority  of  the  cases  are 
in  adult  males.  The  main  symptoms  are  enlargement  of  the  spleen,  an 
anaemia  of  a  secondary  type  without  leucocytosis,  hsemorrhages  in  some 
cases,  and  usually  a  gradual  downward  course.  The  spleen  is  greatly  en- 
larged, reaching  often  to  the  navel.  In  some  cases  this  enlargement  seems 
to  have  preceded  the  anaemia.  Haemorrhages  from  the  stomach  occurred 
in  many  of  my  cases,  usually  at  intervals  of  some  months.  Several  patients 
also  passed  blood  by  the  bowels.  In  some  they  were  almost  lethal,  and  in 
one  case  after  splenectomy  death  followed  a  profuse  haematemesis.  The 
autopsy  showed  oesophageal  varices.     Ascites   may   occur   even  without 


DISEASES  OF  THE  THYROID  GLAND.  835 

cirrhosis  of  the  liver.  The  lymphatic  glands  are  not  specially  enlarged. 
The  blood  condition  is  that  of  a  secondary  anaemia.  Many  of  the  patients 
do  not  present  the  objective  features  of  a  severe  anaemia.  The  average 
number  of  red  corpuscles  in  my  series  has  been  over  three  millions  per  cubic 
millimetre.  The  haemoglobin  is  relatively  low.  The  leucocytes  are  usually 
diminished  in  number.  The  differential  count  shows  no  special  features. 
There  is  frequently  marked  pigmentation  of  the  skin.  As  the  disease  ad- 
vances there  is  emaciation  and  progressive  asthenia.  S.  West,  in  Allbutt's 
System,  has  described  three  stages.  The  duration  is  variable.  It  has  been 
given  as  from  six  months  to  three  years,  but  the  majority  of  my  cases 
have  had  a  much  longer  course.  Many  of  them  had  existed  over  five  years, 
and  one  probably  for  twelve  years.  Several  of  my  patients  were  in  good 
health  even  after  a  duration  of  some  years,  with  the  exception  of  the  recur- 
ring haemorrhages,  for  which  they  sought  relief. 

The  diagnosis  has  to  be  made  from  splenic  leukaemia,  Hodgkin's  disease 
with  an  enlarged  spleen,  cirrhosis  of  the  liver,  either  alcoholic,  syphilitic, 
or  hypertrophic,  with  an  enlarged  spleen,  and  old  cases  of  malaria  with 
the  same  condition.  It  is  not  likely  to  be  mistaken  for  pernicious  anaemia, 
although  three  cases  in  my  wards  showed  features  of  both  conditions.  They 
had  an  enlarged  spleen,  the  blood  picture  of  pernicious  anaemia,  and  a 
long  duration.  The  blood  features  and  associated  conditions  may  serve  to 
prevent  error. 

The  treatment  must  be  that  of  anaemia  generally.  Splenectomy  has  been 
successful  in  some  instances.  Warren  gives  20  recoveries  among  25  cases 
of  operation.  One  out  of  three  cases  operated  on  from  my  wards  recov- 
ered and  is  well  three  years  after.  The  ultimate  outlook,  apart  from 
operation,  is  not  hopeful,  although  the  course  is  not  always  progressively 
downward. 


X.    DISEASES    OF   THE   THYROID    GLAND. 

1.    GOITKE. 

Definition. — Hypertrophy  of  the  thyroid  gland,  occurring  sporad- 
ically or  endemically. 

In  this  country  sporadic  cases  are  common.  The  endemic  centres  re- 
ferred to  in  Barton's  monograph  (1810)  and  in  Hirsch's  Geographical 
Pathology  no  longer  exist.  The  disease  is  very  prevalent  about  the  eastern 
end  of  Lake  Ontario,  and  in  parts  of  Michigan  (Dock).  Endemically  it 
is  found  particularly  in  the  mountainous  regions  of  Switzerland  and  in 
parts  of  Italy.  No  satisfactory  explanation  has  been  given  of  the  existence 
of  the  disease  in  this  form. 

Anatomically  the  following  varieties  ma*y  be  distinguished:  (a)  Paren- 
chymatous, in  which  the  enlargement  is  general  and  the  follicles,  usually 
newly  formed,  contain  a  gelatinous  colloid  material.  (&)  Vascular,  in 
which  the  enlargement  is  chiefly  due  to  dilatation  of  the  blood-vessels 
without  the  new  formation  of  glandular  tissue,  {c)  Cystic  goitre,  in  which 
the  enlarged  gland  is  occupied  by  large  cysts,  the  walls  of  which  often 
undergo  calcification. 


836  DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 

Symptoms. — The  enlargement  may  be  uniform  throughout  the  en- 
tire gland,  or  affect  only  one  lobe,  or  the  isthmus  alone.  When  small,  a 
goitre  causes  no  inconvenience.  In  its  growth  it  may  compress  the  trachea, 
causing  dyspnoea,  or  may  pass  beneath  the  sternum  and  compress  the  veins. 
These,  however,  are  exceptional  circumstances,  and  in  a  large  proportion 
of  all  cases  no  serious  symptoms  are  noted.  The  affection  usually  comes 
under  the  care  of  the  surgeon.  Sudden  death  occasionally  occurs  in  large 
bronchoceles.  In  some  instances  it  may  be  difficult  to  determine  the  cause, 
and  it  has  been  thought  to  be  associated  with  pressure  on  the  vagi.  I  have 
reported  an  instance  in  which  it  resulted  from  hsemorrhage  into  the  gland 
and  into  the  adjacent  tissues.  The  blood  passed  into^he  cellular  tissues 
of  the  neck  and  under  the  sternum,  covering  the  aorta  and  pericardium. 
In  regions  in  which  goitre  prevails  the  drinking-water  should  be  boiled. 
Change  of  locality  is  sometimes  followed  by  cure.  The  medicinal  treat- 
ment is  very  unsatisfactory.  Iodine  and  various  counterirritants  exter- 
nally, iodide  of  potash,  ergot,  and  many  other  drugs  are  recommended  by 
writers.  The  thyroid  extract  has  been  used  with  success  by  Bruns  in  9 
of  12  cases. 

2.    TUMOES    OF    THE    ThTROID. 

These  are  very  varied,  (a)  Adenomata,  either  simple  or  malignant. 
The  latter  may  form  extensive  metastases.  A  case  is  reported  by  Hay- 
ward  in  which  growths  resembling  thyroid  tissue  occurred  in  the  lungs  and 
various  bones  of  the  body.  (&)  Cancer,  of  which  several  forms  have  been 
described,  (c)  Sarcoma.  All  of  these  have  a  surgical  rather  than  a  medi- 
cal interest. 

It  may  be  mentioned  that  the  aberrant  or  accessory  thyroid  gland  may 
form  large  tumors  in  the  mediastinum  or  in  the  pleura.  Cases  have  been 
reported  by  F.  A.  Packard  and  myself,  and  an  instance  is  on  record  in 
which  an  enormous  cystic  accessory  thyroid  occupied  the  entire  right 
pleura. 

Lingual  goitre  occasionally  develops  at  the  base  of  the  tongue,  and  is 
an  enlarged  accessory  thyroid  in  that  situation.  It  may  lead  to  difficult  deg- 
lutition and  interference  with  articulation. 

Thyroid  abscess  is  rare.  In  Havel's  monograph  on  Strumitis  (1892) 
cases  are  given  after  nearly  every  one  of  the  specific  diseases,  and  he  re- 
ports 18  cases  from  Kocher's  clinic,  nearly  all  secondary  or  metastatic. 

3.  Exophthalmic  Goitre  {Parry's  Disease). 

Definition. — A  disease  characterized  by  exophthalmos,  enlargement 
of  the  thyroid,  and  functional  disturbance  of  the  vascular  system.  It  is 
very  possibly  caused  by  disturbed  function  of  the  thyroid  gland  (hyper- 
thyroidism). 

Historical  Note. — In  the  posthumous  writings  of  Caleb  Hillier  Parry 
(1825)  is  a  description  of  8  cases  of  Enlargement  of  the  Thyroid  Gland 
in  Connection  with  Enlargement  or  Palpitation  of  the  Heart.  In  the  first 
case,  seen  in  1786,  he  also  describes  the  exophthalmos:  "  The  eyes  were  pro- 


DISEASES  OP  THE  THYROID  GLAND.  83Y 

truded  from  their  sockets,  and  the  countenance  exhibited  an  appearance 
of  agitation  and  distress,  especially  in  any  muscular  movement."  The 
Italians  claim  that  Flajani  described  the  disease  in  1800.  I  have  not  been 
able  to  see  his  original  account,  but  Moebius  states  that  it  is  meagre  and 
inaccurate,  and  bears  no  comparison  with  that  of  Parry.  If  the  name  of 
any  physician  is  to  be  associated  with  the  disease,  undoubtedly  it  should 
be  that  of  the  distinguished  old  Bath  physician.  G-raves  described  the  dis- 
ease in  1835  and  Basedow  in  1840. 

Etiology. — The  disease  is  more  frequent  in  women  than  in  men.  Of 
200  cases  tabulated  by  Eshner,  there  were  161  females.  The  age  of  onset 
is  usually  from  the  twentieth  to  the  thirtieth  year.  It  is  sometimes  seen  in 
several  members  of  the  same  family.  Worry,  fright,  and  depressing  emo- 
tions precede  the  development  of  the  disease  in  a  number  of  cases. 

The  disease  is  regarded  by  some  as  a  pure  neurosis,  in  favor  of  which  is 
urged  the  onset  after  a  profound  emotion,  the  absence  of  lesions,  and  the 
cure  which  has  followed  in  a  few  cases  after  operations  upon  the  nose.  Others 
believe  that  it  is  caused  by  a  central  lesion  in  the  medulla  oblongata.  In 
support  of  this  there  is  a  certain  amount  of  experimental  evidence,  and  in 
a  few  autopsies  changes  have  been  found  in  the  medulla.  Of  late  years 
the  view  has  been  urged,  particularly  by  Moebius  and  by  Greenfield,  that 
exophthalmic  goitre  is  primarily  a  disease  of  the  thyroid  gland  (fiyper- 
thyrea),  in  antithesis  to  myxoedema  (athyrea).  The  clinical  contrast  be- 
tween these  two  diseases  is  most  suggestive — ^the  increased  excitability  of 
the  nervous  system,  the  flushed,  moist  skin,  the  vascular  erythism  in  the 
one;  the  dull  apathy,  the  low  temperature,  slow  pulse,  and  dry  skin  of  the 
other.  The  changes  in  the  gland  in  exophthalmic  goitre  are,  as  shoM^n  by 
Greenfield,  those  of  an  organ  in  active  evolution — viz.,  increased  prolifera- 
tion, with  the  production  of  newly  formed  tubular  spaces  and  absorption 
of  the  colloid  material  which  is  replaced  by  a  more  mucinous  fluid  (Brad- 
shaw  Lecture,  1893).  The  thyroid  extract  given  in  excess  nroduces  symp- 
toms not  unlike  those  of  Parry's  disease — tachycardia,  tremor,  headache, 
sweating,  and  prostration.  Beclere  has  recently  reported  a  case  in  which 
exophthalmos  developed  after  an  overdose.  Use  of  the  thyroid  extract 
usually  aggravates  the  symptoms  of  exophthalmic  goitre.  The  most  suc- 
cessful line  of  treatment  has  been  that  directed  to  diminish  the  bulk  of 
the  goitre.  These  are  some  of  the  considerations  which  favor  the  view 
that  the  symptoms  are  due  to  disturbed  function  of  the  thyroid  gland, 
probably  to  a  hypersecretion  of  certain  materials,  which  induce  a  sort  of 
chronic  intoxication.  Myxoedema  may  develop  in  the  late  stages,  and 
there  are  transient  oedema  and  in  a  few  cases  scleroderma,  which  indicate 
that  the  nutrition  of  the  skin  is  involved.  Persistence  of  the  thymus  is 
almost  the  rule  (Hector  Mackenzie),  but  its  significance  is  unknown. 

Symptoms. — Acute  and  chronic  forms  may  be  recognized.  In  the 
acute  form  the  disease  may  develop  with  great  rapidity.  In  a  patient  of 
J.  H.  Lloyd's,  of  Philadelphia,  a  woman,  aged  thirty-nine,  who  had  been 
considered  perfectly  healthy,  but  whose  friends  had  noticed  that  for  some 
time  her  eyes  looked  rather  large,  was  suddenly  seized  with  intense  vomit- 
ing and  diarrhoea,  rapid  action  of  the  heart,  and  great  throbbing  of  the 


838  DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 

arteries.  The  eyes  were  prominent  and  staring  and  the  thyroid  gland  was 
found  much  enlarged  and  soft.  The  gastro-intestinal  symptoms  contin- 
ued, the  pulse  became  more  rapid,  the  vomiting  was  incessant,  and  the 
patient  died  on  the  third  day  of  the  illness.  Only  the  abdominal  and 
thoracic  organs  could  be  examined  and  no  changes  were  found.  Two 
rapidly  fatal  cases  occurred  at  the  Philadelphia  Hospital,  one  of  which, 
under  F.  P.  Henry's  care,  had  marked  cerebral  symptoms.  The  acute  cases 
are  not  always  associated  with  delirium.  In  a  case  reported  by  Sutcliff 
death  occurred  within  three  months  from  the  onset  of  the  symptoms,  owing 
to  repeated  and  uncontrollable  vomiting.  More  frequently  the  onset  is 
gradual  and  the  disease  is  chronic.  There  are  four  characteristic  symptoms 
of  the  disease — exophthalmos,  tachycardia,  enlargement  of  the  thyroid, 
and  tremor. 

Tachycardia. — Eapid  heart  action  is  only  one  of  a  series  of  remarkable 
vascular  phenomena  in  the  disease.  The  pulse-rate  at  first  may  be  not 
more  than  95  or  100,  but  when  the  disease  is  established  it  may  be  from 
140  to  160,  or  even  higher.  Irregularity  is  not  common,  except  toward 
the  close.  In  a  well-developed  case  the  visible  area  of  cardiac  pulsation  is 
much  increased,  the  action  is  heaving  and  forcible,  and  the  shock  of  the 
heart-sounds  is  well  felt.  The  large  arteries  at  the  root  of  the  neck  throb 
forcibly.  There  is  visible  pulsation  in  the  peripheral  arteries.  The  capil- 
lary pulse  is  readily  seen,  and  there  are  few  diseases  in  which  one  may  see 
at  times  with  greater  distinctness  the  venous  pulse  in  the  veins  of  the  hand. 
The  throbbing  pulsation  of  the  arteries  may  be  felt  even  in  the  finger  tips. 
On  auscultation  murmurs  are  usually  heard  over  the  heart,  a  loud  apex 
systolic  and  loud  bruits  at  the  base  and  over  the  manubrium.  The  sounds 
of  the  heart  may  be  very  intense.  In  rare  instances  they  may  be  heard 
at  some  distance  from  the  patient;  according  to  Graves,  as  far  as  four 
feet. 

Exophthalmos,  which  may  be  unilateral,  usually  follows  the  vascular 
disturbance.  It  is  readily  recognized  by  the  protrusion  of  the  balls,  and 
partly  by  the  fact  that  the  lids  do  not  completely  cover  the  sclerotics,  so 
that  a  rim  of  white  is  seen  above  and  below  the  cornea.  The  protrusion 
may  become  very  great  and  the  eye  may  even  be  dislocated  from  the  socket, 
or  both  eyes  may  be  destroyed  by  panophthalmitis,  a  condition  present  in 
one  of  Basedow's  cases.  The  vision  is  normal.  Graefe  noted  that  when 
the  eyeball  is  moved  downward  the  upper  lid  does  not  follow  it  as  in  health. 
This  is  known  as  Graefe's  sign.  It  seems  to  be  rare;  it  was  not  present 
in  any  one  of  17  cases  examined  at  my  clinic  (Oppenheimer).  The  palpebral 
aperture  is  wider  than  in  health,  owing  to  spasm  or  retraction  of  the  upper 
lid  (Stellwag's  sign).  The  patient  winks  less  frequently  than  in  health. 
Moebius  has  called  attention  to  the  lack  of  convergence  of  the  two  eyes. 
Changes  in  the  pupils  and  in  the  optic  nerves  are  rare.  Pulsation  of  the 
retinal  arteries  is  common. 

Enlargement  of  the  thyroid  commonly  develops  with  the  exophthalmos. 
It  may  be  general  or  in  only  one  lobe,  and  is  rarely  so  large  as  in  ordinary 
goitre.  The  vessels  are  usually  much  dilated,  and  the  whole  gland  may 
be  seen  to  pulsate.    A  thrill  may  be  felt  on  palpation  and  on  auscultation 


DISEASES  OP  THE  THYROID   GLAND.  839 

a  loud  systolic  murmur,  or  more  commonly  a  b7-uit  de  diabU.  A  double 
murmur  is  common  and  is  pathognomonic  (Guttmann). 

Tremor  is  the  fourth  cardinal  symptom,  and  was  really  first  described 
by  Basedow.  It  is  involuntary,  fine,  about  eight  to  the  second.  It  is  of 
great  importance  in  the  diagnosis  of  the  early  cases. 

Among  other  symptoms  which  may  develop  are  anemia,  emaciation, 
and  slight  fever.  Attacks  of  vomiting  and  diarrhoea  may  occur.  The 
latter  may  be  very  severe  and  distressing,  recurring  at  intervals.  The  great- 
est complaint  is  of  the  forcible  throbbing  in  the  arteries,  often  accompanied 
with  unpleasant  flushes  of  heat  and  profuse  perspirations.  Skin  symptoms 
are  not  infrequent — pigmentation,  which  may  be  intense  and  simulate 
Addison's  disease,  patches  of  leucoderma,  or  atrophy  of  pigment,  and 
urticaria.  Patches  of  solid  oedema  have  been  seen.  Occasionally  myx- 
cedema  has  been  present.  In  the  very  acute  case  above  referred  to  urticaria 
was  a  prominent  symptom.  Occasionally  pruritus  is  an  early  and  most 
distressing  symptom.  I  have  seen  one  case  in  which  it  persisted  and  became 
almost  unbearable.  Irritability  of  temper,  change  in  disposition,  and  great 
mental  depression  have  been  described.  An  important  complication  is 
acute  mania,  in  which  the  patient  may  die  in  a  few  days.  Weakness  of 
the  muscles  is  not  uncommon,  particularly  a  feeling  of  "  giving  way  "  of 
the  legs.  If  the  patient  holds  the  head  down  and  is  asked  to  look  up  with- 
out raising  the  head,  the  forehead  remains  smooth  and  is  not  wrinkled,  as 
in  a  normal  individual  (Joffroy).  A  feature  of  interest  noted  by  Charcot 
is  the  great  diminution  in  the  electrical  resistance,  which  may  be  due  to  the 
saturation  of  the  skin  with  moisture  owing  to  the  vaso-motor  dilatation 
(Ilirt).  Bryson  has  noted  the  fact  that  the  chest  expansion  may  be  greatly 
diminished.  The  emaciation  may  be  extreme.  Glycosuria  and  albuminuria 
are  not  infrequent  complications.     True  diabetes  may  occur. 

The  course  of  the  disease  is  usually  chronic,  lasting  several  years.  After 
persisting  for  six  months  or  a  year  the  symptoms  may  disappear.  There 
are  remarkable  instances  in  which  the  symptoms  have  come  on  with  great 
intensity,  following  fright,  and  have  disappeared  again  in  a  few  days.  A 
certain  proportion  of  the  cases  get  well,  but  when  the  disease  is  well  ad- 
vanced recovery  is  rare. 

Treatment. — Medicinal  measures  are  notoriously  uncertain.  The 
combination  of  digitalis  and  iron  may  be  tried,  and,  when  there  is  anaemia, 
often  does  good.  I  have  never  seen  any  advantage  from  the  use  of  aco- 
nite or  veratrum  viride.  The  tincture  of  strophanthus  will  sometimes 
reduce  the  rapidity  of  the  heart's  action.  Ergot  is  warmly  recommended 
by  some  writers.  Belladonna  gives  relief  occasionally,  and  should  be  ad- 
ministered until  the  dryness  of  the  throat  is  obtained.  Phosphate  of  soda 
is  sometimes  beneficial.  No  measures  are  so  successful  as  protracted  rest 
in  bed  with  an  ice-bag  applied  continuously,  by  day,  over  the  heart,  or,  what 
is  sometimes  more  agreeable,  over  the  lower  part  of  the  neck  and  the 
manubrium  sterni.  I  have  known  the  pulse  to  be  reduced  in  this  way 
from  140  to  90.  Electricity  has  been  much  lauded  and  instances  of  cure 
have  been  reported.  In  many  cases  temporary  improvement  certainly 
follows  the  use  of  the  galvanic  current.    Erb  states  that  the  anode  should 


840  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

be  placed  over  the  cervical  spine  and  the  cathode  upon  the  peripheral 
nerves.  The  use  of  the  thyroid  extract  has  not  been  successful.  The  thy- 
mus extract  has  not  proved  satisfactory.  The  treatment  of  the  disease  by 
small  doses  of  opium  has  been  successful  in  some  cases  (Musser).  Eemoval 
of  part  of  the  thyroid  gland  offers  the  best  hope  of  permanent  cure.  The 
recent  figures  from  Kocher's  Clinic  (1903)  give  a  remarkable  percentage  of 
recoveries.  The  operation  under  cocaine  obviates  the  serious  risk  of  the 
anaesthetic.  Tying  of  the  arteries  and  exothyropexia  are  also  recommended. 
Excision  of  the  superior  cervical  ganglia  of  the  sympathetic  has  one  bene- 
ficial result,  viz.,  the  production  of  slight  ptosis,  which  obviates  the  staring 
character  of  the  exophthalmos. 

4.  Mtxcedema  (Athyrea). 

Definition. — A  constitutional  affection,  due  to  the  loss  of  function  of 
the  thyroid  gland.  The  disease,  which  was  described  by  Sir  William  Gull 
as  a  cretinoid  change,  and  later  by  Ord,  is  characterized  clinically  by  a 
myxoedematous  condition  of  the  subcutaneous  tissues  and  mental  failure, 
and  anatomically  by  atrophy  of  the  thyroid  gland. 

Clinical  Forms. — Three  groups  of  eases  may  be  recognized — cretinism, 
myxoedema  proper,  and  operative  myxoedema. 

Cretinism. 

This  remarkable  impairment  of  nutrition  follows  absence  or  loss  of 
function  of  the  thyroid  gland,  either  congenital  or  appearing  at  any  time 
before  puberty.  There  is  remarkable  retardation  of  development,  reten- 
tion of  the  infantile  state,  and  an  extraordinary  disproportion  between  the 
different  parts  of  the  body.  Two  forms  of  cretinism  are  recognized,  the 
sporadic  and  the  endemic.  In  the  sporadic  form  the  gland  may  be  con- 
genitally  absent,  it  may  be  atrophied  after  one  of  the  specific  fevers,  or  the 
condition  may  develop  with  goitre.  Since  we  have  learned  to  recognize  the 
disease  it  is  surprising  how  many  cases  have  been  reported.  I  was  able  to 
collect  60  cases  in  this  country  to  May  1,  1897.* 

The  condition  is  rarely  recognized  before  the  infant  is  six  or  seven 
months  old.  Then  it  is  noticed  that  the  child  does  not  grow  so  rapidly 
and  is  not  bright  mentally.  The  tongue  looks  large  and  hangs  out  of  the 
mouth.  The  hair  may  be  thin  and  the  skin  very  dry.  Usually  by  the  end 
of  the  first  year  and  during  the  second  year  the  signs  of  cretinism  become 
very  marked.  The  face  is  large,  looks  bloated,  the  eyelids  are  puffy  and 
swollen;  the  alse  nasi  are  thick,  the  nose  looks  depressed  and  flat.  Denti- 
tion is  delayed,  and  the  teeth  which  appear  decay  early.  The  abdomen 
is  swollen,  the  legs  are  thick  and  short,  and  the  hands  and  feet  are  undevel- 
oped and  pudgy.  The  face  is  pale  and  sometimes  has  a  waxy,  sallow  tint. 
The  fontanelles  remain  open;  there  is  much  muscular  weakness,  and  the 
child  cannot  support  itself.  In  the  supraclavicular  regions  there  are  large 
pads  of  fat.  The  child  does  not  develop  mentally;  there  are  various  grades 
of  idiocy  and  imbecility. 

*  Sporadic  cretinism  in  America,  Transactions  of  the  Congress  of  American  Physi- 
cians and  Surgeons,  vol.  iv. 


DISEASES  OP  THE  THYROlD  GLAND.  841 

A  very  interesting  form  is  that  in  which,  after  the  child  has  thriven 
and  developed  until  its  fourth  or  fifth  year,  or  even  later,  the  symptoms 
begin  after  a  fever,  in  consequence  of  an  atrophy  of  the  gland.  Parker 
suggests  for  this  variety  the  name  juvenile  myxoedema. 

Endemic  cretinism  develops  under  local  conditions,  as  yet  unknown,  in 
association  with  goitre.  It  is  met  with  chiefly  in  Switzerland  and  parts 
of  Italy  and  France.  The  common  opinion  is  that  it  too  is  associated  with 
loss  of  function  of  the  thyroid. 

The  diagnosis  of  cretinism  is  very  easy  after  one  has  seen  a  case  or  good 
illustrations.  Infants  a  year  or  so  old  sometimes  become  flabby,  lose  their 
vivacity,  or  show  a  protuberant  abdomen  and  lax  skin  with  slight  cretinoid 
appearance.  These  milder  forms,  as  they  have  been  termed,  are  probably 
due  to  transient  functional  disturbance  in  the  gland.  There  is  rarely  any 
difficulty  in  recognizing  the  different  other  types  of  idiocy.  The  condi- 
tion known  as  fcetal  rickets,  acJiondroplasia,  or  the  chondrodystrophia  foetalis, 
is  more  likely  to  be  mistaken  for  cretinism.  The  children  which  survive 
birth  grow  up  as  a  remarkable  form  of  dwarfs,  characterized  by  shortness 
of  the  limbs  (micromelia)  and  enormous  enlargement  of  the  articulations, 
due  to  hyperplasia  of  the  cartilaginous  ends  of  the  bones.  Infantilism — 
the  condition  characterized  by  a  preservation  in  the  adult  of  the  exterior 
form  of  infancy  with  the  non-appearance  of  the  secondary  sexual  char- 
acters— could  scarcely  be  mistaken  for  cretinism. 

MyxtEDEMA  OF  Adults  {OulVs  Disease), 

In  this,  women  are  very  much  more  frequently  affected  than  men — in 
a  ratio  of  6  to  1.  The  disease  may  affect  several  members  of  a  family,  and 
it  may  be*transmitted  through  the  mother.  In  some  instances  there  has 
been  first  the  appearance  of  exophthalmic  goitre.  Though  occurring  most 
commonly  in  women,  it  seems  to  have  no  special  relation  to  the  catamenia 
or  to  pregnancy;  the  symptoms  of  myxoedema  may  disappear  during  preg- 
nacy  or  may  develop  post  partum.  Myxoedema  and  exophthalmic  goitre 
may  occur  in  sisters.  It  is  not  so  common  in  this  country  as  in  England. 
The  symptoms  of  this  form,  as  given  by  Ord,*  are  marked  increase  in 
the  general  bulk  of  the  body,  a  firm,  inelastic  swelling  of  the  skin,  which 
does  not  pit  on  pressure;  dryness  and  roughness,  which  tend,  with  the 
swelling,  to  obliterate  in  the  face  the  lines  of  expression;  imperfect  nutri- 
tion of  the  hair;  local  tumefaction  of  the  skin  and  subcutaneous  tissues, 
particularly  in  the  supraclavicular  region.  The  physiognomy  is  altered 
in  a  remarkable  way:  the  features  are  coarse  and  broad,  the  lips  thick,  the 
nostrils  broad  and  thick,  and  the  mouth  is  enlarged.  Over  the  cheeks, 
sometimes  the  nose,  there  is  a  reddish  patch.  There  is  a  striking  slowness 
of  thought  and  of  movement.  The  memory  becomes  defective,  the  patients 
grow  irritable  and  suspicious,  and  there  may  be  headache.  In  some  in- 
stances there  are  delusions  and  hallucinations,  leading  to  a  final  condition 
of  dementia.    The  gait  is  heavy  and  slow.    The  temperature  may  be  below 

*  Report  on  Myxoedema,  Clinical  Society's  Transactions,  1888. 
52 


842  DISEASES  OP  THE  BLOOD  AND  DUCTLESS  GLANDS. 

normal.  The  functions  of  the  hearty  lungs,  and  abdominal  organs  are 
normal.  Haemorrhage  sometimes  occurs.  Albuminuria  is  sometimes  pres- 
ent, more  rarely  glycosuria.  Death  is  usually  due  to  some  intercurrent 
disease,  most  frequently  tuberculosis  (Greenfield).  The  thyroid  gland  is 
diminished  in  size  and  may  become  completely  atrophied  and  converted 
into  a  fibrous  mass.  The  subcutaneous  fat  is  abundant,  and  in  one  or  two 
instances  a  great  increase  in  the  mucin  has  been  found. 

The  course  of  the  disease  is  slow  but  progressive,  and  extends  over  ten 
or  fifteen  years.  A  condition  of  acute  and  temporary  myxoedema  may 
develop  in  connection  with  enlargement  of  the  thyroid  in  young  persons. 
Myxoedema  may  follow  exophthalmic  goitre.  In  other  instances  the  symp- 
toms of  the  two  diseases  have  been  combined.  I  have  reported  a  case  in 
which  a  young  man  became  bloated  and  increased  in  weight  enormously 
during  three  months,  then  developed  tachycardia  with  tremor  and  active 
delirium,  and  died  within  six  months  of  the  onset  of  the  symptoms. 

Operative  Myxcedema  ;  Cachexia  Strumipriva. 

Horsley,  in  a  series  of  interesting  experiments,  showed  that  complete 
removal  of  the  thyroid  in  monkeys  was  followed  by  the  production  of  a 
condition  similar  to  that  of  myxcedema  and  often  associated  with  spasms 
or  tetanoid  contractures,  and  followed  by  apathy  and  coma.  Wlien  the 
monkeys  were  kept  warm  myxoedema  was  averted,  and,  instead  of  an  acute 
myxoedema,  the  animals  developed  a  condition  which  closely  resembled 
cretinism.  An  identical  condition  may  follow  extirpation  of  the  thyroid 
in  man.  Kocher,  of  Bern,  found  that  after  complete  extirpation  a  cachectic 
condition  followed  in  many  cases,  the  symptoms  of  which  are  practically 
identical  with  those  of  myxcedema.  The  disease  follows  only  a  certain 
number  of  total  and  a  much  smaller  proportion  of  partial  removals  of  the 
thyroid  gland.  Of  408  cases,  in  69  the  operative  myxoedema  developed. 
It  has  been  thought  that  if  a  small  fragment  of  the  thyroid  remains, 
or  if  there  are  accessory  glands,  which  in  animals  are  very  common, 
these  symptoms  do  not  develop.  It  is  possible  that  in  men,  in  the  cases 
of  complete  removal,  the  accessory  fragments  subserve  the  function  of 
the  gland.  Operative  myxoedema  is  very  rare  in  America;  I  have  been 
able  to  find  only  2  cases  in  this  country.  McGraw's  case,  referred  to  in 
previous  editions  of  this  work,  has  since  been  cured  with  the  thyroid 
extract. 

The  diagnosis  of  myxoedema  is  easy,  as  a  rule.  The  general  aspect  of 
the  patient — the  subcutaneous  swelling  and  the  pallor — suggests  Bright's 
disease,  which  may  be  strengthened  by  the  discovery  of  tube-casts  and  of 
albumin  in  the  urine;  but  the  solid  character  of  the  swelling,  the  exceed- 
ing dryness  of  the  skin,  the  yellowish-white  color,  the  low  temperature, 
the  loss  of  hair,  and  the  dull,  listless  mental  state  should  suffice  to  differ- 
entiate the  two  conditions.  In  dubious  cases  not  too  much  stress  should 
be  laid  upon  the  supraclavicular  swellings.  There  may  be  marked  fibro- 
fatty  enlargements  in  this  situation  in  healthy  persons,  the  supraclavicular 
pseudo-lipomata  of  Verneuil. 


DISEASES  OF  THE  THYMUS  GLAND.  843 

Treatment. — The  patients  suffer  in  cold  and  improve  greatly  in  warm 
weather.  They  should  therefore  be  kept  at  an  even  temperature,  and 
should,  if  possible,  move  to  a  warm  climate  during  the  winter  months.  Re- 
peated warm  baths  with  shampooing  are  useful.  Our  art  has  made  no 
more  brilliant  advance  than  in  the  cure  of  these  disorders  due  to  disturbed 
function  of  the  thyroid  gland.  That  we  can  to-day  rescue  children  other- 
wise doomed  to  helpless  idiocy — that  we  can  restore  to  life  the  hopeless 
victims  of  myxoedema — is  a  triumph  of  experimental  medicine  for  which  we 
are  indebted  very  largely  to  Victor  Horsley  and  to  his  pupil  Murray.  Trans- 
plantation of  the  gland  was  first  tried;  then  Murray  used  an  extract  sub- 
cutaneously.  Hector  Mackenzie  in  London  and  Howitz  in  Copenhagen 
introduced  the  method  of  feeding.  We  now  know  that  the  gland,  taken 
either  fresh,  or  as  the  watery  or  glycerin  extract,  or  dried  and  powdered, 
is  equally  efficacious  in  a  majority  of  all  the  cases  of  myxoedema  in  infants 
or  adults.  Many  preparations  are  now  on  the  market,  but  it  makes  little 
difference  how  the  gland  is  administered.  The  dried  powdered  gland  and 
the  glycerin  extract  are  most  convenient.  It  is  well  to  begin  with  the 
powdered  gland,  1  grain  three  times  a  day,  of  the  Parke-Davis  preparation, 
or  one  of  the  Burroughs  and  Welcome  tablets.  The  dose  may  be  increased 
gradually  until  the  patient  takes  10  or  15  grains  in  the  day.  In  many  cases 
there  are  no  unpleasant  symptoms;  in  others  there  are  irritation  of  the 
skin,  restlessness,  rapid  pulse,  and  delirium;  in  rare  instances  tonic  spasms, 
the  condition  to  which  the  term  thyroidism  is  applied.  The  results,  as  a 
rule,  are_most  astounding — unparalleled  by  anything  in  the  whole  range 
of  curative  measures.  Within  six  weeks  a  poor,  feeble-minded,  toad-like 
caricature  of  humanity  may  be  restored  to  mental  and  bodily  health.  Loss 
of  weight  is  one  of  the  first  and  most  striking  effects;  one  of  my  patients 
lost  over  30  pounds  within  six  weeks.  The  skin  becomes  moist,  the  urine 
is  increased,  the  perspiration  returns,  the  temperature  rises,  the  pulse-rate 
quickens  and  the  mental  torpor  lessens.  Ill  effects  are  rare.  Two  or  three 
cases  with  old  heart  lesions  have  died  during  or  after  the  treatment;  in  one 
instance  a  temporary  condition  of  Graves'  disease  was  induced. 

The  treatment,  as  Murray  suggests,  must  be  carried  out  in  two  stages — 
one,  early,  in  which  full  doses  are  given  until  the  cure  is  effected;  the  other, 
the  permanent  use  of  small  doses  sufficient  to  preserve  the  normal  metab- 
olism. In  the  cases  of  cretinism  it  seems  to  be  necessary  to  keep  up  the 
treatment  indefinitely.  I  have  seen  several  instances  of  remarkable  relapse 
follow  the  cessation  of  the  use  of  the  extract. 


XI.    DISEASES    OF    THE    THYMUS    GLAND. 

The  functions  of  this  gland  are  unknown.  It  is  a  suggestive  fact  that 
Baumann  found  in  irt  minute  quantities  of  a  compound  containing  iodine. 
It  has  been  thought  that  its  internal  secretion  has  an  influence  in  com- 
bating infective  agents.  The  weight  of  the  organ  is  about  14  grammes 
at  birth,  about  20  at  the  ninth  month,  and  25  to  30  at  the  second  year. 


844  DISEASES  OF  THE   BLOOD  AND  DUCTLESS  GLANDS. 

The  organ,  after  reaching  its  largest  size  about  the  end  of  the  second 
year,  gradually  wastes,  until  at  the  time  of  puberty  it  is  a  mere  fatty  rem- 
nant, in  which,  however,  there  are  "  traces  of  its  original  structure  in  the 
form  of  small  masses  of  thymus  corpuscles,  and  even  of  concentric  cor- 
puscles "  (Quain).  A  complete  consideration  of  the  affections  of  this  gland 
is  to  be  found  in  Friedleben's  remarkable  monograph.  Die  Physiologic  der 
Thymusdrlise,  1858.    The  following  are  the  most  important  conditions: 

I.  Persistence  of  the  organ  after  the  fifteenth  year,  met  with  occa- 
sionally, but  under  circumstances  so  varied  that  a  satisfactory  explanation 
cannot  be  offered.  It  is  said  that  the  existence  of  the  gland  may  be  deter- 
mined by  the  presence  of  an  area  of  dulness  along  the  left  sternal  border 
from  the  second  to  the  fourth  ribs. 

II.  Hypertrophy  of  the  Thymus. — The  size  of  the  gland  varies  widely, 
so  that  it  is  difficult  to  define  exactly  the  limits  between  persistence  and 
enlargement.  The  condition  is  of  interest  from  three  standpoints:  (a)  The 
supposed  occurrence  of  thymic  asthma,  due  to  pressure  from  the  enlarged 
gland.  A*  number  of  observers  have  attributed  the  symptoms  of  laryngismus 
stridulus  to  pressure  exerted  by  the  enlarged  thymus.  Many  German  writers 
consider  thymic  asthma  identical  with  the  laryngismus  stridulus  of  English 
authors,  who,  as  a  rule,  have  laid  no  stress  whatever  on  the  association. 
There  can  be,  I  think,  no  question  that  the  ordinary  laryngismus  seen  in 
rickety  children  is  a  convulsive  affection  and  is  not  the  result  of  compression. 
But  a  very  greatly  enlarged  thymus  may  seriously  hamper  the  structures 
within  the  thorax.  Jacobi,  in  his  monograph  on  the  gland  (Transactions  of 
the  Association  of  American  Physicians,  vol.  iii),  states  that  in  an  infant  of 
eight  months  the  distance  between  the  manubrium  sterni  and  the  vertebral 
column  is  2.2  cm.,  a  space  which  he  thinks  might  be  completely  filled  by 
an  enlarged  and  congested  thymus.  Siegel's  case  also  points  to  the  possi- 
bility of  this  compression.  A  boy  aged  two  years  and  a  half  had  had  for 
two  weeks  cough  and  bronchial  rales  with  dyspnoea,  which  was  more  or 
less  constant  with  nocturnal  exacerbations.  Laryngismus  stridulus  was 
diagnosed.  Tracheotomy  was  performed  shortly  after  admission  without 
relief,  but  when  subsequently  the  anterior  mediastinum  was  opened  from 
above  by  extending  the  incision  from  the  tracheotomy  wound,  a  piece  of 
the  thymus  as  large  as  a  hazel-nut  appeared  with  each  inspiration.  The 
gland  was  drawn  up  with  forceps  and  fastened  by  three  stitches  to  the 
fascia  over  the  sternum.  The  child  rested  quietly  after  the  operation,  had 
no  dyspnoea,  and  made  a  complete  recovery  (Berl.  klin.  Woch.,  1896,  No. 
40).  From  a  child  aged  two  months  (dyspnoeic  from  the  eighth  day) 
Koenig  removed  a  portion  of  the  thymus,  leaving  the  substernal  part. 
These  are  cases  that  go  far  to  disprove  Friedleben's  dictum — es  giebt  Tcein 
asthma  thymicum. 

(h)  Thymus  Enlargement  and  Sudden  Death. — In  considering  the  ques- 
tion of  the  so-called  lymphatic  constitution,  with  which  an  enlarged  thy- 
mus is  usually  associated,  we  have  spoken  of  the  occurrence  of  sudden  death. 
Two  groups  of  cases  are  met  with  in  the  literature:  First,  such  instances 
as  those  described  by  Grawitz,  Jacobi,  and  others,  in  which  young  infants 
have  been  either  found  dead  in  bed  or  have  been  attacked  suddenly  with 


DISEASES  OF  THE  THYMUS  GLAND.  845 

dyspnoea,  have  become  cyanotic  and  died  in  a  few  minutes.  In  such  cases 
the  thymus  has  been  found  greatly  enlarged,  and  death  has  been  thought 
to  be  directly  due  either  to  pressure  on  the  air-passages,  pressure  on  the 
pneumogastric  (causing  spasm  of  the  glottis),  or  pressure  on  the  great  ves- 
sels. To  the  second  group  belong  the  cases  in  adults  which  have  been  de- 
scribed of  late  by  Nordmann,  Paltauf,  Ohlmacher,  and  others,  in  which 
the  sudden  death  has  occurred  under  such  conditions  as  anaesthesia  or 
while  bathing.  In  a  number  of  these  cases  not  only  has  the  thymus  lieen 
found  enlarged,  but  the  spleen  and  lymphatic  tissues  generally.  The  ques- 
tion is  one  of  considerable  medico-legal  interest,  and  has  been  spoken  of 
under  Lymphatism. 

Kolleston  reports  a  case  of  sudden  death  after  signs  of  cardiac  failure 
lasting  for  only  twenty  minutes,  in  which  there  was  hyperplasia  of  a  per- 
sistent thymus.    The  gland  with  the  trachea  weighed  11  ounces. 

(c)  Thymus  Gland  and  Exophthalmic  Goitre. — That  there  is  some  asso- 
ciation between  these  conditions  is  urged  on  two  grounds:  First,  the  per- 
sistence of  the  gland  in  Graves'  disease.  W.  W.  Ord  and  Hector  Mac- 
kenzie state  that  it  has  been  found  enlarged  in  all  the  cases  recently  exam- 
ined at  St.  Thomas's  Hospital.  Hektoen  concludes  from  a  very  thorough 
study  of  the  question  that  the  coexistence  is  more  than  accidental.  Sec- 
ondly, the  good  results  which  are  stated  to  follow  the  feeding  of  the  thymus 
gland  in  Graves'  disease  are  held  to  bear  out  the  idea  that  the  enlargement 
during  life  is  compensatory.  The  general  conclusion,  however,  reached  by 
Hector  Mackenzie  and  by  Kinnicutt  is  that  the  thymus  feeding  has  at  best 
only  slight  influence  upon  Graves'  disease. 

It  is  interesting  to  note  in  connection  with  the  question  of  enlarged 
thymus  and  sudden  death  that  two  of  Hale  White's  cases  of  exophthalmic 
goitre  died  suddenly,  and  autopsy  showed  no  reasonable  cause  .of  death. 

Among  other  conditions  with  which  enlarged  thymus  has  been  associ- 
ated may  be  mentioned  epilepsy  (Ohlmacher). 

III.  Other  Morbid  Conditions  of  the  Thymus. — Hcemorrhages  are  not 
uncommon,  and  are  found  particularly  in  children  who  have  died  of 
asphyxia. 

Tumors  of  the  gland,  particularly  sarcoma  and  lympho-sarcoma,  have 
been  frequently  described.  Many  mediastinal  tumors  originate  in  the  rem- 
nants of  the  thymus.  Dermoid  tumors  and  cysts  have  also  been  met  with. 
Tuberculosis  of  the  gland,  chiefly  in  the  form  of  miliary  nodules,  is  well 
described  in  Jacobi's  monograph.  There  is  a  well-authenticated  case  in 
which  it  was  primary.  Focal  necroses  in  diphtheria  have  also  been  de- 
scribed by  Jacobi.  •• 

Abscess  of  the  Thymus. — Dubois,  in  1850,  noted  the  occurrence  of  foci 
of  suppuration  in  the  gland  in  subjects  of  congenital  syphilis.  Throughout 
it  round  or  fissure-like  cavities  are  seen  filled  with  a  purulent  fluid.  Chiari 
states  that  some  of  these  supposed  abscesses  are  areas  of  post-mortem  soften- 
ing, or  cysts  lined  with  flattened  epithelium  containing  detritus  of  thymus 
cells.    In  one  case  Jacobi  found  a  small  gumma. 


SECTION  IX. 
DISEASES   OE  THE   KIDI^ETS. 


I.   MALFORMATIONS. 

Newman  classifies  the  malformations  of  the  kidney  as  follows:  A.  Dis- 
placements without  mobility — (1)  congenital  displacement  without  de- 
formity; (2)  congenital  displacement  with  deformity;  (3)  acquired  dis- 
placements. B.  Malformations  of  the  kidney.  I.  Variations  in  number — 
(a)  supernumerary  kidney;  (&)  single  kidney,  congenital  absence  of  one 
kidney,  atrophy  of  one  kidney;  (c)  absence  of  both  kidneys.  II.  Varia- 
tions in  form  and  size — (a)  generar variations  in  form,  lobulation,  etc.;  (h) 
hypertrophy  of  one  kidney;  (c)  fusion  of  two  kidneys — ^liorseshoe  kidney, 
sigmoid  kidney,  disk-shaped  kidney.  C.  Variations  in  pelvis,  ureters,  and 
blood-vessels. 

The  fused  kidneys  may  form  a  large  mass,  which  is  often  displaced,  being 
either  in  an  iliac  fossa  or  in  the  middle  line  of  the  abdomen,  or  even  in  the 
pelvis.  Under  these  circumstances  it  may  be  mistaken  for  a  new  growth. 
In  Polk's  case  the  organ  was  removed  under  the  belief  that  it  was  a  floating 
kidney.*  The  patient  lived  eleven  days,  had  complete  anuria,  and  it  was 
found  post  mortem  that  a  single  unsymmetrical  kidney,  as  this  form  is 
called,  had  been  removed. 


II.    MOVABLE    KIDNEY. 

(Floating  Kidney  ;  Palpable  Kidney  ;  Ben  mohilis ;  Nephroptosis). 

The  kidney  is  held  in  position  by  its  fatty  capsule,  by  the  peritonaeum 
which  passes  in  front  of  it,  and  by  the  blood-vessels.  Normally  the  kidney 
is  firmly  fixed,  but  under  certain  circumstances  one  or  the  other  organ, 
more  rarely  both,  becomes  movable.  In  very  rare  cases  the  kidney  is  sur- 
rounded, to  a  greater  or  less  extent,  by  the  peritonaeum,  and  is  anchored 
at  the  hilus  by  a  mesonephron.  Some  would  limit  the  term  floating  kidney 
to  this  condition. 

Movable  kidney  is  almost  always  acquired.     It  is  more  common  in 

*  New  York  Medical  Journal,  1883. 
846 


MOVABLE  KIDNEY.  847 

women.  Of  the  667  cases  collected  in  the  literature  by  Kuttner,  584  were 
in  women  and  only  83  in  men.  It  is  more  common  on  the  right  than  on 
the  left  side.  Of  737  cases  analyzed  by  this  author,  it  occurred  on  the  right 
in  553  cases,  on  the  left  in  81,  and  on  both  sides  in  93.  The  greater  fre- 
quency of  the  condition  in  women  may  be  attributed  to  compression  of  the 
lower  thoracic  zone  by  tight  lacing,  and,  more  important  still,  to  the  relaxa- 
tion of  the  abdominal  walls  which  follows  repeated  pregnancies.  This  does 
not  account  for  all  the  cases,  as  movable  kidney  is  by  no  means  uncommon 
in  nulliparse.  Drummond  believes  that  in  a  majority  of  the  cases  there  is 
a  congenitally  relaxed  condition  of  the  peritoneal  attachments.  The  condi- 
tion has  been  met  with  in  infants.  Wasting  of  the  fat  about  the  kidney 
may  be  a  cause  in  some  instances.  Trauma  and  the  lifting  of  heavy  weights 
are  occasionally  factors  in  its  production.  The  kidney  is  sometimes  dragged 
down  by  tumors.  The  greater  frequency  on  the  right  side  is  probably  asso- 
ciated with  the  position  of  the  kidney  just  beneath  the  liver,  and  the  de- 
pression to  which  the  organ,  is  subjected  with  each  descent  of  the  diaphragm 
in  inspiration. 

And,  lastly,  movable  kidney  is  met  with  in  many  cases  which  present 
that  combination  of  neurasthenia  with  gastro-intestinal  disturbance  which 
has  been  described  by  Glenard  as  enteroptosis  (see  p.  541). 

To  determine  the  presence  of  a  movable  kidney  the  patient  should  be 
placed  in  the  dorsal  position,  with  the  head  moderately  low  and  the  ab- 
dominal walls  relaxed.  The  left  hand  is  placed  in  the  lumbar  region  behind 
the  eleventh  and  twelfth  ribs;  the  right  hand  in  the  hypochondriac  region, 
in  the  nipple  line,  just  under  the  edge  of  the  liver.  Bimanual  palpation 
may  detect  the  presence  of  a  firm,  rounded  body  just  below  the  edge  of  the 
ribs.  If  nothing  can  be  felt,  the  patient  should  be  asked  to  draw  a  deep 
breath,  when,  if  the  organ  is  palpable,  it  is  touched  by  the  fingers  of  the 
right  hand.  Various  grades  of  mobility  may  be  recognized.  It  may  be 
possible  barely  to  feel  the  lower  edge  on  deep  palpation — palpable  kidney — 
or  the  organ  may  be  so  far  displaced  that  on  drawing  the  deepest  breath 
the  fingers  of  the  right  hand  may  be,  in  a  thin  person,  slipped  above  the 
upper  end  of  the  organ,  which  can  be  readily  held  down,  but  cannot  be 
pushed  below  the  level  of  the  navel — movable  hidney.  In  a  third  group  of 
cases  the  organ  is  freely  movable,  and  may  even  be  felt  just  above  Poupart's 
ligament,  or  may  be  in  the  middle  line  of  the  abdomen,  or  can  even  be 
pushed  over  beyond  this  point.  To  this  the  term  floating  Tcidney  is  appro- 
priate. 

The  movable  kidney  is  not  painful  on  pressure,  except  when  it  is  grasped 
very  firmly,  when  there  is  a  dull  pain,  or  sometimes  a  sickening  sensation. 
Examination  of  the  patient  from  behind  may  show  a  distinct  flattening 
in  the  lumbar  region  on  the  side  in  which  the  kidney  is  mobile. 

Symptoms. — In  a  large  majority  of  cases  there  are  no  symptoms,  and 
if  detected  accidentally  it  is  well  not  to  let  the  patient  know  of  its  presence. 
Far  too  much  stress  has  been  laid  upon  the  condition  of  late  years.  In 
other  instances  there  is  pain  in  the  lumbar  region  or  a  sense  of  dragging 
and  discomfort,  or  there  may  be  intercostal  neuralgia.  In  a  large  group 
the  symptoms  are  those  of  neurasthenia  with  dyspeptic  disturbance.     In 


848  DISEASES  OF  THE  KIDNEYS. 

women  the  hysterical  symptoms  may  be  marked,  and  in  men  various  grades 
of  hypochondriasis.  The  gastric  disturbance  is  usually  a  form  of  nervous 
dyspepsia.  Dilatation  of  the  stomach  has  been  observed,  owing,  as  suggested 
by  Bartels,  to  pressure  of  the  dislocated  kidney  upon  the  duodenum.  This 
view  has  been  supported  by  Oser,  Landau,  and  Ewald.  On  the  other  hand, 
Litten  holds  that  the  dilatation  of  the  stomach  is  the  cause  of  the  mobility 
of  the  kidney,  and  he  found  in  40  cases  of  depression  and  dilatation  of  the 
stomach  22  instances  of  dislocation  of  the  kidney  on  the  right  side.  My 
own  experience  coincides  with  that  of  Drummond,  who  has  very  excep- 
tionally found  the  two  conditions  to  coexist.  The  association,  however, 
with  a  depressed  stomach  is  certainly  not  uncommon  in  women.  Constipa- 
tion is  not  infrequent.  Some  writers  have  described  pressure  upon  the 
gall-ducts,  with  jaundice,  but  it  is  not  very  likely  to  occur.  Fsecal  accumu- 
lation and  even  obstruction  may  be  associated  with  the  displaced  organ. 

DietVs  Crises. — In  floating  kidney  there  are  attacks  characterized  by 
severe  abdominal  pain,  chills,  nausea,  vomiting,  fever,  and  collapse.  Scarcely 
any  mention  is  made  of  such  symptoms,  which  were  first  described  by  Dietl 
in  1864,  and  a  more  widespread  knowledge  of  their  occurrence  in  connec- 
tion with  this  condition  is  desirable.  My  attention  was  called  to  them  in 
1880  by  Palmer  Howard  in  the  case  of  a  stout  lady,  who  suffered  repeatedly 
with  the  most  severe  attacks  of  abdominal  pain  and  vomiting,  which  con- 
stantly required  morphia.  A  tumor  was  discovered  a  little  to  the  right  of 
the  navel,  and  the  diagnosis  of  probable  neoplasm  was  concurred  in  by 
Flint  (Sr.)  and  Gaillard  Thomas.  The  patient  lost  weight  rapidly,  became 
emaciated,  and  in  the  spring  of  1881  again  went  to  New  York,  where  she 
saw  Van  Buren,  who  diagnosed  a  floating  kidney  and  said  that  these  parox- 
ysms were  associated  with  it  in  a  gouty  person.  He  cut  off  all  stimulants, 
reassured  the  lady  that  she  had  no  cancer,  and  from  that  time  she  rapidly 
recovered,  and  the  attacks  have  been  few  and  far  between.  In  this  patient 
any  overindulgence  in  eating  or  in  drinking  is  still  liable  to  be  followed 
by  a  very  severe  attack.  These  attacks  may  also  be  mistaken  for  renal  colic, 
and  the  operation  of  nephrotomy  has  been  performed. 

In  other  instances  the  attacks  of  pain  may  be  thought  to  be  due  to  in- 
testinal disease  or  to  recurring  appendicitis.  The  cause  of  these  parox- 
ysmal attacks  is  not  quite  clear.  Dietl  thought  they  were  due  to  strangu- 
lation of  the  kidney  or  to  twists  or  kinks  in  the  renal  vessels  due  to  the 
extreme  mobility.  During  the  attacks  the  urine  is  sometimes  high-colored 
and  contains  an  excess  of  uric  acid  or  of  the  oxalates.  It  is  stated,  too, 
that  blood  or  pus  may  be  present.  The  kidney  may  be  tender,  sAvollen, 
and  less  freely  movable.  Cheyne  describes  intermittent  hsematuria  in  this 
condition. 

Intermittent  hydronephrosis  is  sometimes  associated  with  movable  kid- 
ney. Three  cases  are  reported  in  my  Lectures  on  Abdominal  Tumors.  In 
two  the  condition  has  been  completely  relieved  by  a  well-adapted  pad  and 
belt;  in  the  third,  attacks  recur  at  long  intervals. 

The  diagnosis  is  rarely  doubtful,  as  the  shape  of  the  organ  is  usually 
distinctive  and  the  mobility  marked.  Tumors  of  the  gall-bladder,  ovarian 
growths,  and  tumors  of  the  bowels  may  in  rare  instances  be  confounded 
with  it. 


CIRCULATORY  DISTURBANCES.  849 

Treatment. — The  kidney  has  been  extirpated  in  many  instances,  but 
the  operation  is  not  without  risk,  and  there  have  been  several  fatal  cases. 
Stitching  of  the  kidney — nephrorrhaphy — as  recommended  by  Hahn,  is  the 
most  suitable  procedure,  and  statistics  published  by  Keen  show  that  relief 
is  afforded  in  many  cases  by  the  procedure,  though  not  in  all.  Treatment 
designed  to  increase  fat-formation  often  helps  to  hold  the  kidney  in  place. 

In  many  instances  the  greatest  relief  is  experienced  from  a  bandage  and 
pad.  It  should  be  applied  in  the  morning,  with  the  patient  in  the  dorsal  or 
knee-breast  position,  and  she  should  be  taught  how  to  push  up  the  kidney. 
An  air  pad  may  be  used  if  the  organ  is  sensitive.  In  other  cases  a  broad 
bandage  well  padded  in  the  lower  abdominal  zone  pushes  up  the  intestines 
and  makes  them  act  as  a  support.  In  the  attacks  of  severe  colic  morphia 
is  required.  When  dependent,  as  seems  sometimes  the  case,  upon  an  excess 
of  uric  acid  or  the  oxalates,  the  diet  must  be  carefully  regulated. 

For  an  exhaustive  consideration  of  all  aspects  of  the  subject,  see  Fischer, 
in  Nos.  1-5  of  the  Centralblatt  f.  d.  Grenzgebiete  der  Medicin  und  Chirur- 

gie,  1898. 

*• 

III.  CIRCULATORY  DISTURBANCES. 

Normally  the  secretion  of  urine  is  accomplished  by  the  maintenance 
of  a  certain  blood-pressure  within  the  glomeruli  and  by  the  activity  of 
the  renal  epithelium.  Bowman's  views  on  this  question  have  been  gen- 
erally accepted,  and  the  watery  elements  are  held  to  be  filtered  from  the 
glomeruli;  the  amount  depending  on  the  rapidity  and  the  pressure  of  the 
blood  current;  the  quality,  whether  normal  or  abnormal,  depending  upon 
the  condition  of  the  capillary  and  glomerular  epithelium;  while  the  greater 
portion  of  the  solid  ingredients  are  excreted  by  the  epithelium  of  the  con- 
voluted tubules.  The  integrity  of  the  epithelium  covering  the  capillary 
tufts  within  Bowman's  capsule  is  essential  to  the  production  of  a  normal 
urine.  If  under  any  circumstances  their  nutrition  fails,  as  when,  for  ex- 
ample, the  rapidity  of  the  blood  current  is  lowered,  so  that  they  are  deprived 
of  the  necessary  amount  of  oxygen,  the  material  which  filters  through  is 
no  longer  normal  (i.  e.,  water),  but  contains  serum  albumin.  Cohnheim 
has  shown  that  the  renal  epithelium  is  extremely  sensitive  to  circulatory 
changes,  and  that  compression  of  the  renal  artery  for  only  a  few  minutes 
causes  serious  disturbance. 

The  circulation  of  the  kidney  is  remarkably  influenced  by  reflex  stimuli 
coming  from  the  skin.  Exposure  to  cold  causes  heightened  blood-pressure 
within  the  kidneys  and  increased  secretion  of  urine.  Bradford  has  shown 
that  after  excision  of  portions  of  the  kidney,  to  as  much  as  one  third  of 
the  total  weight,  there  is  a  remarkable  increase  in  the  flow  of  urine. 

Congestion  of  the  Kidneys. — (1)  Active  Congestion  ;  Hypercemia. — 
Acute  congestion  of  the  kidney  is  met  with  in  the  early  stage  of  nephritis, 
whether  due  to  cold  or  to  the  action  of  poisons  and  severe  irritants.  Tur- 
pentine, cubebs,  cantharides,  and  copaiba  are  all  stated  to  cause  extreme 
hypcraemia  of  the  organ.  The  most  typical  congestion  of  the  kidney  which 
we  see  post  mortem  is  that  in  the  early  stage  of  acute  Bright's  disease,  when 


850  DISEASES  OP  THE  KIDNEYS. 

the  organ  may  be  large,  soft,  of  a  dark  color,  and  on  section  blood  drips 
from  it  freely. 

It  has  been  held  that  in  all  the  acute  fevers  the  kidneys  are  congested, 
and  that  this  explained  the  scanty,  high-colored,  and  often  albuminous 
urine.  On  the  other  hand,  by  Koy's  oncometer,  Walter  Mendelson  has 
shown  that  the  kidney  in  acute  fever  is  in  a  state  of  extreme  anaemia,  small, 
pale,  and  bloodless;  and  that  this  anaemia,  increasing  with  the  pyrexia  and 
interfering  with  the  nutrition  of  the  glomerular  epithelium,  accounts  for 
the  scanty,  dark-colored  urine  of  fever  and  for  the  presence  of  albumin. 
In  the  prolonged  fevers,  however,  it  is  probable  that  relaxation  of  the 
arteries  again  takes  place.  Certainly  it  is  rare  to  find  post  mortem  such 
a  condition  of  the  kidney  as  is  described  by  Mendelson.  On  the  contrary, 
the  kidney  of  fever  is  commonly  swollen,  the  blood-vessels  are  congested, 
and  the  cortex  frequently  shows  traces  of  cloudy  swelling.  However,  the 
circulatory  disturbances  in  acute  fevers  are  probably  less  important  tlian 
the  irritative  efi^ects  of  either  the  specific  agents  of  the  disease  or  the  prod- 
ucts produced  in  their  growth  or  in  the  altered  metabolism  of  the  tissues. 
The  urine  is  diminished  in  amount,  and  may  contain  albumin  and  tube- 
casts. 

(2)  Passive  Congestion;  Mechanical  Hypercemia. — This  is  found  in  cases 
of  chronic  disease  of  the  heart  or  lung,  with  impeded  circulation,  and  as  a 
result  of  pressure  upon  the  renal  veins  by  tumors,  the  pregnant  uterus,  or 
ascitic  fluid.  In  the  cardiac  kidney,  as  it  is  called,  the  cyanotic  induration 
associated  with  chronic  heart-disease,  the  organs  are  enlarged  and  firm, 
the  capsule  strips  off,  as  a  rule,  readily,  the  cortex  is  of  a  deep  red  color, 
and  the  pyramids  of  a  purple  red.  The  section  is  coarse-looking,  the  sub- 
stance is  very  firm,  and  resists  cutting  and  tearing.  The  interstitial  tissue 
is  increased,  and  there  is  a  small-celled  infiltration  between  the  tubules. 
Here  and  there  the  Malpighian  tufts  have  become  sclerosed.  The  blood- 
vessels are  usually  thickened,  and  there  may  be  more  or  less  granular,  fatty, 
or  hyaline  changes  in  the  epithelium  of  the  tubules.  The  condition  is  in- 
deed a  diffuse  nephritis.  The  urine  is  usually  reduced,  is  of  high  specific 
gravity,  and  contains  more  or  less  albumin.  Hyaline  tube-casts  and  blood- 
corpuscles  are  not  uncommon.  In  uncomplicated  cases  of  the  cyanotic  in- 
duration urgemia  is  rare.  On  the  other  hand,  in  the  cardiac  cases  with  ex- 
tensive arterio-sclerosis,  the  kidneys  are  more  involved  and  the  renal  func- 
tion is  likely  to  be  disturbed. 


IV.    ANOMALIES   OF   THE   URINARY   SECRETION. 

1.  Anueia. 

Total  suppression  of  urine  occurs  under  the  following  conditions: 

(1)  As  an  event  in  the  intense  congestion  of  acute  nephritis.     For  a 
time  no  urine  may  be  formed;  more  often  the  amount  is  greatly  reduced. 

(2)  More  commonly  complete  anuria  is  seen  in  subjects  of  renal  stone, 
fragments  of  which  block  both  ureters.    Sir  William  Eoberts  calls  the  con- 


ANOMALIES  OF  THE  URINARY  SECRETION.  851 

dition  "  latent  nraeniia."  There  may  be  very  little  discomfort,  and  the 
symptoms  are  very  unlike  those  of  ordinary  uraemia.  Convulsions  occurred 
in  only  5  of  41  cases  (Herter);  headache  in  only  6;  vomiting  in  only  12. 
Consciousness  is  retained;  the  pupils  are  usually  contracted;  the  tempera- 
ture may  be  low;  there  are  twitchings  and  perhaps  occasional  vomiting. 
Of  41  cases  in  the  literature,  35  occurred  in  males.  Of  36  cases  in  which 
there  was  absolute  anuria,  in  11  the  condition  lasted  more  than  four  days, 
in  18  cases  from  seven  to  fourteen  days,  and  in  7  cases  longer  than  four- 
teen days  (Herter). 

(3)  Cases  occur  occasionally  in  which  the  suppression  is  prerenal.  The 
following  are  among  the  more  important  conditions  with  which  this  form 
of  anuria  may  be  associated  (Hensley):  Fevers  and  inflammations;  acute 
poisoning  by  phosphorus,  lead,  and  turpentine;  in  the  collapse  after  severe 
injuries  or  after  operations,  or,  indeed,  after  the  passing  of  a  catheter;  in 
the  collapse  stage  of  cholera  and  yellow  fever;  and,  lastly,  there  is  an 
hysterical  anuria,  of  which  Charcot  reports  a  case  in  which  the  suppression 
lasted  for  eleven  days.  Bailey  reports  the  case  of  a  young  girl,  aged  eleven, 
inmate  of  an  orphan  asylum,  who  passed  no  urine  from  October  10th  to 
December  12th  (when  8  ounces  were  withdrawn),  and  again  from  this  date  to 
March  1st!    The  question  of  hysterical  deception  was  considered  in  the  case. 

A  patient  may  live  for  from  ten  days  to  two  weeks  with  complete  sup- 
pression. In  Polkas  case,  in  which  the  only  kidney  was  removed,  the  pa- 
tient lived  eleven  days.  It  is  remarkable  that  in  many  instances  there  are 
no  toxic  features.  Adams  reports  a  case  of  recovery  after  nineteen  days  of 
suppression. 

In  the  obstructive  cases  surgical  interference  should  be  resorted  to. 
In  the  non-obstructive  cases,  particularly  when  due  to  extreme  congestion 
of  the  kidney,  cupping  over  the  loins,  hot  applications,  free  purging,  and 
sweating  with  pilocarpine  and  hot  air  are  indicated.  When  the  secretion  is 
once  started  diuretin  often  acts  well.  Large  hot  irrigations,  with  normal 
salt  solution,  with  Kemp's  double-current  rectal  tubes,  should  be  tried,  as 
they  are  stated  to  stimulate  the  activity  of  the  kidneys  in  a  remarkable  way. 

2.   H^MATUEIA. 

The  following  division  may  be  made  of  the  causes  of  hsematuria: 

(1)  General  Diseases. — The  malignant  forms  of  the  acute  specific  fevers. 
Occasionally  in  leukaemia  hsematuria  occurs. 

(2)  Renal  Causes. — Acute  congestion  and  inflammation,  as  in  Bright's 
disease,  or  the  effect  of  toxic  agents,  such  as  turpentine,  carbolic  acid,  and 
cantharides.  When  the  carbolic  spray  was  in  use  many  surgeons  suffered 
from  haematuria  in  consequence  of  this  poison.  Eenal  infarction,  as  in 
ulcerative  endocarditis.  New  growths,  in  which  the  bleeding  is  usually 
profuse.  In  tuberculosis  at  the  onset,  when  the  papillae  are  involved,  there 
may  be  bleeding.  Stone  in  the  kidney  is  a  frequent  cause.  Parasites:  The 
Filaria  sanguinis  hominis  and  the  Bilharzia  cause  a  form  of  hematuria  met 
with  in  the  tropics.  The  echinococcus  is  rarely  associated  with  hasmor- 
rhage.      It  is  sometimes  met  with  in  floating  kidney. 


852  DISEASES  OP  THE  KIDNEYS. 

(3)  Affections  of  the  Urinary  Passages. — Stone  in  the  ureter^  tumor  or 
ulceration  of  the  hladder,  the  presence  of  a  calculus,  parasites,  and,  very 
rarely,  ruptured  veins  in  the  bladder.  Bleeding  from  the  urethra  occa- 
sionally occurs  in  gonorrhoea  and  as  a  result  of  the  lodgment  of  a  calculus. 
Hsematuria  may  be  an  early  symptom  in  enlarged  prostate. 

(4)  Traumatism. — Injuries  may  produce  bleeding  from  any  part  of  the 
urinary  passages.  By  a  fall  or  blow  on  the  back  the  kidney  may  be  rup- 
tured, and  this  may  he  followed  by  very  free  bleeding;  less  commonly  the 
blood  comes  from  injury  of  the  bladder  or  of  the  prostate.  Blood  from  the 
urethra  is  frequently  due  to  injury  by  the  passage  of  a  catheter,  or  some- 
times to  falls.    Transient  hematuria  follows  all  operations  on  the  kidney. 

And,  lastly,  there  is  a  very  interesting  group,  carefully  studied  of  late 
years,  particularly  by  Klemperer  and  M.  L.  Harris,  in  which  no  known 
lesions  have  been  found.  It  is  probably  in  this  group  of  cases  that  Gull's 
"  renal  epistaxis  "occurs.  Harris  has  recently  collected  18  of  these  cases 
from  the  literature.  The  first-named  author  thinks  it  is  a  form  of  angio- 
neurotic hsematuria.  An  interesting  point  is  that  in  the  18  cases  collected 
by  Harris  nephrotomy  was  done;  of  these,  9  cases  were  completely  re- 
lieved. 

Of  special  interest  is  the  malarial  hsematuria  which  prevails  in  certain 
districts  and  has  already  been  considered  in  the  section  on  paludism. 

The  diagnosis  of  hsematuria  is  usually  easy.  The  color  of  the  urine 
varies  from  a  light  smoky  to  a  bright  red,  or  it  may  have  a  dark  porter 
color.  Examined  with  the  microscope,  the  blood-corpuscles  are  readily 
recognized,  either  plainly  visible  and  retaining  their  color,  in  which  case 
they  are  usually  crenated,  or  simply  as  shadows.  In  ammoniacal  urine 
or  urines  of  low  specific  gravity  the  hgemoglobin  is  rapidly  dissolved  from 
the  corpuscles,  but  in  normal  urine  they  remain  for  many  hours  unchanged. 

For  other  tests  the  student  is  referred  to  the  works  on  Clinical  Diag- 
nosis, by  Simon  and  by  von  Jaksch. 

It  is  important  to  distinguish  between  blood  coming  from  the  bladder 
and  from  the  kidneys,  though  this  is  not  always  easy.  From  the  bladder 
the  blood  may  be  foimd  only  with  the  last  portions  of  urine,  or  only  at  the 
termination  of  micturition.  In  hgemorrhage  from  the  kidneys  the  blood 
and  urine  are  intimately  mixed.  Clots  are  more  commonly  found  in  the 
blood  from  the  kidneys,  and  may  form  moulds  of  the  pelvis  or  of  the  ureter. 
When  the  seat  of  the  bleeding  is  in  the  bladder,  on  washing  out  this  organ, 
the  water  is  more  or  less  blood-tinged;  but  if  the  source  of  the  bleeding  is 
higher,  the  water  comes  away  clear.  In  many  instances  it  is  difficult  to 
settle  the  question  by  the  examination  of  the  urine  alone,  and  the  symp- 
toms and  the  physical  signs  must  also  be  taken  into  account.  Cystoscopic 
examination  of  the  bladder,  paying  especial  attention  to  the  urine  flowing 
from  each  ureteral  orifice,  and  catheterization  of  the  ureters  are  aids  in 
the  diagnosis  of  doubtful  cases. 

3.    HEMOGLOBINURIA. 

This  condition  is  characterized  by  the  presence  of  blood-pigment  in 
the  urine.     The  blood-cells  are  either  absent  or  in  insignificant  numbers. 


ANOMALIES  OF  THE  URINARY  SECRETION.  853 

The  coloring  matter  is  not  hsematin,  as  indicated  by  the  old  name,  hcema- 
tinuria,  nor  in  reality  always  haemoglobin,  but  it  is  most  frequently  methse- 
moglobin.  The  urine  has  a  red  or  brownish-red,  sometimes  quite  black 
color,  and  usually  deposits  a  very  heavy  brownish  sediment.  When  the 
hsemoglobin  occurs  only  in  small  quantities,  it  may  give  a  lake  or  smoky 
color  to  the  urine.  Microscopical  examination  shows  the  presence  of  granu- 
lar pigment,  sometimes  fragments  of  blood-disks,  epithelium,  and  very  often 
darkly  pigmented  urates.  The  urine  is  also  albuminous.  The  number  ol 
red  blood-corpuscles  bears  no  proportion  whatever  to  the  intensity  of  the 
color  of  the  urine.  Examined  spectroscopically,  there  are  either  the  two 
absorption  bands  of  oxyhemoglobin,  which  is  rare,  or,  more  commonly, 
there  are  the  three  absorption  bands  of  methgemoglobin,  of  which  the  one 
in  the  red  near  C  is  characteristic.  Two  clinical  groups  may  be  distin- 
guished. 

(1)  Toxic  Haemoglobinuria. — This  is  caused  by  poisons  which  produce 
rapid  dissolution  of  the  blood-corpuscles,  such  as  potassium  chlorate  in  large 
doses,  pyrogallic  acid,  carbolic  acid,  arseniuretted  hydrogen,  carbon  mon- 
oxide, naphthol,  and  muscarine;  also  the  poisons  of  scarlet  fever,  yellow 
fever,  typhoid  fever,  malaria,  and  syphilis.  According  to  Bastianelli,  hgemo- 
globinuria  due  to  the  administration  of  quinine  never  occurs  excepting  in 
patients  who  are  suffering  or  who  have  recently  suffered  from  malarial 
fever.  It  has  also  followed  severe  burns.  Exposure  to  excessive  cold  and 
violent  muscular  exertion  are  stated  to  produce  hemoglobinuria.  A  most 
remarkable  toxic  form  occurs  in  horses,  coming  on  with  great  suddenness 
and  associated  with  paresis  of  the  hind  legs.  Death  may  occur  in  a  few 
hours  or  a  few  days.  The  animals  are  attacked  only  after  being  stalled 
for  some  days  and  then  taken  out  and  driven,  particularly  in  cold  weather. 
The  form  of  hemoglobinuria  from  cold  and  exertion  is  extremely  rare.  No 
instance  of  it,  even  in  association  with  frost-bites,  came  under  my  observa- 
tion in  Canada.  Blood  transfused  from  one  mammal  into  another  causes 
dissolution  of  the  corpuscles  with  the  production  of  hemoglobinuria;  and, 
lastly,  there  is  the  epidemic  hcemoglohinuria  of  the  new-born,  associated  with 
jaundice,  cyanosis,  and  nervous  symptoms. 

(2)  Paroxysmal  HaBinoglobiniiria. — This  rare  disease  is  characterized 
by  the  occasional  passage  of  bloody  urine,  in  which  the  coloring  matter 
only  is  present.  It  is  more  frequent  in  males  than  in  females,  and  occurs 
chiefly  in  adults.  It  seems  specially  associated  with  cold  and  exertion,  and 
has  often  been  brought  on,  in  a  susceptible  person,  by  the  use  of  a  cold 
foot-bath.  Paroxysmal  hemoglobinuria  has  been  found,  too,  in  persons 
subject  to  the  various  forms  of  Raynaud's  disease.  Many  regard  the  rela- 
tion between  these  two  affections  as  extremely  close;  some  hold  that  they 
are  manifestations  of  one  and  the  same  disorder.  Druitt,  the  author  of  the 
well-known  Surgical  Vade-mecum,  has  given  a  graphic  description  of  his 
sufferings,  which  lasted  for  many  years,  and  were  accompanied  with  local 
asphyxia  and  local  syncope.  The  connection,  however,  is  not  very  common. 
In  only  one  of  the  cases  of  Raynaud's  disease  which  I  have  seen  was  parox- 
ysmal hemoglobinuria  present,  and  in  it  epileptic  attacks  occurred  at  the 
same  time.    The  relation  of  the  disease  to  malaria  is  not  so  close  as  has  been 


854       -  DISEASES  OF  THE  KIDNEYS. 

thought  by  many  writers.  Bastianelli  asserts  that  it  is  practically  proved 
that  malarial  hgemoglobinuria  occurs  only  in  infections  with  the  sestivo- 
autumnal  parasite.  It  rarely,  if  ever,  occurs  in  the  first  attack,  usually 
appearing  with  the  first  relapse  or  after  repeated  relapses.  No  doubt  it  has 
been  frequently  confounded  with  a  malarial  haematuria. 

The  attacks  may  come  on  suddenly  after  exposure  to  cold  or  as  a  result 
of  mental  or  bodily  exhaustion.  They  may  be  preceded  by  chills  and 
pyrexia.  In  other  instances  the  temperature  is  subnormal.  There  may  be 
vomiting  and  diarrhoea.  Pain  in  the  lumbar  region  is  not  uncommon.  The 
hsemoglobinuria  rarely  persists  for  more  than  a  day  or  two — sometimes, 
indeed,  not  for  a  day.  There  are  instances  in  which,  even  in  the  course  of 
a  single  day,  there  have  been  two  or  three  paroxysms,  and  in  the  intervals 
clear  urine  has  been  passed.  Jaundice  has  been  present  in  a  number  of 
cases.  According  to  Ealfe,  paroxysmal  hgemoglobinuria  may  alternate  with 
general  symptoms  of  the  same  character,  but  associated  only  with  the  pas- 
sage of  albumin  and  an  increased  quantity  of  urea  in  the  urine.  In  such 
cases  he  supposes  that  the  toxic  agent,  whatever  its  nature,  has  destroyed 
only  a  limited  number  of  the  corpuscles,  the  coloring  matter  of  which  is 
readily  dealt  with  by  the  spleen  and  liver,  while  the  globulin  is  excreted 
in  the  urine.    The  cases  are  rarely  if  ever  fatal. 

The  essential  pathology  of  the  disease  is  unknown,  and  it  is  difficult 
to  form  a  theory  which  will  meet  all  the  facts — particularly  the  relation 
with  Eaynaud's  disease,  which  is  rightly  regarded  as  a  vaso-motor  disorder. 
Increased  haemolysis  and  solution  of  the  hsemoglobin  in  the  blood-serum 
(hsemoglobingemia)  precedes,  in  each  instance,  the  appearance  of  the  color- 
ing matter  in  the  urine.  A  full  discussion  of  the  subject  is  to  be  found 
in  F.  Chvostek's  monograph.  Blanc  regards  it  as  distinctly  nervous  in 
origin. 

Treatment. — In  all  forms  of  hsematuria  rest  is  essential.  In  that 
produced  by  renal  calculi  the  recumbent  posture  may  suffice  to  check  the 
bleeding.  Full  doses  of  acetate  of  lead  and  opium  should  be  tried,  then 
ergot,  gallic  and  tannic  acid,  and  the  dilute  sulphuric  acid.  The  oil  of 
turpentine,  which  is  sometimes  recommended,  is  a  risky  remedy  in  hsema- 
turia. Extr.  hamamelis  virgin,  and  extr.  hydrastis  canad.  are  also  recom- 
mended. Cold  may  be  applied  to  the  loins  or  dry  cups  in  the  lumbar  re- 
gion.   Incision  of  the  kidney  has  cured  the  so-called  renal  epistaxis. 

The  treatment  of  hgemoglobinuria  is  unsatisfactory.  Amyl  nitrite  will 
sometimes  cut  short  or  prevent  an  attack  (Chvostek).  During  the  parox- 
ysm the  patient  should  be  kept  warm  and  given  hot  drinks.  Quinine  is 
recommended  in  large  doses,  on  the  supposition — as  yet  unwarranted — 
that  the  disease  is  specially  connected  with  malaria.  If  there  is  a  syphi- 
litic history,  iodide  of  potassium  in  full  doses  may  be  tried.  In  a  warm 
climate  the  attacks  are  much  less  frequent. 

4.  Albuminuria. 

The  presence  of  albumin  in  the  urine,  formerly  regarded  as  indicative 
of  Bright's  disease,  is  now  recognized  as  occurring  under  many  circum- 
stances without  the  existence  of  serious  organic  change  in  the  kidney.    Two 


ANOMALIES  OF  THE  URINARY  SECRETION.  855 

groups  of  cases  may  be  recognized — those  in  which  the  kidneys  show  no 
coarse  lesions,  and  those  in  which  there  are  evident  anatomical  changes. 

Albuminuria  without  Coarse  Renal  Lesions. — (a)  Functional,  so-called 
Physiological  Albuminuria. — In  a  normal  condition  of  the  kidney  only  the 
water  and  the  salts  are  allowed  to  pass  from  the  blood.  When  albuminous 
substances  transude  there  is  probably  disturbance  in  the  nutrition  of  the 
epithelium  of  the  capillaries  of  the  tuft,  or  of  the  cells  surrounding  the 
glomerulus.  This  statement  is  still,  however,  in  dispute,  and  Senator, 
Grainger  Stewart,  and  others  hold  that  there  is  a  physiological  albuminuria 
which  may  follow  muscular  work,  the  ingestion  of  food  rich  in  albumin, 
violent  emotions,  cold  bathing,  and  dyspepsia.  The  differences  of  opinion 
on  this  point  are  striking,  and  observers  of  equal  thoroughness  and  relia- 
bility have  arrived  at  directly  opposite  conclusions.  The  presence  of  albu- 
min in  the  urine,  in  any  form  and  under  any  circumstance,  may  be  regarded 
as  indicative  of  change  in  the  renal  or  glomerular  epithelium,  a  change, 
however,  which  may  be  transient,  slight,  and  unimportant,  depending  upon 
variations  in  the  circulation  or  upon  the  irritating  effects  of  substances 
taken  with  the  food  or  temporarily  present,  as  in  febrile  states. 

Albuminuria  of  adolescence  and  cyclic  albuminuria,  in  which  the  albu- 
min is  present  only  at  certain  times  during  the  day,  are  interesting  forms. 
A  majority  of  the  cases  occur  in  young  persons — boys  more  commonly  than 
girls — and  the  condition  is  often  discovered  accidentally.  The  urine,  as  a 
rule,  contains  only  a  very  small  amount  of  albumin,  but  in  some  instances 
large  quantities  are  present.  The  most  striking  feature  is  the  variability. 
It  may  be  absent  in  the  morning  and  only  present  after  exertion,  or  it  may 
be  greatly  increased  after  taking  food,  particularly  proteids.  The  quan- 
tity of  urine  may  be  but  little,  if  at  all,  increased,  the  specific  gravity  is 
usually  normal,  and  the  color  may  be  high.  Occasionally  hyaline  casts 
may  be  found,  and  in  some  instances  there  has  been  transient  glycosuria. 
As  a  rule,  the  pulse  is  not  of  high  tension  and  the  second  aortic  sound  is 
not  accentuated. 

Various  forms  of  this  affection  have  been  recognized  by  writers,  such 
as  neurotic,  dietetic,  cyclic,  intermittent,  and  paroxysmal — names  which 
indicate  the  characters  of  the  different  varieties.  A  large  proportion  of 
the  cases  get  well  after  the  condition  has  persisted  for  a  variable  period. 
This  in  itself  is  an  evidence  that  the  changes,  whatever  their  nature,  are 
transient  and  slight.  In  these  instances  the  albumin  exists  in  small  quan- 
tity, tube-casts  are  rarely  present,  and  the  arterial  tension  is  not  increased. 
In  a  second  group  the  albumin  is  more  persistent,  the  amount  is  larger, 
though  it  may  vary  from  day  to  day,  and  the  pulse  tension  is  increased. 
In  such  instances  the  persistent  albuminuria  probably  indicates  actual 
organic  change  in  the  kidney. 

(&)  Febrile  Albuminuria. — Pyrexia,  by  whatever  cause  produced,  may 
cause  slight  albuminuria.  The  presence  of  the  albumin  is  due  to  slight 
changes  in  the  glomeruli  induced  by  the  fever,  j^guch  as  cloudy  swelling, 
which  cannot  be  regarded  as  an  organic  lesion.  It  is  extremely  common, 
occurring  in  pneumonia,  diphtheria,  typhoid  fever,  malaria,  and  even  in 
the  fever  of  acute  tonsillitis.     The  amount  of  albumin  is  slight,  and  it 


856  DISEASES  OF  THE  KIDNEYS. 

usually  disappears  from  the  urine  with  the  cessation  of  the  fever.    Hyaline 
and  even  epithelial  casts  accompany  the  condition. 

(c)  Hcemic  Changes. — Purpura,  scurvy,  chronic  poisoning  by  lead  or 
mercury,  syphilis,  leukgemia,  and  profound  anaemia  may  be  associated 
with  slight  albuminuria.  Abnormal  ingredients  in  the  blood,  such  as 
bile-pigment  and  sugar,  may  cause  the  passage  of  small  amounts  of  al- 
bumin. 

The  transient  albuminuria  of  pregnancy  may  belong  to  this  hsemic 
group,  although  in  a  majority  of  such  cases  there  are  changes  in  the  renal 
tissue.  Albumin  may  be  found  sometimes  after  the  inhalation  of  ether  or 
chloroform. 

(d)  Albuminuria  occurs  in  certain  affections  of  the  nervous  system.  This 
so-called  neurotic  albuminuria  is  seen  after  an  epileptic  seizure  and  in  apo- 
plexy, tetanus,  exophthalmic  goitre,  and  injuries  of  the  head. 

Albumiimria  with  Definite  Lesions  of  the  Urinary  Organs.~(a)  Con- 
gestion of  the  kidney,  either  active,  such  as  follows  exposure  to  cold  and 
is  associated  with  the  early  stages  of  nephritis,  or  passive,  due  to  obstructed 
outflow  in  disease  of  the  heart  or  lungs,  or  to  pressure  on  the  renal  veins 
by  the  pregnant  uterus  or  tumors. 

(h)  Organic  disease  of  the  kidneys — acute  and  chronic  Bright's  disease, 
amyloid  and  fatty  degeneration,  suppurative  nephritis,  and  tumors. 

(c)  Affections  of  the  pelvis,  ureters,  and  bladder,  when  associated  with 
the  formation  of  pus. 

Tests  for  Albumin. — Both  morning  and  evening  urine  should  be 
examined,  and  in  doubtful  cases  at  least  three  specimens.  If  turbid,  the 
urine  should  be  filtered,  though  turbidity  from  the  urates  is  of  no  moment, 
since  it  disappears  at  once  on  the  application  of  heat. 

Heat  and  Nitric-acid  Test. — The  urine  is  boiled  in  a  test-tube  over  a 
spirit-lamp,  and  a  drop  of  nitric  acid  is  then  added.  If  a  cloudiness  occurs 
on  boiling,  it  may  be  due  to  phosphates,  which  are  dissolved  on  the  addition 
of  an  acid.    Persistence  of  the  cloudiness  indicates  albumin. 

Heller's  Test. — A  small  quantity  of  fuming  nitric  acid  is  poured  into 
the  test-tube,  and  with  a  pipette  the  urine  is  allowed  to  flow  gently  down 
the  side  upon  the  acid.  At  the  line  of  junction  of  the  two  fluids,  if  albumin 
is  present,  a  white  ring  is  formed.  This  contact  method  is  trustworthy, 
and,  for  the  routine  clinical  work,  is  probably  the  most  satisfactory.  A 
diffused  haze,  due  to  mucin  (nucleo-albumin),  is  sometimes  seen  just  above 
the  white  ring  of  albumin;  and  in  very  concentrated  urines,  or  after  the 
taking  of  balsamic  remedies,  a  slight  cloudiness  may  be  due  to  urates  or 
uric  acid,  which  clears  on  heating  or  warming.  A  colored  ring  at  the  junc- 
tion of  the  acid  and  the  urine  is  due  to  the  oxidation  of  the  coloring  matters 
in  the  urine. 

Ferrocyanide-of -potassium  and  Acetic-acid  Test. — Fill  an  ordinary  test- 
tube  half  full  of  urine,  and  add  5  or  6  cc.  of  potassium-ferrocyanide  solu- 
tion (1  in  20).  Thoroughly  mix  the  urine  and  reagent  and  add  10  to  15 
drops  of  acetic  acid.  If  albumin  be  present,  a  cloudiness  varying  in  de- 
gree according  to  the  amount  of  albumin  will  be  produced.  This  is  a  very 
reliable  test,  as  it  precipitates  all  forms  of  albumin,  acid  and  alkaline,  but 


ANOMALIES  OF  THE  URINARY  SECRSJTION.  857 

does  not  precipitate  mucin,  peptones,  phosphates,  urates,  vegetable  alkaloids, 
or  the  pine  acids. 

Sir  William  Roberts  strongly  recommends  the  magnesium-nitric  test. 
One  volume  of  strong  nitric  acid  is  mixed  with  five  volumes  of  the  satu- 
rated solution  of  sulphate  of  magnesium.  This  is  used  in  the  same  way  as 
the  nitric  acid  in  Heller's  test. 

Picric  acid,  introduced  by  George  Johnson,  is  a  delicate  and  useful 
test  for  albumin.  A  saturated  solution  is  used  and  employed  as  in  the 
contact  method.  It  has  been  urged  against  this  test  that  it  throws  down 
the  mucin,  peptones,  and  certain  vegetable  alkaloids,  but  these  are  dis- 
solved by  heat. 

For  minute  traces  of  albumin  the  trichloracetic  acid  may  be  used,  or 
Millard's  fluid,  which  is  extremely  delicate  and  consists  of  glacial  carbolic 
acid  (95  per  cent),  2  drachms;  pure  acetic  acid,  7  drachms;  liquor  potassae, 
2  ounces  6  drachms. 

A  quantitative  estimate  of  the  albumin  can  be  made  by  means  of  Es- 
bach's  tube,  but  the  rough  method  of  heating  and  boiling  a  certain  quan- 
tity of  acidulated  urine  in  a  test-tube  and  allowing  it  to  stand,  is  often 
employed.  The  depth  of  deposit  can  then  be  compared  with  the  whole 
amount  of  urine,  and  the  proportion  is  expressed  as  a  mere  trace,  almost 
solid — one  fourth,  one  half,  and  so  on.  This,  of  course,  does  not  give  an 
accurate  indication  of  the  proportion  of  albumin  in  the  total  quantity  of 
urine.  For  the  more  elaborate  methods  the  reader  is  referred  to  the  works 
on  urinalysis. 

The  above  tests  refer  entirely  to  serum  albumin.  Other  albuminous 
substances  occur,  such  as  albumose,  serum  globulin,  peptones,  and  hemi- 
albumose  or  propepton.    They  are  not  of  much  clinical  importance. 

Albumosuria. — Traces  of  albumoses  are  found  in  the  urine  in  many 
febrile  diseases  and  in  chronic  suppuration,  and  have  little  clinical  signifi- 
cance. Marked  and  persistent  albumosuria  is  associated  with  multiple 
myelomata.  The  first  observation  in  this  class  was  recorded  by  Benee 
Jones  in  1848,  as  a  case  of  mollities  ossium,  with  a  modified  form  of  albu- 
min in  the  urine.  As  Kahler  subsequently  recognized  the  condition  in  a 
similar  case  as  one  of  multiple  myeloma,  the  Italians  have  given  the  disease 
his  name.  In  this  country  Fitz  referred  briefly  to  an  instance  at  a  recent 
meeting  (1898)  of  the  Association  of  American  Physicians,  and  lately 
Hamburger  (Johns  Hopkins  Hospital  Bulletin,  February,  1901)  has  pub- 
lished from  my  clinic  the  details  of  two  cases,  with  a  review  of  the  subject. 
In  Bradshaw's  case  the  patient  passed  at  intervals  for  a  year  a  turbid,  milky 
urine,  which  deposited  a  copious  white  sediment.  On  adding  nitric  acid  to  a 
urine  containing  albumose  a  white  precipitate  is  forped,  which  is  dissolved 
when  the  specimen  is  boiled,  but  reappears  on  cooling. 

Globulin  rarely  occurs  in  the  urine  alone,  but  generally  in  association 
with  serum-albumin.  The  latter  is  usually  present  in  greater  quantity,  but 
in  severe  organic  renal  disease  and  in  diabetes  Maguire  has  found  that  the 
proportion  of  globulin  to  albumin  is  often  2.5  to  1.  Senator  states  that 
more  globulin  is  present  with  the  lardaceous  kidney  than  in  other  forms  of 
nephritis.  The  clinical  significance  of  globulin  is  the  same  as  that  of 
serum-albumin. 
53 


ggg  DISEASES  OF  THE  KIDNEYS. 

Prognosis. — This  depends,  of  course,  entirely  upon  the  cause.  Ve- 
brile  albuminuria  is  transient,  and  in  a  majority  of  the  cases  depending 
upon  hasmic  causes  the  condition  disappears  and  leaves  the  kidneys  intact. 
An  occasional  trace  of  albumin  in  a  man  over  forty,  with  or  without  a  few 
hyaline  casts,  and  with  increased  tension  and  thick  vessel  walls,  usually 
indicates  changes  in  the  kidneys.  The  persistence  of  a  slight  amount  of 
albumin  in  young  men  without  increased  arterial  tension  is  less  serious, 
as  even  after  continuing  for  years  it  may  disappear.  I  have  already  spoken 
of  the  outlook  in  the  so-called  cyclic  albuminuria. 

Practically  in  all  cases  the  presence  of  albumin  indicates  a  change  of 
some"  sort  in  the  glomeruli,  the  nature,  extent,  and  gravity  of  which  it  is 
difficult  to  estimate;  so  that  other  considerations,  such  as  the  presence  of 
tube-casts,  the  existence  of  increased  tension,  the  general  condition  of  the 
patient,  and  the  influence  of  digestion  upon  the  albumin,  must  be  carefully 
considered. 

The  physician  is  daily  consulted  as  to  the  relation  of  albuminuria  and 
life  assurance.  As  his  function  is  to  protect  the  interests  of  the  company, 
he  should  reject  all  cases  in  which  albumin  occurs  in  the  urine.  It  is  evei;, 
doubtful  if  an  exception  should  be  made  in  young  persons  with  transient 
albuminuria.  Naturally,  companies  lay  great  stress  upon  the  presence  or 
absence  of  albumin,  but  in  the  most  serious  and  fatal  malady  with  which 
they  have  to  deal — chronic  interstitial  nephritis — ^the  albumin  is  often  ab- 
sent or  transient,  even  when  the  disease  is  well  developed.  After  the  forti- 
eth year,  from  a  standpoint  of  life  insurance,  the  state  of  the  arteries  is  far 
more  important  than  the  condition  of  the  urine. 

With  reference  to  the  significance  of  albuminuria  in  adults,  I  quite 
agree  with  the  following  conclusions  of  F.  C.  Shattuck: 

(1)  Eenal  albuminuria,  as  proved  by  the  presence  of  both  albumin  and 
casts,  is  much  more  common  in  adults,  quite  apart  from  Bright's  disease 
or  any  obvious  source  of  renal  irritation,  than  is  generally  supposed. 

(2)  The  frequency  increases  steadily  and  progressively  with  advancing 
age. 

(3)  This  increase  with  age  suggests  the  explanation  that  the  albumi- 
nuria is  often  an  indication  of  senile  degeneration. 

(4)  Though  it  cannot  be  regarded  as  yet  as  absolutely  proved,  it  is 
highly  probable  that  faint  traces  of  albumin  and  hyaline  and  finely  'granu- 
lar casts  of  small  diameter  are  often,  especially  in  those  past  fifty  years  of 
age,  of  little  or  no  practical  importance. 

5.  Pyueia  (Pus  in  the  Urine). 

Causes. — (1)  Pyelitis  and  Pyelonepliritis. — In  large  abscesses  of  the  kid- 
ney, pyonephrosis,  the  pus  may  be  intermittent,  while  in  calculous  and 
tuberculous  pyelitis  the  pyuria  is  usually  continuous,  though  varying  in 
intensity.  In  cases  due  to  the  colon  or  tubercle  bacillus  the  urine  is  acid, 
in  those  due  to  the  proteus  bacillus  alkaline,  while  in  the  staphylococcus 
cases  the  urine  is  either  less  acid  than  normal,  or  alkaline.  In  the  pyelitis 
and  pyelonephritis  following  cystitis  the  urine  is  alkaline  or  acid,  depend- 


ANOMALIES  OP  THE  URINARY  SECRETION.  859 

ing  upon  the  infecting  micro-organism;  more  mucus,  frequent  micturi- 
tion, and  a  previous  bladder  history  are  aids  in  diagnosis. 

(2)  Cystitis. — The  urine  is  usually  acid,  especially  in  women,  since 
the  colon  bacillus  is  a  very  common  cause  of  these  infections.  The  pus 
and  mucus  are  more  ropy,  and  triple  phosphate  crystals  are  found  in  the 
freshly  passed  urine  in  the  alkaline  infections. 

(3)  Urethritis,  particularly  gonorrhoea.  The  pus  appears  first,  is  in 
small  quantities,  and  there  are  signs  of  local  inflammation. 

(4)  In  leucorrhcea  the  quantity  of  pus  is  usually  small,  and  large  flakes 
of  vaginal  epithelium  are  numerous.  In  doubtful  cases,  when  leucorrhcea 
is  present,  the  urine  should  be  withdrawn  through  a  catheter. 

(5)  Rupture  of  Abscesses  into  the  Urinary  Passages. — In  such  cases  as 
pelvic  or  perityphlitic  abscess  there  have  been  previous  symptoms  of  pus 
formation.  A  large  amount  is  passed  within  a  short  time,  then  the  dis- 
charge stops  abruptly  or  rapidly  diminishes  within  a  few  days. 

Pus  gives  to  the  urine  a  white  or  yellowish-white  appearance.  On  set- 
tling, the  sediment  is  sometimes  ropy,  the  supernatant  fluid  usually  turbid. 
In  cases  due  to  urea-decomposing  microbes  (proteus  bacillus,  various 
staphylococci)  the  odor  may  be  ammoniacal  even  in  fresh  urine.  Examina- 
tion with  the  microscope  reveals  the  presence  of  a  large  number  of  pus- 
corpuscles,  which  are  usually,  when  the  pus  comes  from  the  bladder,  well 
formed;  the  protoplasm  is  granular,  and  often  shows  many  translucent 
processes. 

The  only  sediment  likely  to  be  confounded  with  pus  is  that  of  the 
phosphates;  but  it  is  whiter  and  less  dense,  and  is  distinguished  immedi- 
ately by  microscopical  examination  or  by  the  addition  of  acid. 

With  the  pus  there  is  always  more  or  less  epithelium  from  the  bladder 
and  pelves  of  the  kidneys,  but  since  in  these  situations  the  forms  of  cells 
are  practically  identical,  they  afford  no  information  as  to  the  locality  from 
which  the  pus  has  come. 

The  treatment  of  pus  in  the  urine  is  considered  under  the  conditions 
in  which  it  occurs. 

6.    ChTLURIA ISTON-PAEASITIC. 

This  is  a  rare  affection,  occurring  in  temperate  regions  and  unassoci- 
ated  with  the  Filaria  hancrofti.  The  urine  is  of  an  opaque  white  color; 
it  resembles  milk  closely,  is  occasionally  mixed  with  blood  (ha3matochy- 
luria),  and  sometimes  coagulates  into  a  firm,  jelly-like  mass.  In  other 
instances  there  is  at  the  bottom  of  the  vessel  a  loose  clot  which  may  be 
distinctly  blood-tinged.  Under  the  microscope  the  turbidity  seems  to  be 
caused  by  numerous  minute  granules — more  rarely  oil  droplets  similar  to 
those  of  milk.  In  Montreal  I  made  the  dissection  of  a  case  of  thirteen  years' 
duration  and  could  find  no  trace  of  parasites. 

7.  LiTHUEiA  (Lithcemia;  Lithic-acid  Diathesis). 

The  general  relations  of  uric  acid  have  already  been  considered  in  speak- 
ing of  gout. 


860  DISEASES  OF  THE  KIDNEYS. 

Occurrence  in  the  Urine. — The  uric  acid  occurs  in  combination  chiefly 
with  ammonium  and  sodium,  forming  the  acid  urates.  In  smaller  quan- 
tities are  the  potassium,  calcium,  and  lithium  salts.  The  uric  acid  may 
be  separated  from  its  bases  and  crystallizes  in  rhombs  or  prisms,  which 
are  usually  of  a  deep  red  color,  owing  to  the  staining  of  the  urinary  pig- 
ments. The  sediment  formed  is  granular  and  the  groups  of  crystals  look 
like  grains  of  Cayenne  pepper.  It  is  very  important  not  to  mistake  a  de- 
posit of  uric  acid  for  an  excess.  The  deposition  of  numerous  grains  in  the 
urine  within  a  few  hours  after  passing  is  more  likely  to  be  due  to  condi- 
tions which  diminish  the  solvent  power  than  to  increase  in  the  quantity. 
Of  the  conditions  which  cause  precipitation  of  the  uric  acid  Eoberts  gives 
the  following:  "  (1)  High  acidity;  (2)  poverty  in  mineral  salts;  (3)  low 
pigmentation;  and  (4)  high  percentage  of  uric  acid."  The  grade  of  acid- 
ity is  probably  the  most  important  element. 

In  health  the  weight  of  uric  acid  excreted  bears  a  fairly  constant  ratio 
to  the  weight  of  urea  eliminated.  According  to  von  Woorden,  the  average 
ratio  is  1  to  50,  while  the  average  ratio  of  the  nitrogen  of  uric  acid  to  the 
total  nitrogen  eliminated  in  the  urine  is  1  to  70.  In  several  of  the  cases 
of  gout  in  my  wards  Futeher  found  that  in  the  intervals  between  the  acute 
arthritic  attacks  the  uric  acid  was  reduced  to  a  much  greater  extent  than 
the  urea,  so  that  the  ratio  of  the  former  to  the  latter  often  varied  between 
1  to  300  up  to  (in  one  case)  1  to  1,500,  a  return  to  about  the  normal  propor- 
tions occurring  during  the  acute  attacks. 

More  common  is  the  precipitation  of  amorphous  urates,  forming  the 
so-called  brick-dust  or  lateritious  deposit,  which  has  a  pinkish  color,  due 
to  the  presence  of  urinary  pigment.  It  is  composed  chiefly  of  the  acid 
sodium  urates.  It  occurs  particularly  in  very  acid  urine  of  a  high  specific 
gravity.  As  the  urates  are  more  soluble  in  warm  solutions,  they  frequently 
deposit  as  the  urine  cools.  Here,  too,  the  deposition  does  not  necessarily, 
indeed  usually  does  not,  mean  an  excessive  excretion,  but  the  existence  of 
conditions  favoring  the  deposit. 

Lithcemia. — In  addition  to  what  has  already  been  said  under  gout,  we 
may  consider  here  the  hypothetical  condition  known  as  lithremia,  or  the 
uric-acid  diathesis.  Murchison  introduced  the  term  to  designate  certain 
symptoms  due,  as  he  supposed,  to  functional  disturbance  of  the  liver.  Not 
only  have  his  views  been  widely  adopted,  but,  as  is  so  often  the  case  Avhen 
we  give  the  rein  to  theoretical  conceptions  of  disease,  the  so-called  mani- 
festations of  this  state  have  so  multiplied  that  some  authors  attribute  to 
this  cause  a  considerable  proportion  of  the  ailments .  affecting  the  various 
systems  of  the  body.  Thus  one  writer  enumerates  not  fewer  than  thirty- 
nine  separate  morbid  conditions  associated  with  lithff'mia!  From  our  lack 
of  knowledge  of  the  mode  of  formation  and  elimination  of  uric  acid  it  is 
very  evident  that  the  physiology  of  the  subject  must  be  widely  extended 
before  we  are  in  a  position  to  draw  safe  conclusions.  Thus  it  is  by  no 
means  sure  that,  as  Murchison  supposed,  the  essential  defect  is  in  a  func- 
tional disorder  of  the  liver,  disturbing  the  metabolism  of  tbe  albiiminoiis 
ingredients,  nor  is  it  at  all  certain  that  the  only  offending  substance  is  uric 
acid.     In  the  present  imperfect  state  of  knowledge  it  is  impossible  with 


ANOMALIES  OF  THE  URINARY  SECRETION.  861 

any  clearness  to  define  the  pathology  of  the  so-called  uric-acid  diathesis. 
We  may  say  that  certain  symptoms  arise  in  connection  with  defective  food 
or  tissue  metabolism,  more  particularly  of  the  nitrogenous  elements.  De- 
ficient oxidation  is  probably  the  most  essential  factor  in  the  process,  with 
the  result  of  the  formation  of  less  readily  soluble  and  less  readily  eliminated 
products  of  retrograde  metamorphosis.  This  faulty  metabolism  if  long 
continued  may  lead  to  gout,  with  uratic  deposits  in  the  joints,  acute  in- 
flammations, and  arterial  and  renal  disease.  In  a  large  group  of  cases  the 
disturbed  metabolism  produces  high  tension  in  the  arteries  (probably  as  a 
direct  sequence  of  interference  with  the  capillary  circulation)  and  ulti- 
mately degenerations  in  various  tissues,  particularly  the  scleroses. 

Overeating  and  overdrinicing,  when  c^^mbined  with  deficient  muscular 
exercise,  lie  at  the  basis  of  this  nutritionar  disturbance.  The  symptoms 
wdiich  are  believed  to  characterize  the  uric-acid  diathesis  have  already  been 
briefly  treated  of  under  the  section  on  irregular  gout,  and  the  question  of 
diet  and  exercise  has  also  been  there  considered. 


8.    OXALURIA. 

The  discovery  of  calcium-oxalate  crystals  in  the  urine  by  Donne  in  1838 
led  to  the  description  of  the  so-called  oxalic-acid  diathesis.  It  is  claimed 
that  all  the  oxalic  acid  found  in  the  urine  is  taken  into  the  body  with  the 
food  (Dunlop).  In  health  none,  or  only  a  trace,  is  formed  in  the  body.  The 
amount  fluctuates  with  the  quantity  of  food  taken,  and  is  usually  below  10 
milligrammes  daily  (H.  Baldwin).  It  seems  to  be  formed  in  the  body  when 
there  is  an  absence  of  free  hydrochloric  acid  in  the  gastric  juice,  and  in 
connection  with  excessive  fermentation  in  the  intestines.  It  never  forms 
a  heavy  deposit,  but  the  crystals — usually  octahedral,  rarely  dumb-bell- 
shaped — collect  in  the  mucus-cloud  and  on  the  sides  of  the  vessel. 

When  in  excess  and  present  for  any  considerable  time,  the  condition  is 
kown  as  oxaluria,  the  chief  interest  of  which  is  in  the  fact  that  the  crys- 
tals may  be  deposited  before  the  urine  is  voided,  and  form  a  calculus.  It 
is  held  by  many  that  there  is  a  special  diathesis  associated  with  its  presence 
in  excess  and  manifested  clinically  by  dyspepsia,  particularly  the  nervous 
form,  irritability,  depression  of  spirits,  lassitude,  and  sometimes  marked 
hypochondriasis.  There  may  be  in  addition  neuralgic  pains  and  the  gen- 
eral symptoms  of  neurasthenia.  The  local  and  general  symptoms  are  prob- 
ably dependent  upon  some  disturbance  of  metabolism  of  which  the  oxaluria 
is  one  of  the  manifestations.  It  is  a  feature  also  in  many  gouty  persons, 
and  in  the  condition  called  lithaemia. 


9.  Cystinuria. 

Stadthagen  claims  that  normal  urine  does  not  contain  cystin,  thougli 
Baumann  and  Ooldmann  succeeded  in  separating  it  in  very  small  quan- 
tities from  healthy  urine  as  a  benzoyl  compound.  It  is  associated  with 
elimination  of  diamines  both  in  the  fasces  and  urine.    It  is  very  rarely  met 


862  "DISEASES  OF  THE  KIDNEYS.    / 

with,  and  its  chief  interest  is  owing  to  the  fact  that  it  may  form  a  calcu- 
lus. It  is  a  sort  of  chemical  malformation  (Garrod),  and  its  presence  has 
been  determined  in  many  members  of  the  same  family.  The  condition  ap- 
pears sometimes  to  be  hereditary.  As  it  contains  sulphui;,  it  is  thought  to 
be  formed  from  the  tauiin  of  the  bile. 

10.  Phosphatijeia. 

The  phosphoric  acid  is  excreted  from  the  body  in  combination  with 
potassium,  sodium,  calcium,  and  magnesium,  forming  two  classes,  the  alka- 
line phosphates  of  sodium  and  potassium  and  the  earthy  phosphates  of 
lime  and  magnesia.  The  amount  of  phosphoric  acid  (P2O5)  excreted  in  the 
twenty-four  hours  yinie^  acfdV^'V7i|g  to  Hammarsten,  between  1  and  5 
grammes,  with  an  average  of  2.5  grammes.  It  is  derived  mainly  from  the 
phosphoric  acid  taken  in  the  food,  but  also  in  part  as  a  decomposition  prod- 
uct from  nuclein,  protagon,  and  lecithin.  Of  the- alkaline  phosphates,  those 
in  combination  with  sodium  are  the  most  abundant.  The  ?Jkaline  phos- 
phates of  the  urine  are  more  abundant  than  the  earthy  phosphates. 

Of  the  earthy  phosphates,  those  of  lime  are  abundant,  of  magnesium 
scanty.  In  urine  which  has  undergone  the  ammoniacal  fermentation,  either 
inside  or  outside  the  body,  there  is  in  addition  the  ammonio-magnesium 
or  triple  phosphate,  which  occurs  in  triangular  prisms  or  in  feathery  or 
stellate  crystals;  hence  the  term  given  to  this  form  of  stellar  phosphates. 
The  earthy  phosphates  occur  as  a  sediment  in  the  urine  when  the  alka- 
linity is  due  to  a  fixed  alkali,  or  under  certain  circumstances  the  deposit 
may  take  place  within  the  bladder,  and  then  the  phosphates  are  passed 
at  the  end  of  micturition  as  a  whitish  fluid,  which  is  popularly  confounded 
with  spermatorrhoea.  The  calcium  phosphate  may  be  precipitated  by  heat 
and  produce  a  cloudiness  which  may  be  mistaken  for  albumin,  but  is  at 
once  dissolved  upon  making  the  urine  acid.  This  condition  is  very  fre- 
quent in  persons  suffering  from  dyspepsia  or  from  debility  of  any  kind. 
The  phosphates  may  be  in  great  excess,  rising  in  the  twenty-four  hours  to 
from  7  to  9  grammes  (Tessier),  whereas  the  normal  amount  is  not  more 
than  2.5  grammes.  And,  lastly,  the  phosphates  may  be  deposited  in  urine 
which  has  undergone  decomposition,  in  which  the  carbonate  of  ammonia 
from  the  urea  combines  with  the  magnesium  phosphates,  forming  the  triple 
salt.     This  is  seen  in  cystitis,  due  to  a  urea-decomposing  microbe. 

The  clinical  significance  of  an  excess  of  phosphates,  to  which  the  term 
phosphaturia  is  applied,  has  been  much  discussed.  It  must  be  remem- 
bered that  a  deposit  does  not  necessarily  mean  an  excess,  to  determine 
which  a  careful  analysis  of  the  twenty-four  hours'  secretion  should  be  made. 
It  has  long  been  thought  that  there  is  a  relation  between  the  activity  of 
the  nerve-tissues  and  the  output  of  phosphoric  acid;  but  the  question  can 
not  yet  be  considered  settled.  The  amount  is  increased  in  wasting  dis- 
eases, such  as  phthisis,  acute  yellow  atrophy  of  the  liver,  leukaemia,  and 
severe  anemia,  whereas  it  is  diminished  in  acute  diseases  and  during 
pregnancy. 

In  a  condition  termed  by  Tessier,  Ealfe,  and  others,  phosphatic  dia- 
betes there  are  polyuria,  thirst,  emaciation,  and  a  great  increase  in  the 


ANOMALIES  OF  THE   URINARY  SECRETION.  863 

excretion  of  phosphates,  which  may  be  as  miicli  as  from  7  to  9  grammes  in 
the  day.  The  urine  is  usually  acid  and  free  from  sugar;  the  patients  are 
nervous;  in  some  instances  sugar  has  been  present  in  the  urine,  and  in 
others  it  subsequently  makes  its  appearance. 

11.  Indicanueia. 

The  substance  in  the  urine  which  has  received  this  name  is  the  indoxyl- 
sulphate  of  potassium,  in  which  form  it  appears  in  the  urine  and  is  color- 
less. When  concentrated  acids  or  strong  oxidizing  agents  are  added  to 
the  urine,  this  substance  is  decomposed  and  the  indigo  set  free.  It  is  pres- 
ent only  in  small  quantities  in  healthy  urine.  It  is  derived  from  the  indol, 
a  product  formed  in  the  intestine  by  the  decomposition  of  the  albumin 
under  the  influence  of  bacteria.  When  absorbed,  this  is  oxidized  in  the 
tissues  to  indoxyl,  which  combines  with  the  potassium  sulphate,  forming 
the  above-named  substance. 

The  quantity  of  indican  is  diminished  on  a  milk  (and  a  Kefir)  diet. 
It  is  increased  in  all  wasting'  diseases,  as  carcinoma,  and  whenever  any 
large  quantities  of  albuminous  substances  are  undergoing  rapid  decompo- 
sition, as  in  the  severer  forms  of  peritonitis  and  empyema.  It  is  not  usually 
increased  in  constipation,  but  is  met  with  in  ileus,  particularly  in  obstruc- 
tion of  the  small  intestine.  Indican  has  occasionally  been  found  in  calculi. 
Though,  as  a  rule,  the  urine  is  colorless  when  passed,  there  are  instances 
in  which  the  decomposition  has  taken  place  within  the  body,  and  a  blue 
color  has  been  noticed  immediately  after  the  urine  was  voided.  Sometimes, 
too,  in  alkaline  urine  on  exposure  there  is  a  bluish  film  on  the  surface. 

To  test  for  indican,  place  4  or  5  cc.  of  nitric  or  hydrochloric  acid  in  a 
test-tube;  boil,  and  add  an  equal  quantity  of  urine.  A  bluish  ring  develops 
at  the  point  of  contact.  Add  1  or  2  cc.  of  chloroform  and  shake  the  test- 
tube;  on  separation  the  chloroform  has  a  violet  or  bluish  color  due  to  the 
presence  of  indican. 

12.  Melanuria. 

In  melanotic  cancer  the  urine,  either  at  the  time  of  voiding  or  after 
exposure  to  the  air,  may  present  a  dark  color.  This  pigment  is  known  as 
melanin,  and  it  may  occur  in  solution  or  in  the  form  of  small  granules. 
The  urine  may  be  voided  clear,  and  subsequently,  on  exposure  to  the  air 
or  on  the  addition  of  oxidizing  substances,  becomes  dark.  In  these  cases 
it  contains  a  chromogen  called  melanogen,  which  turns  dark  by  oxidation. 
Von  Jaksch  has  found  that  "  in  urine  containing  melanin  or  its  precursor, 
melanogen,  Prussian  blue  is  formed  by  adding  a  nitroprusside,  aqueous 
potash,  and  an  acid.  This  reaction,  however,  does  not  seem  to  depend  on 
the  presence  of  melanin,  as  it  is  not  given  by  that  substance  when  sep- 
arated from  the  urine,  but  apparently  by  some  other  at  present  unknown 
substance,  which  is  present  in  traces  in  normal  urine  and  is  increased  in 
cases  of  melanuria,  and  also  in  those  conditions  where  excess  of  indigo 
occurs  in  the  urine  "  (Halliburton).       * 


864  DISEASES  OF  THE  KIDNEYS. 

13.  Pneumatueia. 

Gas  may  be  passed  with  the  urine — 
'      1.  After  mechanical  introduction  of  air  in  vesical  irrigation  or  cysto- 
scopic  examination  in  the  knee-elbow  position. 

2.  As  a  result  of  the  introduction  of  gas-forming  organisms  in  catheter- 
ization or  other  operation.  Glycosuria  has  been  present  in  a  majority  of 
the  cases.  The  yeast  fungus,  the  colon  bacillus,  and  the  bacillus  aerogenes 
capsulatus  have  been  found. 

3.  In  cases  of  vesico-enteric  fistula. 

In  gas  production  within  the  bladder  the  symptoms  are  those  of  a  mild 
cystitis,  with  the  passage  of  gas  at  the  end  of  micturition,  sometimes  with 
a  loud  sound.     The  diagnosis  is  readily  made  by  causing  the  patient  to 
"urinate  in  a  bath  or  by  plunging  the  end  of  the  catheter  under  water. 

14.  Othee  Substan'Ces. 

Fat  in  the  urine,  or  lipuria,  occurs,  according  to  Halliburton,  first,  with- 
out disease  of  the  kidneys,  as  in  excess  of  fat  in  the  food,  after  the  admin- 
istration of  cod-liver  oil,  in  fat  embolism  occurring  after  fractures,  in  the 
fatty  degeneration  in  phosphorus  poisoning,  in  prolonged  suppuration,  as 
in  phthisis  and  pyaemia,  in  the  lipsemia  of  diabetes  mellitus;  secondly,  with 
disease  of  the  kidneys,  as  in  the  fatty  stage  of  chronic  Bright^s  disease,  in 
which  fat  casts  are  sometimes  present,  and,  according  to  Ebstein,  in  pyo- 
nephrosis; and,  thirdly,  in  the  affection  known  as  chyluria.  The  urine 
is  usually  turbid,  but  there  may  be  fat  drops  as  well,  and  fatty  crystals  have 
been  found. 

Lipaciduria  is  a  term  applied  by  von  Jaksch  to  the  condition  in  which 
there  are  volatile  fatty  acids  in  the  urine,  such  as  acetic,  butyric,  formic, 
and  propionic  acid. 

Acetonuria. — Von  Jaksch  distinguishes  the  following  forms  of  patho- 
logical acetonuria:  The  febrile,  the  diabetic,  the  acetonuria  with  certain 
forms  of  cancer,  the  form  associated  with  inanition,  acetonuria  in  psychoses, 
and  the  acetonuria  which  results  from  auto-intoxication.  It  is  doubtful, 
however,  whether  the  symptoms  in  these  are  really  due  to  the  acetone.  It 
may  be  the  substances  from  which  this  is  formed,  particularly  the  diacetic 
acid  or  the  /3-oxy-butyric  acid.  The  odor  of  the  acetone  may  be  marked 
in  the  breath  and  evident  in  the  urine.  The  tests  have  been  given  in  the 
section  on  diabetes. 

Diacetic  acid  is  probably  never  present  in  the  urine  in  health.  With 
a  solution  of  ferric  chloride  it  gives  a  Burgundy-red  color.  A  similar  re- 
action is  given  by  acetic,  formic,  and  oxy-butyric  acids;  it  may  be  present 
in  the  urine  of  patients  who  are  taking  antipyrin,  thallin,  and  the  sali- 
cylates. Hammarsten  states  that  if  the  reaction  be  due  to  the  presence  of 
diacetic  acid,  it  will  not  be  obtained  in  carrying  out  the  test  with  a  second 
specimen  of  urine  which  has  been  boiled  and  allowed  to  cool.  The  ethereal 
extract  of  the  acidulated  urine  gives  the  reaction  if  diacetic  acid  be  present, 
whereas  the  other  substances  which  may  be  mistaken  for  diacetic  acid  are 
insoluble  in  ether. 


URJEMIA.  865 

/8-oxy-butyric  acid  is  believed  by  Stadelmann,  Kiilz,  and  Minkowski  to 
be  the  cause  of  diabetic  coma.  It  is  a  product  of  the  decomposition  of  the 
tissue  albumins,  and  from  it  diacetic  acid  is  readily  formed  by  oxidation. 
Its  tests  have  already  been  given. 

Alcaptonuria. — Aromatic  compounds  occur  after  the  administration  of 
carbolic  acid  or  gallic  acid,  and  the  urine  on  exposure  to  air  becomes  dark. 
In  carboluria  the  substance  causing  the  black  color  is  known  as  hydro- 
chinon.  Many  years  ago  Boedeker  met  with  cases  in  which  the  urine  be- 
came dark,  owing  to  the  presence  of  an  aromatic  compound  which  he  called 
alcapton.  The  urine  is  clear  on  passing,  and  then  darkens  on  exposure  to 
the  air,  or  on  the  addition  of  liquor  potassse.  Baumann  isolated  a  substance 
from  the  urine  of  a  case  of  alcaptonuria,  to  which  he  gave  the  name  of 
homogentisinic  acid.  Later  observers  have  isolated  this  substance  in  other 
cases.  Kirk  believed  the  reaction  in  his  case  was  due  to  uroleucinic  acid. 
In  several  instances  more  than  one  member  of  a  family  has  shown  this 
urinary  change.  The  substance  is  apparently  without  clinical  significance 
except  in  so  far  as  it  is  capable  of  reducing  the  Fehling  solution,  and  may 
be  mistaken  for  sugar.  Alcapton  urine  may  be  distinguished  from  diabetic 
urine  from  the  fact  that  it  does  not  ferment  nor  reduce  alkaline  bismuth 
solutions,  and  because  it  is  optically  inactive  (see  Alcaptonuria,  by  T.  B. 
Futcher,  New  York  Med.  Jour.,  189^,  ii). 

Choluria  and  glycosuria  have  already  been  considered  under  jaundice 
and  diabetes. 

HcematoporpJiyrin  occasionally  occurs  in  the  urine.  It  was  first  recog- 
nized by  Hoppe-Seyler.  Nencki  and  Sieler  determined  its  exact  formula, 
and  the  former  demonstrated  that  the  only  chemical  difference  between 
hsematin  and  hgematoporphyrin  is  that  the  latter  is  simply  h^matin  free 
from  iron.  It  has  been  found  in  the  urine  in  pulmonary  tuberculosis, 
pleurisy  with  effusion,  acute  rheumatism,  lead  poisoning,  and  intestinal 
hsemorrhages.  This  pigment  has  been  found  very  frequently  after  the  ad- 
ministration of  sulphonal,  and  sometimes  imparts  a  very  dark  color  to  the 
urine. 

V.    UR>EMIA. 

Definition. — A  toxsemia  developing  in  the  course  of  nephritis  or  in 
conditions  associated  with  anuria.  The  nature  of  the  poison  or  poisons  is 
as  yet  unknown,  whether  they  are  the  retained  normal  products  or  the 
products  of  an  abnormal  metabolism. 

Theories  of  Uraemia. — The  view  most  widely  held  is  that  uraemia 
is  due  to  the  accumulation  in  the  blood  of  excrementitious  material — body 
poisons — which  should  be  thrown  off  by  the  kidneys.  "  If,  however,  from 
any  cause,  these  organs  make  default,  or  if  there  be  any  prolonged  obstruc- 
tion to  the  outflow  of  urine,  accumulation  of  some  or  of  all  the  poisons 
takes  place,  and  the  characteristic  symptoms  are  manifested,  but  the  ac- 
cumulation may  be  very  slow  and  the  earlier  symptoms,  corresponding  to 
the  comparatively  small  dose  of  poison,  may  be  very  slight;  yet  they  are  in 
kind,  though  not  in  degree,  as  indicative  of  uraemia  as  are  the  more  alarm- 


866  DISEASES  OF  THE  KIDNEYS. 

ing,  which  appear  toward  the  end,  and  to  which  alone  the  name  uraemia  is 
often  given  "  (Carter).  Herter  and  others  have  shown  that  the  toxicity  of 
the  blood-serum  in  ursemic  states  is  increased.  The  part  played  by  urea 
itself,  by  the  salts,  and  by  the  nitrogenous  extractives  has  not  been  deter- 
mined. 

Another  view  is  that  uraemia  depends  on  the  products  of  an  abnormal 
metabolism.  Brown-Sequard  suggested  that  the  kidney  has  an  internal 
secretion,  and  it  is  urged  that  the  symptoms  of  uraemia  are  due  to  its  dis- 
turbance. Bradford's  experiments  show  that  the  kidneys  do  influence  pro- 
foundly the  metabolism  of  the  tissues  of  the  body,  particularly  of  the  mus- 
cles. If  more  than  one  third  of  the  total  kidney  weight  be  removed,  there 
is  an  extraordinary  increase  in  the  production  of  urea  and  of  the  nitrogenous 
bodies  of  the  creatin  class.  He  favors  this  view,  but  acknowledges  that  we 
are  still  ignorant  of  the  nature  of  the  poison.  From  a  careful  study  of  the 
question,  Hughes  and  Carter  concluded  that  the  poison  was  an  albuminous 
product  quite  different  from  anything  in  normal  urine.  In  Bradford's  Goul- 
stonian  Lectures  (1898)  will  be  found  a  full  discussion  of  the  question. 

Traube  believed  that  the  symptoms  of  uraemia,  particularly  the  coma 
and  convulsions,  were  due  to  localized  oedema  of  the  brain. 

Symptoms. — Clinically,  we  may  recognize  latent,  acute,  and  chronic 
forms  of  uraemia.  The  latent  form  has  been  considered  under  the  section 
on  anuria.  Acute  ursemia  may  develop  in  any  form  of  nephritis.  It  is 
more  common  in  the  post-febrile  varieties.  Bradford  thinks  that  it  is  spe- 
cially associated  with  a  form  of  contracted  white  kidney  in  young  subjects. 
Chronic  forms  of  uraemia  are  more  frequent  in  the  arterio-sclerotic  and 
granular  kidney.  For  convenience  the  symptoms  of  uraemia  may  be  de- 
scribed under  cerebral,  dyspnoeic,  and  gastro-intestinal  manifestations. 

Among  the  cerebral  symptoms  of  uraemia  may  be  described: 

(a)  Mania. — This  may  come  on  abruptly  in  an  individual  who  has 
shown  no  previous  indications  of  mental  trouble,  and  who  may  not  be 
known  to  have  Bright's  disease.  In  a  remarkable  case  of  this  kind  which 
came  under  my  observation  the  patient  became  suddenly  maniacal  and  died 
in  six  days.  More  commonly  the  delirium  is  less  violent,  but  the  patient 
is  noisy,  talkative,  restless,  and  sleepless. 

(b)  Delusional  Insanity  (Folie  Briglitique). — Cases  are  by  no  means  un- 
common, and  excellent  clinical  reports  have  been  issued  on  the  subject 
from  several  of  the  asylums  of  this  country,  particularly  by  Bremer,  Chris- 
tian, and  Alice  Bennett.  Delusions  of  persecution  are  common.  One  of 
my  cases  committed  suicide  by  Jumping  out  of  a  window.  The  condition 
is  of  interest  medico-legally  because  of  its  bearing  on  testamentary  capacity. 
Profound  melancholia  may  also  supervene. 

(c)  Convulsions. — These  may  come  on  unexpectedly  or  be  preceded  by 
pain  in  the  head  and  restlessness.  The  attacks  may  be  general  and  iden- 
tical with  those  of  ordinary  epilepsy,  though  the  initial  cry  may  not  be 
present.  The  fits  may  recur  rapidly,  and  in  the  interval  the  patient  is 
usually  unconscious.  Sometimes  the  temperature  is  elevated,  but  more 
frequently  it  is  depressed,  and  may  sink  rapidly  after  the  attack.  Local 
or  Jacksonian  epilepsy  may  occur  in  most  characteristic  form  in  uraemia. 


UREMIA.  867 

A  remarkable  sequence  of  the  convulsions  is  blindness — urcemic  amaurosis 
— which  may  persist  for  several  days.  This,  however,  may  occur  apart  from 
the  convulsions.  It  usually  passes  off  in  a  day  or  two.  There  are,  as  a  rule, 
no  ophthalmoscopic  changes.  Sometimes  urasmic  deafness  supervenes,  and 
is  probably  also  a  cerebral  manifestation.  It  may  also  occur  in  connection 
with  persistent  headache,  nausea,  and  other  gastric  symptoms. 

{d)  Coma. — Unconsciousness  invariably  accompanies  the  general  con- 
vulsions, but  a  coma  may  develop  gradually  without  any  convulsive  seizures. 
Frequently  it  is  preceded  by  headache,  and  the  patient  gradually  becomes 
dull  and  apathetic.  In  these  cases  there  may  have  been  no  previous  indi- 
cations of  renal  disease,  and  unless  the  urine  is  examined  the  nature  of  the 
case  may  be  overlooked.  Twitchings  of  the  muscles  occur,  particularly  in 
the  face  and  hands,  but  there  are  many  cases  of  coma  in  which  the  muscles 
are  not  involved.  In  some  of  these  cases  a  condition  of  torpor  persists  for 
weeks  or  even  months.  The  tongue  is  usually  furred  and  the  breath  very 
foul  and  heavy. 

(e)  Local  Palsies. — In  the  course  of  chronic  Bright's  disease  hemiplegia 
or  monoplegia  may  come  on  spontaneously  or  follow  a  convulsion,  and  post 
mortem  no  gross  lesions  of  the  brain  be  found,  but  only  a  localized  or  dif- 
fused oedema.  These  cases,  which  are  not  very  uncommon,  may  simulate 
almost  every  form  of  organic  paralysis  of  cerebral  origin. 

(/)  Of  other  cerebral  symptoms,  headache  is  important.  It  is  most 
often  occipital  and  extends  to  the  neck.  It  may  be  an  early  feature  and 
associated  with  giddiness.  Other  nervous  symptoms  of  uremia  are  intense 
itching  of  the  skin,  numbness  and  tingling  in  the  fingers,  and  cramps  in 
the  muscles  of  the  calves,  particularly  at  night.  An  erythema  may  be 
present. 

Urcemic  dyspnoea  is  classified  by  Palmer  Howard  as  follows:  (1)  Con- 
tinuous dyspnoea;  (2)  paroxysmal  dyspnoea;  (3)  both  types  alternating;  and 
(4)  Cheyne-Stokes  breathing.  The  attacks  of  dyspnoea  are  most  commonly 
nocturnal;  the  patient  may  sit  up,  gasp  for  breath,  and  evince  as  much 
distress  as  in  true  asthma.  Occasionally  the  breathing  is  noisy  and  stridu- 
lous.  The  Cheyne-Stokes  type  may  persist  for  weeks,  and  is  not  necessarily 
associated  with  coma.  I  have  seen  it  in  a  man  who  travelled  over  a  hun- 
dred miles  to  consult  a  physician.  In  another  instance  a  patient,  up  and 
about,  could  when  at  meals  feed  himself  only  in  the  apnoea  period.  Though 
usually  of  serious  omen  and  occurring  with  coma  and  other  symptoms,  re- 
covery may  follow  even  after  persistence  for  weeks  or  even  months. 

The  gastro-intestinal  manifestations  of  uraemia  often  set  in  with  abrupt- 
ness. Uncontrollable  vomiting  may  come  on  and  its  cause  be  quite  un- 
recognizable. A  young  married  woman  was  admitted  to  my  wards  in  the 
Montreal  General  Hospital  with  persistent  vomiting  of  four  or  five  days' 
duration.  The  urine  was  slightly  albuminous,  but  she  had  none  of  the 
usual  signs  of  uraemia,  and  the  case  was  not  regarded  as  one  of  Bright's 
disease.  The  vomiting  persisted  and  caused  death.  The  post  mortem 
showed  extensive  sclerosis  of  both  kidneys.  The  attacks  may  be  preceded 
by  nausea  and  may  be  associated  with  diarrhoea.  In  some  instances  the 
diarrhoea  may  come  on  without  the  vomiting;  sometimes  it  is  profuse  and 


868  DISEASES  OF  THE  KIDNEYS. 

associated  with  an  intense  catarrhal  or  even  diphtheritic  inflammation  of 
the  colon. 

A  special  uremic  stomatitis  has  been  described  (Barie)  in  which  the 
mucosa  of  the  lips,  gums,  and  tongue  is  swollen  and  erythematous.  The 
saliva  may  be  increased,  and  there  is  difficulty  in  swallowing  and  in  mastica- 
tion. The  tongue  is  usually  very  foul  and  the  breath  heavy  and  fetid.  A 
cutaneous  erythema  may  occur  and  a  remarkable  urea  "  frost  "  on  the  skin. 

Fever  is  not  uncommon  in  ursemic  states,  and  may  occur  with  the  acute 
nephritis,  with  the  complications,  and  as  a  manifestation  of  the  uraemia 
itself  (Stengel). 

Very  many  patients  with  chronic  ursemia  succumb  to  what  I  have  called 
terminal  infections — acute  peritonitis,  pericarditis,  pleurisy,  meningitis,  or 
endocarditis. 

Diagnosis. — Herter  calls  attention  to  the  value  of  the  clinical  deter- 
mination of  the  urea  in  the  blood  (for  which  purpose  only  a  few  cubic  centi- 
metres are  required)  as  an  index  of  the  degree  of  renal  inadequacy.  So  far 
as  the  urine  is  concerned,  the  volume  and  specific  gravity  indicate  the  total 
solids,  and  the  determination  of  the  urea  itself  in  the  urine  gives  no  indica- 
tion of  the  quantity  in  the  blood.    Uremia  may  be  confounded  with: 

(a)  Cerebral  lesions,  such  as  haemorrhage,  meningitis,  or  even  tumor. 
In  apoplexy,  which  is  so  commonly  associated  with  kidney  disease  and 
stiff  arteries,  the  sudden  loss  of  consciousness,  particularly  if  with  convul- 
sions, may  simulate  a  urgemic  attack;  but  the  mode  of  onset,  the  existence 
of  complete  hemiplegia,  with  conjugate  deviation  of  the  eyes,  suggest 
haemorrhage.  As  already  noted,  there  are  cases  of  urgemic  hemiplegia  or 
monoplegia  which  cannot  be  separated  from  those  of  organic  lesion  and 
which  post  mortem  show  no  trace  of  coarse  disease  of  the  brain.  I  know 
of  an  instance  in  which  a  consultation  was  held  upon  the  propriety  of  opera- 
tion in  a  case  of  hemiplegia  believed  to  be  due  to  subdural  haemorrhage 
which  post  mortem  was  shown  to  be  ursemic.  Indeed,  in  some  of  these  cases 
it  is  quite  impossible  to  distinguish  between  the  two  conditions.  So,  too, 
cases  of  meningitis,  in  a  condition  of  deep  coma,  with  perhaps  slight  fever, 
furred  tongue,  but  without  localizing  symptoms,  may  readily  be  confounded 
with  uraemia. 

(h)  With  certain  infectious  diseases.  Uremia  may  persist  for  weeks 
or  months  and  the  patient  lies  in  a  condition  of  torpor  or  even  uncon- 
sciousness, with  a  heavily  coated,  perhaps  dry,  tongue,  muscular  twitchings, 
a  rapid  feeble  pulse,  with  slight  fever.  This  state  not  unnaturally  suggests 
the  existence  of  one  of  the  infectious  diseases.  Cases  of  the  kind  are  not 
uncommon,  and  I  have  known  them  to  be  mistaken  for  typhoid  fever  and 
for  miliary  tuberculosis. 

(c)  Uraemic  coma  may  be  confounded  with  poisoning  by  alcohol  or 
opium.  In  opium  poisoning  the  pupils  are  contracted;  in  alcoholism  they 
are  more  commonly  dilated.  In  uraemia  they  are  not  constant;  they  may 
be  either  widely  dilated  or  of  medium  size.  The  examination  of  the  eye- 
ground  should  be  made  to  determine  the  presence  or  absence  of  albuminuric 
retinitis.  The  urine  should  be  drawn  off  and  examined.  The  odor  of  the 
breath  sometimes  gives  an  important  hint. 


ACUTE  BRIGHT'S  DISEASE.  869 

The  condition  of  the  heart  and  arteries  should  also  be  taken  into  ac- 
count. Sudden  urasmic  coma  is  more  common  in  the  chronic  interstitial 
nephritis.  The  character  of  the  delirium  in  alcoholism  is  sometimes  im- 
portant, and  the  coma  is  not  so  deep  as  in  uraemia  or  opium  poisoning. 
It  may  for  a  time  be  impossible  to  determine  whether  the  condition  is 
due  to  uraemia,  profound  alcoholism,  or  hsemorrhage  into  the  pons  Varolii. 

And  lastly,  in  connection  with  sudden  coma,  it  is  to  be  remembered 
that  insensibility  may  occur  after  prolonged  muscular  exertion,  as  after 
running  a  ten-mile  race.  In  some  instances  unconsciousness  has  come  on 
rapidly  with  stertorous  breathing  and  dilated  pupils.  Cases  have  occurred 
under  conditions  in  which  sun-stroke  could  be  excluded;  and  Poore,  who 
reports  a  case  in  the  Lancet  (1894),  considers  that  the  condition  is  due  to 
the  too  rapid  accumulation  of  waste  products  in  the  blood,  and  to  hyper- 
pyrexia from  suspension  of  sweating. 

The  treatment  will  be  considered  under  Chronic  Bright's  Disease. 


VI.    ACUTE    BRIGHT'S    DISEASE. 

Definition. — Acute  diffuse  nephritis,  due  to  the  action  of  cold  or  of 
toxic  agents  upon  the  kidneys. 

In  all  instances  changes  exist  in  the  epithelial,  vascular,  and  inter- 
tubular  tissues,  which  vary  in  intensity  in  different  forms;  hence  writers 
have  described  a  tubular,  a  glomerular,  and  an  acute  interstitial  nephritis. 
Delafield  recognizes  acute  exudative  and  acute  productive  forms,  the  latter 
characterized  by  proliferation  of  the  connective-tissue  stroma  and  of  the 
cells  of  the  Malpighian  tufts. 

Etiolog^y. — The  following  are  the  principal  causes  of  acute  nephritis: 

(1)  Cold.  Exposure  to  cold  and  wet  is  one  of  the  most  common  causes. 
It  is  particularly  prone  to  follow  exposure  after  a  drinking-bout. 

(2)  The  poisons  of  the  specific  fevers,  particularly  scarlet  fever,  less 
commonly  typhoid  fever,  measles,  diphtheria,  small-pox,  chicken-pox,  ma- 
laria, cholera,  yellow  fever,  meningitis,  and,  very  rarely,  dysentery.  Acute 
nephritis  may  be  associated  with  syphilis  and  with  acute  tuberculosis.  It 
may  also  occur  in  septicaemia  and  in  acute  tonsillitis.  In  exudative  ery- 
thema and  the  allied  purpuric  affections  acute  nephritis  is  not  uncommon. 
Among  1,832  cases  of  malaria  at  the  Johns  Hopkins  Hospital  there  were 
26  of  nephritis  (Thayer). 

(3)  Toxic  agents,  such  as  turpentine,  cantharides,  potassium  chlorate, 
and  carbolic  acid  may  cause  an  acute  congestion  which  sometimes  ter- 
minates in  nephritis.    Alcohol  probably  never  excites  an  acute  nephritis. 

(4)  Pregnancy,  in  which  the  condition  is  thought  by  some  to  result 
from  compression  of  the  renal  veins,  although  this  is  not  yet  finally  settled. 
The  condition  may  in  reality  be  due  to  toxic  products  as  yet  undetermined. 

(5)  Acute  nephritis  occurs  occasionally  in  connection  with  extensive 
lesions  of  the  skin,  as  in  burns  or  in  chronic  skin-diseases,  and  also  after 
trauma.    It  may  follow  operations  on  the  kidney. 

Morbid  Anatomy. — The  kidneys  may  present  to  the  naked  eye  in 
mild  eases  no  evident  alterations.    When  seen  early  in  more  severe  forms 


870  DISEASES  OP  THE  KIDNEYS. 

the  organs  are  congested,  swollen,  dark,  and  on  section  may  drip  blood. 
In  other  instances  the  surface  is  pale  and  mottled,  the  capsule  strips  off 
readily,  and  the  cortex  is  swollen,  turbid,  and  of  a  grayish-red  color,  while 
the  pyramids  have  an  intense  beefy-red  tint.  The  glomeruli  in  some  in- 
stances stand  out  plainly,  being  deeply  swollen  and  congested;  in  other 
instances  they  are  pale. 

The  histology  may  be  thus  summarized:  (a)  Glomerular  changes.  In 
a  majority  of  the  cases  of  nephritis  due  to  toxic  agents,  which  reach  the 
kidney  through  the  blood-vessels,  the  tufts  suffer  first,  and  there  is  either 
an  acute  intracapillary  glomerulitis,  in  which  the  capillaries  become  filled 
with  cells  and  thrombi,  or  involvement  of  the  epithelium  of  the  tuft  and 
of  Bowman's  capsule,  the  cavity  of  which  contains  leucocytes  and  red 
blood-corpuscles.  Hyaline  degeneration  of  the  contents  and  of  the  walls 
of  the  capillaries  of  the  tuft  is  an  extremely  common  event.  These  pro- 
cesses are  perhaps  best  marked  in  scarlatinal  nephritis.  There  may  be 
proliferation  about  Bowman's  capsule.  These  changes  interfere  with  the 
circulation  in  the  tufts  and  seriously  influence  the  nutrition  of  the  tubular 
structures  beyond  them. 

(h)  The  alterations  in  the  tubular  epithelium  consist  in  cloudy  swelling, 
fatty  change,  and  hyaline  degeneration.  In  the  convoluted  tubules,  the 
accumulation  of  altered  cells  with  leucocytes  and  blood-corpuscles  causes 
the  enlargement  and  swelling  of  the  organ.  The  epithelial  cells  lose  their 
striation,  the  nuclei  are  obscured,  and  hyaline  droplets  often  accumulate 
in  them. 

(c)  Interstitial  changes.  In  the  milder  forms  a  simple  inflammatory 
exudate — serum  mixed  with  leucocytes  and  red  blood-corpuscles — exists 
between  the  tubules.  In  severer  eases  areas  of  small-celled  infiltration 
occur  about  the  capsules  and  between  the  convoluted  tubes.  These  changes 
may  be  widespread  and  uniform  throughout  the  organs  or  more  intense 
in  certain  regions. 

Councilman  has  described  an  acute  interstitial  nephritis  occurring  chiefly 
in  children  after  fevers,  characterized  by  the  presence  of  cells  similar  to 
those  described  by  Unna  as  plasma  cells.  He  thinks  that  these  cells  are 
formed  in  other  organs,  chiefly  the  spleen  and  bone  marrow,  and  are  car- 
ried to  the  kidneys  in  the  blood  current. 

Symptoms. — The  onset  is  usually  sudden,  and  when  the  nephritis 
follows  cold,  dropsy  may  be  noticed  within  twenty-four  hours.  After  fevers 
the  onset  is  less  abrupt,  but  the  patient  gradually  becomes  pale  and  a  pufli- 
ness  of  the  face  or  swelling  of  the  ankles  is  first  noticed.  In  children  there 
may  at  the  outset  be  convulsions.  Chilliness  or  rigors  initiate  the  attack 
in  a  limited  number  of  cases.  Pain  in  the  back,  nausea,  and  vomiting  may 
be  pTcsent.  The  fever  is  variable.  Many  cases  in  adults  have  no  rise  in 
temperature.  In  young  children  with  nephritis  from  cold  or  scarlet  fever 
the  temperature  may,  for  a  few  days,  range  from  101°  to  103°. 

The  most  characteristic  symptoms  are  the  urinary  changes.  There  may 
at  first  be  suppression;  more  commonly  the  urine  is  scanty,  highly  colored, 
and  contains  l3lood,  albumin,  and  tube-casts.  The  quantity  is  reduced  and 
only  4  or  5  ounces  may  be  passed  in  the  twenty-four  hours;  the  specific 


ACUTE  BRIGHT'S  DISEASE.  871 

gravity  is  high — 1.035,  or  even  more;  the  color  varies  from  a  smoky  to  a 
deep  porter  color,  but  is  seldom  bright  red.  On  standing  there  is  a  heavy 
deposit;  microscopically  there  are  blood-corpuscles,  epithelium  from  the 
urinary  passages,  and  hyaline,  blood,  and  epithelial  tube-casts.  The  albu- 
min is  abundant,  forming  a  curdy,  thick  precipitate.  The  total  excretion 
of  urea  is  reduced,  though  the  percentage  is  high. 

Anaemia  is  an  early  and  marked  symptom.  In  cases  of  extensive  dropsy, 
effusion  may  take  place  into  the  pleurae  and  peritonaeum.  There  are  cases 
of  scarlatinal  nephritis  in  which  the  dropsy  of  the  extremities  is  trivial  and 
effusion  into  the  pleuree  extensive.  The  lungs  may  become  oedematous.  In 
rare  cases  there  is  oedema  of  the  glottis.  Epistaxis  may  occur  or  cutaneous 
ecchymoses  may  develop  in  the  course  of  the  disease. 

The  pulse  may  be  hard,  the  tension  increased,  and  the  second  sound 
in  the  aortic  area  accentuated.  Occasionally  dilatation  of  the  heart  comes 
on  rapidly  and  may  cause  sudden  death  (Goodhart).  The  skin  is  dry  and 
it  may  be  difficult  to  induce  sweating. 

Uraemic  symptoms  develop  in  a  limited  number  of  cases.  They  may 
occur  at  the  onset  with  suppression,  more  commonly  later  in  the  disease. 
Ocular  changes  are  not  so  common  in  acute  as  in  chronic  Bright's  disease, 
but  hsemorrhagic  retinitis  may  occur  and  occasionally  papillitis. 

The  course  of  acute  Bright's  disease  varies  considerably.  The  descrip- 
tion just  given  is  of  the  form  which  most  commonly  follows  cold  or  scarlet 
fever.  In  many  of  the  febrile  cases  dropsy  is  not  a  prominent  symptom, 
and  the  diagnosis  rests  rather  with  the  examination  of  the  urine.  More- 
over, the  condition  may  be  transient  and  less  serious.  In  other  cases,  as 
in  the  acute  nephritis  of  typhoid  fever,  there  may  be  haematuria  and  pro- 
nounced signs  of  interference  with  the  renal  function.  The  most  intense 
acute  nephritis  may  exist  without  anasarca. 

In  scarlatinal  nephritis,  in  which  the  glomeruli  are  most  seriously  af- 
fected, suppression  of  the  urine  may  be  an  early  symptom,  the  dropsy  is 
apt  to  be  extreme,  and  uraemic  manifestations  are  common.  Acute  Bright's 
disease  in  children,  however,  may  set  in  very  insidiously  and  be  associated 
with  transient  or  slight  oedema,  and  the  symptoms  may  point  rather  to 
affection  of  the  digestive  system  or  to  brain-disease. 

Diagnosis. — It  is  very  important  to  bear  in  mind  that  the  most  seri- 
ous involvement  of  the  kidneys  may  be  manifested  only  by  slight  oedema 
of  the  feet  or  puffiness  of  the  eyelids,  without  impairment  of  the  general 
health.  The  first  indication  of  trouble  may  be  a  urasmic  convulsion.  This 
is  particularly  the  case  in  the  acute  nephritis  of  pregnancy,  and  it  is  a  good 
rule  for  the  practitioner,  when  engaged  to  attend  a  case,  invariably  to  ask 
that  during  the  seventh  and  eighth  months  the  urine  should  occasionally 
be  sent  for  examination. 

In  nephritis  from  cold  and  in  scarlet  fever  the  symptoms  are  usually 
marked  and  the  diagnosis  is  rarely  in  doubt.  As  already  mentioned,  every 
case  in  which  albumin  is  present  must  not  be  called  acute  Bright's  disease, 
not  even  if  tube-casts  be  present.  Thus  the  common  febrile  albuminuria, 
although  it  represents  the  first  link  in  the  chain  of  events  leading  to  acute 
Bright's  disease,  should  not  be  placed  in  the  same  category. 


872  DISEASES  OF  THE  KIDNEYS. 

There  are  occasional  cases  of  acute  Bright's  disease  with  anasarca,  in 
which  albumin  is  either  absent  or  present  only  as  a  trace.  This  is  a  rare 
condition.  Tube-casts  are  usually  found,  and  the  absence  of  albumin  is 
rarely  permanent.    The  urine  may  be  reduced  in  amount. 

The  character  of  the  casts  is  of  use  in  the  diagnosis  of  the  form  of 
Bright's  disease,  but  scarcely  of  such  extreme  value  as  has  been  stated. 
Thus,  the  hyaline  and  granular  casts  are  common  to  all  varieties.  The 
blood  and  epithelial  casts,  particularly  those  made  up  of  leucocytes,  are 
most  common  in  the  acute  cases. 

Prognosis. — The  outlook  varies  somewhat  with  the  cause  of  the  dis- 
ease. Eecoveries  in  the  form  following  exposure  to  cold  are  much  more 
frequent  than  after  scarlatinal  nephritis.  In  young  children  the  mortality 
is  high,  amounting  to  at  least  one  third  of  the  cases.  Serious  symptoms 
are  low  arterial  tension,  the  occurrence  of  uraemia,  and  effusion  into  the 
serous  sacs.  The  persistence  of  the  dropsy  after  the  first  month,  intense 
pallor,  and  a  large  amount  of  albumin  indicate  the  possibility  of  the  dis- 
ease becoming  chronic.  For  some  months  after  the  disappearance  of  the 
dropsy  there  may  be  traces  of  albumin  and  a  few  tube-casts. 

In  a  week  or  ten  days,  in  a  case  of  scarlatinal  nephritis,  if  the  progress 
is  favorable,  the  dropsy  diminishes,  the  urine  increases,  the  albumin  lessens, 
and  by  the  end  of  a  month  the  dropsy  has  disappeared  and  the  urine  is 
nearly  free.  In  very  young  children  the  course  may  be  rapid,  and  I  have 
-known  the  urine  to  be  free  from  albumin  in  the  fourth  week.  Other  cases 
are  more  insidious,  and  though  the  dropsy  may  disappear,  the  albumin  per- 
sists in  the  urine,  the  angemia  is  marked,  and  the  condition  becomes  chronic, 
or,  after  several  recurrences  of  the  dropsy,  improves  and  complete  recovery 
takes  place. 

Treatment. — The  patient  should  be  in  bed  and  there  remain  until 
all  traces  of  the  disease  have  disappeared.  As  sweating  plays  such  an  im- 
portant part  in  the  treatment,  it  is  well,  if  possible,  to  accustom  the  patient 
to  blankets.    He  shou.ld  also  be  clad  in  thin  Canton  flannel. 

The  diet  should  consist  of  milk  or  butter-milk,  gruels  made  of  arrow- 
root or  oat-meal,  barley  water,  and,  if  necessary,  beef  tea  and  chicken  broth. 
It  is  better,  if  possible,  to  confine  the  patient  to  a  strictly  milk  diet.  As 
convalescence  is  established,  bread  and  butter,  lettuce,  water-cress,  grapes, 
oranges,  and  other  fruits  may  be  given.  The  return  to  a  meat  diet  should 
be  gradual. 

The  patient  should  drink  freely  of  alkaline  mineral  waters,  ordinary 
water,  or  lemonade.  The  fluids  keep  the  kidneys  flushed  and  wash  out  the 
debris  from  the  tubes.  A  useful  drink  is  a  drachm  of  cream  of  tartar  in  a 
pint  of  boiling  water,  to  which  may  be  added  the  juice  of  half  a  lemon  and 
a  little  sugar.  Taken  when  cold,  this  is  a  pleasant  and  satisfactory  diluent 
drink. 

No  remedies,  so  far  as  known,  control  directly  the  changes  which  are 
going  on  in  the  kidneys.  The  indications  are:  (1)  To  give  the  excretory 
function  of  the  kidney  rest  by  utilizing  the  skin  and  the  bowels,  in  the  hope 
that  the  natural  processes  may  be  sufficient  to  effect  a  cure;  (3)  to  meet 
the  symptoms  as  they  arise. 


ACUTE  BRIGHT'S  DISEASE.  873 

In  a  case  of  scarlet  fever  it  may  occasionally  be  possible  to  avert  an 
attack,  the  premonitory  symptoms  of  which  are  marked  increase  in  the 
arterial  tension  and  the  presence  of  blood  coloring  matter  in  the  urine 
(Mahomed).  An  active  saline  cathartic  may  completely  relieve  this  con- 
dition. 

At  the  onset,  when  there  is  pain  in  the  back  or  hasmaturia,  the  Paqnelin 
cautery  or  the  dry  or  wet  cups  give  relief.  The  last  should  not  be  used 
in  children.  Warm  poultices  are  often  grateful.  In  cases  which  set  in 
with  suppression  of  urine,  these  measures  should  be  adopted,  and  in  addi- 
tion the  hot  bath  with  subsequent  pack,  copious  diluents,  and  a  free  purge. 
The  dropsy  is  best  treated  by  hydrotherapy — either  the  hot  bath,  the  wet 
pack,  or  the  hot-air  bath.  In  children  the  wet  pack  is  usually  satisfactory. 
It  is  applied  by  wringing  a  blanket  out  of  hot  water,  wrapping  the  child 
in  it,  covering  this  with  a  dry  blanket,  and  then  with  a  rubber  cloth.  In 
this  the  child  may  remain  for  an  hour.  It  may  be  repeated  daily.  In  the 
case  of  adults,  the  hot-air  bath  or  the  vapor  bath  may  be  conveniently  given 
by  allowing  the  vapor  or  air  to  pass  from  a  funnel  beneath  the  bed-clothes, 
which  are  raised  on  a  low  cradle.  More  efficient,  as  a  rule,  is  a  hot  bath  of 
from  fifteen  or  twenty  minutes,  after  which  the  patient  is  wrapped  in 
blankets.  The  sweating  produced  by  these  measures  is  usually  profuse, 
rarely  exhausting,  and  in  a  majority  of  cases  the  dropsy  can  in  this  way  be 
relieved.  There  are  some  cases,  however,  in  which  the  skin  does  not  re- 
spond to  the  baths,  and  if  the  symptoms  are  serious,  particularly  if  uraemia 
supervenes,  jaborandi  or  its  active  principle,  pilocarpine,  may  be  used. 
The  latter  may  be  given  hypodermically,  in  doses  of  from  a  sixth  to  an 
eighth  of  a  grain  in  adults,  and  from  a  twentieth  to  a  twelfth  of  a  grain  in 
children  from  two  to  ten  years. 

The  bowels  should  be  kept  open  by  a  morning  saline  purge;  in  children 
the  fluid  magnesia  is  readily  taken;  in  adults  the  sulphate  of  magnesia  may 
be  given  by  Hay's  method,  in  concentrated  form,  in  the  morning,  before 
anything  is  taken  into  the  stomach.  In  Bright's  disease  it  not  infrequently 
causes  vomiting.  The  compound  powder  of  jalap,  in  half-drachm  doses, 
or,  if  necessary,  elaterium  may  be  used.  If  the  dropsy  is  not  extreme,  the 
urine  not  very  concentrated,  and  ursemic  symptoms  are  not  present,  the 
bowels  should  be  kept  loose  without  active  purgation.  If.  these  measures 
fail  to  reduce  the  dropsy  and  it  has  become  extreme,  the  skin  may  be  punc- 
tured with  a  lancet  or  drained  by  a  small  silver  canula  (Southey's  tube), 
which  is  inserted  beneath  it.  A  fine  aspirator  needle  may  be  used,  and  the 
fluid  allowed  to  drain  through  a  piece  of  long,  narrow  rubber  tubing  into 
a  vessel  beneath  the  bed.  If  the  dyspnoea  is  marked,  owing  to  pressure  of 
fluid  in  the  pleurae,  aspiration  should  be  performed.  In  rare  instances  the 
ascites  is  extreme  and  may  require  paracentesis,  or  a  Southey's  tube  may 
be  inserted  and.  the  fluid  gradually  withdrawn.  If  urjemic  convulsions 
occur,  the  intensity  of  the  paroxysms  may  be  limited  by  the  use  of  chloro- 
form; to  an  adult  a  pilocarpine  injection  should  be  at  once  given,  and 
from  a  robust,  strong  man  20  ounces  of  l)lood  uiay  be  withdrawn.  In  chil- 
dren the  loins  may  be  dry  cupped,  the  wet  pack  used,  and  a  brisk  purgative 
given.  Bromide  of  potassium  and  chloral  sometimes  prove  useful. 
54 


874  DISEASES  OP  THE  KIDNEYS. 

Vomiting  may  be  relieved  by  ice  and  by  restricting  the  amount  of  food. 
Drop  doses  of  creasote,  iodine,  and  carbolic  acid  may  be  given.  The  dilute 
hydrocyanic  acid  with  bismuth  is  often  effectual. 

The  question  of  the  use  of  diuretics  in  acute  Bright's  disease  is  not  yet 
settled.  The  best  diuretic,  after  all,  is  water,  which  may  be  taken  freely 
with  the  citrate  of  potash  or  the  benzoate  of  soda,  salts  which  are  held  to 
favor  the  conversion  of  the  urates  into  less  irritating  and  more  easily  ex- 
creted compounds.  Digitalis  and  strophanthus  are  useful  diuretics,  and 
may  be  employed  without  risk  when  the  arterial  tension  is  low  and  the  car- 
diac impulse  is  not  forcible.  I  have  never  seen  any  injurious  effects  from 
their  employment  after  the  early  symptoms  had  lessened  in  intensity. 

For  the  persistent  albuminuria,  I  agree  with  Eoberts  and  Eosenstein 
that  we  have  no  remedy  of  the  slightest  value.  Nothing  indicates  more 
clearly  our  helplessness  in  controlling  kidney  metabolism  than  inability  to 
meet  this  common  symptom.  Astringents,  alkalies,  nitroglycerin,  and  mer- 
cury have  been  recommended. 

For  the  anaemia  always  associated  with  acute  Bright's  disease  iron  should 
be  employed.  It  should  not  be  given  until  the  acute  symptoms  have  sub- 
sided. In  the  adult  it  may  be  used  in  the  form  of  the  perchloride  in  in- 
creasing doses,  as  convalescence  proceeds.  In  children,  the  syrup  of  the 
iodide  of  iron  or  the  syrup  of  the  phosphate  of  iron  are  better  preparations. 
Tyson  has  recently  urged  caution  in  the  too  free  use  of  iron  in  kidney 
disease.  The  dilatation  of  the  heart  is  best  treated  with  digitalis,  strophan- 
thus, and  strychnia. 

In  the  convalescence  from  acute  Bright's  disease,  care  should  be  taken 
to  guard  the  patient  against  cold.  The  diet  should  still  consist  chiefly  of 
milk  and  a  return  to  mixed  food  should  be  gradual.  A  change  of  air  is 
often  beneficial,  particularly  a  residence  in  a  warm,  equable  climate. 


VII.    CHRONIC    BRIGHT'S    DISEASE. 

Here,  too,  in  all  forms  we  deal  with  a  diffuse  process,  involving  epi- 
thelial, interstitial,  and  glomerular  tissues.  Clinically  two  groups  are  recog- 
nized— (a)  the  chronic  parenchymatous  nephritis,  which  follows  the  acute 
attack  or  comes  on  insidiously,  is  characterized  by  marked  dropsy,  and  post 
mortem  by  the  large  white  Tcidney.  In  the  later  stages  of  this  process  the 
kidney  may  be  smaller — a  condition  known  as  the  small  ivhite  Mdney;  (b) 
chronic  interstitial  nephritis,  in  which  dropsy  is  not  common  and  the  cardio- 
vascular changes  are  pronounced.  Delafield  recognizes  a  chronic  diffuse 
nephritis  with  exudation  and  a  chronic  productive  diffuse  nephritis  with- 
out exudation,  the  latter  corresponding  to  the  contracted  kidney  of  authors. 

The  amyloid  kidney  is  usually  spoken  of  as  a  variety  of  Bright's  dis- 
ease, but  in  reality  it  is  a  degeneration  which  may  accompany  any  form 
of  nephritis. 


CHRONIC  BRIGHT'S  DISEASE.  875 

Cheonic  Parenchymatous  Nephritis 

{Chronic  Desquamative  and  Chronic  Tubal  Nephritis;  Chronic  Diffuse  Nephritis  with 

Exudation). 

Etiology. — In  many  cases  the  disease  follows  the  acute  nephritis  of 
cold,  scarlet  fever,  or  pregnancy.  More  frequently  than  is  usually  stated 
the  disease  has  an  insidious  onset  and  occurs  independently  of  any  acute 
attack.  The  fevers  may  play  an  important  role  in  certain  of  these  eases. 
Eosenstein,  Bartels,  and,  in  this  country,  I.  E.  Atkinson  and  Thayer  have 
laid  special  stress  upon  malaria  as  a  cause.  Beer  and  alcohol  are  believed 
to  lead  to  this  form  of  nephritis.  In  chronic  suppuration,  syphilis,  and 
tuberculosis  the  diffuse  parench5'matous  nephritis  is  not  uncommon,  and  is 
usually  associated  with  amyloid  disease.  Males  are  rather  more  subject  to 
the  affection  than  females.  It  is  met  with  most  commonly  in  young  adults, 
and  is  by  no  means  infrequent  in  children  as  a  sequence  of  scarlatinal 
nephritis. 

Morbid  Anatomy. — Several,  varieties  of  this  form  have  been  recog- 
nized. The  most  common  is  the  large  white  kidney  of  Wilks,  in  which  the 
organ  is  enlarged,  the  capsule  is  thin,  and  the  surface  white  with  the  stellate 
veins  injected.  On  section  the  cortex  is  swollen  and  yellowish  white 
in  color,  and  often  presents  opaque  areas.  The  pyramids  may  be  deeply 
congested.  On  microscopical  examination  it  is  seen  that  the  epithelium 
is  granular  and  fatty,  and  the  tubules  of  the  cortex  are  distended,  and  con- 
tain tube-casts.  Hyaline  changes  are  also  present  in  the  epithelial  cells. 
The  glomeruli  are  large,  the  capsules  thickened,  the  capillaries  show  hyaline 
changes,  and  the  epithelium  of  the  tuft  and  of  the  capsule  is  extensively 
altered.  The  interstitial  tissue  is  everywhere  increased,  though  not  to  an 
extreme  degree. 

The  second  variety  of  this  form  results  from  the  gradual  increase  in 
the  connective  tissue  and  the  subsequent  shrinkage,  forming  what  is  called 
the  small  white  kidney  or  the  pale  granular  kidney.  It  is  doubtful  whether 
this  is  always  preceded  by  the  large  white  kidney.  Some  observers  hold 
that  it  may  be  a  primary  independent  form.  The  capsule  is  thickened  and 
the  surface  is  rough  and  granular.  On  section  the  resistance  is  greatly 
increased,  the  cortex  is  reduced  and  presents  numerous  opaque  white  or 
whitish-yellow  foci,  consisting  of  accumulations  of  fatty  epithelium  in  the 
convoluted  tubules.  This  combination  of  contracted  kidney  with  the  areas 
of  marked  fatty  degeneration  has  given  the  name  of  small  granular,  fatty 
kidney  to  this  form.  The  interstitial  changes  are  marked,  many  of  the 
glomeruli  are  destroyed,  the  degeneration  of  epithelium  in  the  convoluted 
tubules  is  widespread,  and  the  arteries  are  greatly  thickened. 

Belonging  to  this  chronic  tubal  nephritis  is  a  variety  known  as  the 
chronic  licemorrhagic  nephritis,  in  which  the  organs  are  enlarged,  yellowish 
white  in  color,  and  in  the  cortex  are  many  brownish-red  areas,  due  to  hfemor- 
rhage  into  and  about  the  tubes.  In  other  respects  the  changes  are  identical 
with  those  in  the  large  white  kidney. 

Of  changes  in  the  other  organs  the  most  marked  are  thickening  of  the 
blood-vessels  and  hypertrophy  of  the  left  heart. 


876  DISEASES   OF  THE  KIDNEYS. 

SymptoniS. — Following  an.  acute  nephritis,  tlie  disease  may  present, 
in  a  modified  way,  the  symptoms  of  that  affection.  In  many  cases  it  sets 
in  insidiously,  and  after  an  attack  of  dyspepsia  or  a  period  of  failing  health 
and  loss  of  strength  the  patient  becomes  pale,  and  puffiness  of  the  eyelids 
or  swollen  feet  are  noticed  in  the  morning. 

The  symptoms  are  as  follows:  The  urine  is,  as  a  rule,  diminished  in 
quantity,  often  scanty.  It  has  a  dirty-yellow,  sometimes  smoky,  color,  and 
is  turbid  from  the  presence  of  urates.  On  standing,  a  heavy  sediment  falls, 
in  which  are  found  numerous  tube-casts  of  various  forms  and  sizes,  hyaline, 
both  large  and  small,  epithelial,  granular,  and  fatty  casts.  Leucocytes  are 
abundant;  red  blood-corpuscles  are  frequently  met  with,  and  epithelium 
from  the  kidneys  and  pelves.  The  albumin  is  abundant  and  may  amount 
to  one  half  or  one  third  of  the  urine  boiled.  It  is  more  abundant  in  the 
urine  passed  during  the  day.  The  specific  gravity  may  be  high  in  the  early 
stages — from  1.020  to  1.025 — though  in  the  later  stages  it  is  lower.  The 
urea  is  always  reduced  in  quantity. 

Dropsy  is  a  marked  and  obstinate  symptom  of  this  form  of  Bright's 
disease.  The  face  is  pale  and  puffy,  and  in  the  morning  the  eyelids  are 
eedematous.  The  anasarca  is  general,  and  there  may  be  involvement  of  the 
serous  sacs.  In  these  chronic  cases  associated  with  large  white  kidney  there 
is  often  a  distinctive  appearance  in  the  face;  the  complexion  is  pasty,  the 
pallor  marked,  and  the  eyelids  are  oedematous.  The  dropsy  is  peculiarly 
obstinate.  Ursemic  symptoms  are  common,  though  convulsions  are  perhaps 
less  frequent  than  in  the  interstitial  nephritis. 

The  tension  of  the  pulse  is  usually  increased;  the  vessels  ultimately 
become  stiff  and  the  heart  hypertrophied,  though  there  are  instances  of 
this  form  of  nephritis  in  which  the  heart  is  not  enlarged.  The  aortic  second 
sound  is  accentuated.  Retinal  changes  though  less  frequent  than  in  the 
chronic  interstitial  nephritis,  occur  in  a  considerable  number  of  cases. 

Gastro-intestinal  symptoms  are  common.  Vomiting  is  frequently  a 
distressing  and  serious  symptom,  and  diarrhoea  may  be  profuse.  Ulcera- 
tion of  the  colon  may  occur  and  prove  fatal. 

It  is  sometimes  impossible  to  determine,  even  by  the  most  careful  ex- 
amination of  the  urine  or  by  analysis  of  the  symptoms,  whether  the  con- 
dition of  the  kidney  is  that  of  the  large  white  or  of  the  small  white  form. 
In  eases,  however,  which  have  lasted  for  several  years,  with  the  progressive 
increase  in  the  renal  connective  tissue  and  the  cardio-vascular  changes,  the 
clinical  picture  may  approach,  in  certain  respects,  that  of  the  contracted 
kidney.  The  urine  is  increased,  with  low  specific  gravity.  It  is  often  turbid, 
may  contain  traces  of  blood,  the  tube-casts  are  numerous  and  of  every 
variety  of  form  and  size,  and  the  albumin  is  abundant.  Dropsy  is  usually 
present,  though  not  so  extensive  as  in  the  early  stages. 

The  prognosis  is  extremely  grave.  In  a  case  which  has  persisted  for 
more  than  a  year  recovery  rarely  takes  place.  Death  is  caused  either  by 
great  effusion  with  oedema  of  the  lungs,  by  uraemia,  or  by  secondary  inflam- 
mation of  the  serous  membranes.  Occasionally  in  children,  even  when  the 
disease  has  persisted  for  two  years,  the  symptoms  disappear  and  recovery 
takes  place. 


CHRONIC  BRIGHT'S  DISEASE.  877 

Treatment. — Essentially  the  same  treatment  should  be  carried  out  as 
in  acute  Bright's  disease.  Milk  or  butter-milk  should  constitute  the  chief 
article  of  food.  The  dropsy  should  be  treated  by  hydrotherapy.  Iron  prep- 
arations should  be  given  when  there  is  marked  angemia.  It  is  to  be  remem- 
bered that  the  pallor  of  the  face  may  not  be  a  good  index  of  the  blood  con- 
dition. Tyson  thinks  that  the  profession  has  been  much  too  free  in  the 
use  of  iron  in  these  cases.  The  acetate  of  potash,  digitalis,  and  diuretin 
are  useful  in  increasing  the  flow  of  urine.  Basham's  mixture  given  in  plenty 
of  water  will  be  found  beneficial. 

Chkonic  Intekstitial  Nephritis 

{Contracted  Kidney;   Granular  Kidney;   Cirrhosis  of  the  Kidney;   Gouty  Kidney; 

Renal  Sclerosis). 

Sclerosis  of  the  kidney  is  met  with  (a)  as  a  sequence  of  the  large  white 
kidnej^  forming  the  so-called  pale  granular  or  secondary  contracted  kidney; 
(&)  as  an  independent  primary  affection;  (c)  as  a  sequence  of  arterio- 
sclerosis. 

Etiology. — The  primarij  form  is  chronic  from  the  outset,  and  is  a 
slow,  creeping  degeneration  of  the  kidney  substance — in  many  respects 
only  an  anticipation  of  the  gradual  changes  which  take  place  in  the  organ 
in  extreme  old  age.  In  many  cases  no  satisfactory  cause  can  be  assigned. 
In  others  there  are  hereditary  influences,  as  in  the  remarkable  family  studied 
by  Dickinson,  in  which  a  pronounced  tendency  to  chronic  Bright's  disease 
occurred  in  four  generations.  Families  in  which  the  arteries  tend  to  de- 
generate early  are  more  prone  to  interstitial  nephritis.  Syphilis  is  held 
by  some  to  be  a  cause.  Alcohol  probably  plays  an  important  part,  par- 
ticularly in  conjunction  with  other  factors.  Among  the  better  classes  in 
this  country  chronic  Bright's  disease  is  very  common,  and  is,  I  believe, 
caused  more  frequently  by  overeating  than  by  excesses  in  alcohol.  Some  be- 
lieve excessive  use  of  meat  is  injurious,  since  it  increases  the  materials  out 
of  which  uric  acid  is  formed.  By  many  a  functional  disorder  of  the  liver, 
leading  to  litheemia,  is  regarded  as  the  most  efficient  factor.  It  is  quite 
possible  that  in  persons  who  habitually  eat  and  drink  too  much  the  work 
thrown  upon  this  organ  is  excessive,  and  the  elaboration  of  certain  mate- 
rials is  so  defective  that  in  their  excretion  from  the  general  circulation  they 
irritate  the  kidneys.  Actual  gout,  which  in  England  is  a  common  cause 
of  interstitial  nephritis,  is  not  an  important  factor  here.  Lead,  as  is  well 
known,  may  produce  renal  sclerosis.  For  a  full  discussion  on  the  etiology 
and  varieties  of  renal  cirrhosis  the  student  is  referred  to  the  recent  work 
of  S.  West. 

Arteriosclerotic  Form. — By  far  the  most  common  form  in  this  country 
is  secondary  to  arterio-sclerosis.  The  kidneys  are  not  much,  if  at  all,  con- 
tracted, very  hard,  red,  and  show  patches  of  cortical  atrophy.  It  is  seen 
in  men  over  forty  who  have  worked  hard,  eaten  freely,  and  taken  alcohol 
to  excess.  They  are  conspicuous  victims  of  the  "  strenuous  life,"  the  inces- 
sant tension  of  which  is  felt  first  in  the  arteries.  After  forty  in  men  of 
this  class  nothing  is  more  salutary  than  to  experience  the  shock  brought  by 


878  DISEASES  OP  THE  KIDNEYS. 

the  knowledge  of  the  presence  of  albumin  and  tube  casts  in  the  urine. 
The  associated  cardio-yascular  changes  are  of  varying  degrees  of  intensity, 
and  upon  them,  not  upon  the  renal  condition,  does  the  outlook  depend. 

Morbid  Anatomy. — The  contracted  kidneys  are  small,  and  together 
may  weigh  no  more  than  an  ounce  and  a  half.  The  capsule  is  thick  and 
adherent;  the  surfaceof  the  organ  irregular  and  covered  with  small  nodules, 
which  have  given  to  it  the  name  of  granular  kidney.  In  stripping  off  the 
capsule,  portions  of  the  kidney  substance  are  removed.  Small  cysts  are 
frequently  seen  on  the  surface.  The  color  is  usually  reddish,  often  a  very 
dark  red.  On  section  the  substance  is  tough  and  resists  cutting;  the  cortex 
is  thin  and  may  measure  no  more  than  a  couple  of  millimetres.  The  pyra- 
mids are  less  wasted.  The  small  arteries  are  greatly  thickened  and  stand 
out  prominently.    The  fat  about  the  pelvis  is  greatly  increased. 

Microscopically  there  is  seen  a  marked  increase  in  the  connective  tissue 
and  degeneration  and  atrophy  of  the  secreting  structures,  glomerular  and 
tubal,  the  former  predominating  and  giving  the  main  characters  to  the 
lesion.    The  following  are  the  most  important  changes: 

(a)  An  increase  in  the  fibrous  elements,  widely  distributed  throughout 
the  organ,  but  more  advanced  in  the  cortex,  particularly  in  the  tissue  be- 
tween the  medullary  rays.  In  the  pyramids  the  distribution  of  new  growth 
is  less  patchy  and  more  diffuse.  In  the  early  stages  of  the  process  there 
is  a  small-celled  infiltration  between  the  tubes  and  around  the  glomeruli, 
and  finally  this  becomes  fibrillated  and  is  seen  encircling  the  tubules  and 
Bowman's  capsules,  around  the  latter  often  forming  concentric  layers. 

(&)  The  changes  in  the  glomeruli  are  striking,  and  in  advanced  cases 
a  very  considerable  number  of  them  have  undergone  complete  atrophy  and 
are  represented  as  densely  encapsulated  hyaline  structures.  The  atrophy 
is  partly  due  to  changes  in  the  capillary  walls  and  multiplication  of  cells 
between  the  loops,  partly  to  extensive  hyaline  degeneration,  and  in  part, 
no  doubt,  to  the  alterations  in  the  afferent  vessels.  The  normal  glomeruli 
usually  show  some  thickening  of  the  capsule  and  increase  in  the  cells  of  the 
tufts. 

(c)  The  tubules  show  changes  in  the  epithelium,  which  vary  a  good 
deal  in  different  localities.  Where  the  connective-tissue  growth  is  most 
advanced  they  are  greatly  atrophied  and  the  epithelium  may  be  repre- 
sented by  small  cubical  cells.  In  other  instances  the  epithelium  has  entirely 
disappeared.  On  the  other  hand,  in  the  regions  represented  by  the  projecting 
granules  the  tubules  are  usually  dilated,  and  the  epithelium  shows  hyaline, 
fatty,  and  granular  changes.  Very  many  of  them  contain  dark  masses  of 
epithelial  deiris  and  tube-casts.  In  the  interstitial  tissue  and  in  the  tubules 
there  may  be  pigmentary  changes  due  to  hgemorrhage.  The  dilatation  of 
the  tubules  may  reach  an  extreme  grade,  forming  definite  cysts. 

(d)  The  arteries  show  an  advanced  sclerosis.  The  intima  is  greatly 
thickened  and  there  are  changes  in  the  adventitia  and  in  the  media,  con- 
sisting in  increase  in  the  thickness  due  to  proliferation  of  the  connective 
tissue,  in  the  latter  coat  at  the  expense  of  the  muscular  elements. 

The  view  most  generally  entertained  at  present  is  that  the  essential 
lesion  is  in  the  secreting  tissues  of  the  tubules  and  the  glomeruli,  and  that 


CHRONIC  BRIGHT'S  DISEASE.  879 

the  connective-tissue  overgrowth  is  secondary  to  this.  Greenfield  holds  that 
the  primary  change  is  in  most  instances  in  the  glomeruli,  to  which  both  the 
degeneration  in  the  epithelium  of  the  convoluted  tubules  and  the  increase 
in  the  intertubular  connective  tissue  are  secondary. 

Associated  with  contracted  kidney  are  general  arterio-sclerosis  and  hyper- 
trophy of  the  heart.  The  changes  in  the  arteries  have  already  been  de- 
scribed in  the  section  on  arterio-sclerosis.  The  hypertrophy  of  the  heart  is 
constant,  and  the  enlargement  may  reach  an  extreme  grade.  Variations 
depend,  no  doubt,  in  part  upon  the  extent  of  the  diffuse  arterial  degenera- 
tion, but  there  are  instances  in  which  the  term  cor  hovinum  may  be  applied 
to  the  enlarged  organ.  In  such  cases  the  hypertrophy  is  not  confined  to 
the  left  ventricle,  but  involves  the  entire  heart.  The  explanation  of  this 
hypertrophy  has  been  much  discussed.  It  was  at  first  held  to  be  due  to 
the  increased  work  thrown  upon  the  organ  in  driving  the  impure  blood 
through  the  capillary  system.  Basing  his  opinion  upon  the  supposed  mus- 
cular increase  in  the  smaller  arteries,  Johnson  regarded  the  hypertrophy  as 
an  effort  to  overcome  a  sort  of  stop-cock  action  of  these  vessels,  which,  under 
the  influence  of  the  irritating  ingredient  in  the  blood,  contracted  and  in- 
creased greatly  the  peripheral  resistance.  Traube  believed  that  the  oblitera- 
tion of  a  large  number  of  capillary  territories  in  the  kidney  materially  raised 
the  arterial  pressure,  and  in  this  way  led  to  the  hypertrophy  of  the  heart; 
an  additional  factor,  he  thought,  was  the  diminished  excretion  of  water, 
which  also  heightened  the  pressure  within  the  blood-vessels. 

With  our  present  knowledge  the  most  satisfactory  explanation  is  that 
given  by  Cohnheim,  which  is  thus  clearly  and  succinctly  put  by  Fagge: 
"  He  gives  reasons  for  thinking  that  the  activity  of  the  circulation  through 
the  kidneys  at  any  moment — in  other  words,  the  state  of  the  smaller  renal 
arteries  as  regards  contraction  or  dilatation — depends  not  (as  in  the  case 
of  the  tissues  generally)  upon  the  need  of  those  organs  for  blood,  but 
solely  upon  the  amount  of  material  for  the  urinary  secretion  that  the  cir- 
culatory fluid  happens  then  to  contain.  This  suggestion  has  bearings  .  .  . 
upon  the  development  of  hypertrophy  in  one  kidney  when  the  other  has 
been  entirely  destroyed.  But  another  consequence  deducible  from  it  is 
that  when  parts  of  both  kidneys  have  undergone  atrophy,  the  blood-flow 
to  the  parts  that  remain  must,  cceteris  paribus,  be  as  great  as  it  would  have 
been  to  the  whole  of  the  organs  if  they  had  been  intact.  But  in  order  that 
such  a  quantity  of  blood  should  pass  through  the  restricted  capillary  area 
now  open  to  it,  an  excessive  pressure  must  obviously  be  necessary.  This 
can  be  brought  to  bear  only  by  the  exertion  of  more  than  the  normal  degree 
of  force  on  the  part  of  the  left  ventricle,  combined  with  the  maintenance 
of  a  corresponding  resistance  in  all  other  districts  of  the  arterial  system. 
And  so  one  can  account  at  once  for  the  high  arterial  pressure  and  for  the 
cardio-vascular  changes  that  are  secondary  to  it." 

Symptoms. — Perhaps  a  majority  of  the  cases  are  latent,  and  are  not 
recognized  until  the  occurrence  of  one  of  the  serious  or  fatal  complications. 
Even  an  advanced  grade  of  contracted  kidney  may  be  compatible  with  great 
mental  and  bodily  activity.  There  may  have  been  no  symptoms  whatever 
to  suggest  to  the  patient  the  existence  of  a  serious  malady.    In  other  cases 


880  DISEASES  OF  THE  KIDNEYS. 

the  general  health  is  disturbed.  The  patient  complains  of  lassitude,  is 
sleepless,  has  to  get  up  at  night  to  micturate;  the  digestion  is  disordered, 
the  tongue  is  furred;  there  are  complaints  of  headache,  failing  vision,  and 
breathlessness  on  exertion. 

So  complex  and  varied  is  the  clinical  picture  of  chronic  Bright's  disease 
that  it  will  be  best  to  consider  the  symptoms  under  the  various  systems. 

Urinary  System. — In  the  small  contracted  hidney  polyuria  is  the  rule. 
Frequently  the  patient  has  to  get  up  two  or  three  times  during  the  night 
to  empty  the  bladder,  and  there  is  increased  thirst.  It  is  for  these  symp- 
toms occasionally  that  relief  is  sought.  The  color  is  a  light  yellow,  and  the 
specific  gravity  ranges  from  1.005  to  1.012.  Persistent  low  specific  gravity 
is  one  of  the  most  constant  and  important  features  of  the  disease.  Traces 
of  albumin  are  found,  but  may  be  absent  at  times,  particularly  in  the  early 
morning  urine.  It  is  often  simply  a  slight  cloudiness,  and  may  be  apparent 
only  with  the  more  delicate  t-ests.  The  sediment  is  scanty,  and  in  it  a  few 
hyaline  or  granular  casts  are  found.  The  quantity  of  the  solid  constituents 
of  the  urine  is,  as  a  rule,  diminished,  though  in  some  instances  the  urea 
may  be  excreted  in  full  amount.  In  attacks  of  dyspepsia  or  bronchitis,  or 
in  the  later  stages  when  the  heart  fails,  the  quantity  of  albumin  may  be 
greatly  increased  and  the  urine  diminished.  Occasionally  blood  occurs 
in  the  urine,  and  there  may  even  be  hsematuria  (S.  West).  Slight  leakage, 
represented  by  the  constant  presence  of  a  few  red  cells,  may  be  present 
early  in  the  disease  and  persist  for  years.  In  the  arteriosclerotic  form  the 
quantity  of  urine  is  normal,  or  reduced  rather  than  increased;  the  specific 
gravity  is  normal  or  high,  the  color  of  the  urine  is  good,  and  there  are 
hyaline  and  finely  granular  casts.  The  amount  of  albumin  varies  greatly 
with  the  food  and  exercise,  and  is  usually  much  in  excess  of  that  seen  with 
the  contracted  kidneys. 

Circulatory  System. — The  pulse  is  hard,  the  tension  increased,  and  the 
vessel  wall,  as  a  rule,  thickened.  As  already  mentioned,  a  distinction  must 
be  made  between  increased  tension  and  thickening  of  the  arterial  wall.  The 
tension  may  be  plus  in  a  normal  vessel,  but  in  chronic  Bright's  disease  it  is 
more  common  to  have  increased  tension  in  a  stiff  artery. 

A  pulse  of  increased  tension  has  the  following  characters:  It  is  hard 
and  incompressible,  requiring  a  good  deal  of  force  to  overcome  it;  it  is  per- 
sistent, and  in  the  intervals  between  the  beats  the  vessel  feels  full  and  can 
be  rolled  beneath  the  finger.  These  characters  may  be  present  in  a  vessel 
the  walls  of  which  are  little,  if  at  all,  increased  in  thickness.  To  estimate 
the  latter  the  pulse  wave  should  be  obliterated  in  the  radial,  and  the  vessel 
wall  felt  beyond  it.  In  a  perfectly  normal  vessel  the  arterial  coats,  under 
these  circumstances,  cannot  be  differentiated  from  the  surrounding  tissue; 
whereas,  if  thickened,  the  vessel  can  be  rolled  beneath  the  finger.  Per- 
sistent high  tension  is  one  of  the  earliest  and  most  important  symptoms  of 
interstitial  nephritis.  The  cardiac  features  are  equally  important,  though 
often  less  obvious.  Hypertrophy  of  the  left  ventricle  occurs  to  overcome 
the  resistance  offered  in  the  arteries.  The  enlargement  of  the  heart  ulti- 
mately becomes  more  general.  The  apex  is  displaced  downward  and  to  the 
left;  the  impulse  is  forcible  and  may  be  heaving.    In  elderly  persons  with 


CHRONIC  BRIGHT'S  DISEASE.  881 

empliysema,  the  displacement  of  the  apex  may  not  be  evident.  The  first 
sound  at  the  apex  may  be  duplicated;  more  commonly  the  second  sound 
at  the  aortic  cartilage  is  accentuated,  a  very  characteristic  sign  of  increased 
tension.  The  sound  in  extreme  cases  may  have  a  bell-like  quality.  In  many 
cases  a  systolic  murmur  develops  at  the  apex,  probably  as  a  result  of  relative 
insufficiency.  It  may  be  loud  and  transmitted  to  the  axilla.  Finally  the 
hypertrophy  fails,  the  heart  becomes  dilated,  gallop  rhythm  is  present,  and 
the  general  condition  is  that  of  a  chronic  heart-lesion. 

Respiratory  System. — Sudden  oedema  of  the  glottis  may  occur.  Effu- 
sion into  the  pleurse  or  sudden  oedema  of  the  lungs  may  prove  fatal.  Acute 
pleurisy  and  pneumonia  are  not  uncommon.  Bronchitis  is  a  frequent  ac- 
companiment, particularly  in  the  winter.  Sudden  attacks  of  oppressed 
breathing,  particularly  at  night,  are  not  infrequent.  This  is  often  a  urgemic 
symptom,  but  is  sometimes  cardiac.  The  patient  may  sit  up  in  bed  and 
gasp  for  breath,  as  in  true  asthma.  Cheyne-Stokes  breathing  may  be  pres- 
ent, most  commonly  toward  the  close,  but  the  patient  may  be  walking  about 
and  even  attending  to  his  occupation. 

Digestive  System. — Dyspepsia  and  loss  of  appetite  are  common.  Severe 
and  uncontrollable  vomiting  may  be  the  first  symptom.  This  is  usually 
regarded  as  a  manifestation  of  uremia,  but  it  may  be  present  without  any 
other  indications,  and  I  have  known  it  to  prove  fatal  without  any  suspicion 
that  chronic  Bright's  disease  was  present.  Severe  and  even  fatal  diar- 
rhoea may  develop.  The  tongue  may  be  coated  and  the  breath  heavy  and 
urinous. 

Nervous  System. — Various  cerebral  manifestations  have  already  been 
mentioned  under  urgemia.  Headache,  sometimes  of  the  migraine  type,  may 
be  an  early  and  persistent^  feature  of  chronic  Bright's  disease.  Cerebral 
apoplexy  is  closely  related  to  interstitial  nephritis.  The  haemorrhage  may 
take  place  into  the  meninges  or  the  cerebrum.  It  is  usually  associated  with 
marked  changes  in  the  vessels.  Neuralgias,  in  various  regions,  are  not  un- 
common. 

Special  Senses. — Troubles  in  vision  may  be  the  first  symptom  of  the 
disease.  It  is  remarkable  in  how  many  cases  of  interstitial  nephritis  the 
condition  is  diagnosed  first  by  the  ophthalmic  surgeon.  The  flame-shaped 
retinal  haemorrhages  are  the  most  common.  Less  frequent  is  diffuse  retinitis 
or  papillitis.  Sudden  blindness  may  supervene  without  retinal  changes — 
uremic  amaurosis.  Diplopia  is  a  rare  event.  Eecurring  conjunctival  and 
palpebral  haemorrhages  are  fairly  common.  Auditory  troubles  are  by  no 
means  infrequent  in  chronic  Bright's  disease.  Einging  in  the  ears,  with 
dizziness,  is  not  uncommon.    Various  forms  of  deafness  may  occur. 

Skin. — CEdema  is  not  common  in  interstitial  nephritis.  Slight  puffiness 
of  the  ankles  may  be  present,  bvit  in  a  majority  of  the  cases  dropsy  does 
not  supervene.  When  extensive,  it  is  almost  always  the  result  of  gradual 
failure  of  the  hypertrophied  heart.  The  skin  is  often  dry  and  pale,  and 
sweats  are  not  common.  In  some  instances  the  sweat  may  deposit  a  white 
frost  of  urea  on  the  surface  of  the  skin.  Eczema  is  a  common  accompani- 
ment of  chronic  interstitial  nephritis.  Tingling  of  the  fingers  or  numb- 
ness and  pallor — the  dead  fingers — are  not,  as  some  suppose,  in  any  way 


882  DISEASES  OP  THE  KIDNEYS. 

peculiar  to  Bright's  disease.  Intolerable  itching  of  the  skin  may  be  pres- 
ent, and  cramps  in  the  muscles  are  by  no  means  rare. 

Haemorrhages  are  not  infrequent;  epistaxis  may  prove  serious  and  ex- 
tensive;  purpura  may  occur.  Broncho-pulmonary  hsemorrhages  are  said, 
by  some  French  writers,  to  be  common,  but  no  instance  of  it  has  come 
under  my  observation.  Ascites  is  rare  except  in  association  with  cirrhosis 
of  the  liver. 

Diagnosis. — The  autopsy  often  discloses  the  true  nature  of  the  dis- 
ease, one  of  the  many  intercurrent  affections  of  which  may  have  proved 
fatal.  The  early  stages  of  interstitial  nephritis  are  not  recognizable.  In 
a  patient  with  increased  pulse  tension  (particularly  if  the  vessel  wall  is 
sclerotic),  with  the  apex  beat  of  the  heart  dislocated  to  the  left,  the  second 
aortic  sound  ringing  and  accentuated,  the  urine  abundant  and  of  low  spe- 
cific gravity,  with  a  trace  of  albumin  and  an  occasional  hyaline  or  granular 
cast,  the  diagnosis  of  interstitial  nephritis  may  be  safely  made.  Of  all  the 
indications,  that  offered  by  the  pulse  is  the  most  important.  Persistent 
high  tension  with  thickening  of  the  arterial  wall  in  a  man  under  fifty  means 
that  serious  mischief  has  already  taken  place,  that  cardio-vaseular  changes 
are  certainly,  and  renal  most  probably,  present.  It  is  important  in  the  diag- 
nosis of  this  condition  not  to  rest  content  with  a  single  examination  of  the 
urine.  Both  the  evening  and  the  morning  secretion  should  be  studied. 
The  sediment  should  be  collected  in  a  conical  glass,  and  in  looking  for 
tube-casts  a  large  surface  should  be  examined  with  a  tolerably  low  power 
and  little  light.  The  arterio-sclerotic  kidney  may  exist  for  a  long  time 
without  the  occurrence  of  albumin,  or  the  albumin  may  be  in  very  small 
quantities.  Toward  the  end  it  is  impossible  to  differentiate  the  primary 
interstitial  nephritis  from  an  arterio-sclerotic  kidney,  nor  clinically  is  it  of 
any  special  value  so  to  do.  In  middle-aged  men,  with  very  high  tension, 
great  thickening  of  the  superficial  arteries,  and  marked  hypertrophy  of  the 
heart,  the  renal  are  more  likely  to  be  secondary  to  the  arterial  changes. 

Prognosis. — Chronic  Bright's  disease  is  an  incurable  affection,  and 
the  anatomical  conditions  on  which  it  depends  are  quite  as  much  beyond 
the  reach  of  medicines  as  wrinkled  skin  or  gray  hair.  Interstitial  nephritis, 
however,  is  compatible  with  the  enjoyment  of  life  for  many  years,  and  it  is 
now  universally  recognized  that  increased  tension,  thickening  of  the  arterial 
walls,  and  polyuria  with  a  small  quantity  of  albumin,  neither  doom  a  man 
to  death  within  a  short  time  nor  necessarily  interfere  with  the  pursuits  of 
an  active  life  so  long  as  proper  care  be  taken.  I  know  patients  Avho  have 
had  high  tension  and  a  little  albumin  in  the  urine  with  hyaline  casts  for 
ten,  twelve,  and,  in  one  instance,  fifteen  years.  Serious  indications  are  the 
development  of  uremic  symptoms,  dilatation  of  the  heart,  the  onset  of 
serous  effusions,  the  development  of  Cheyne-Stokes  breathing,  persistent 
vomiting,  and  diarrhoea. 

Treatment. — Patients  without  local  indications  or  in  whom  the  con- 
dition has  been  accidentally  discovered  should  so  regulate  their  lives  as  to 
throw  the  least  possible  strain  upon  heart,  arteries,  and  kidneys.  A  quiet 
life  without  mental  worry,  with  gentle  but  not  excessive  exercise,  and  resi- 
dence in  an  equable  climate,  should  be  recommended.     In  addition  they 


CHRONIC   BRIGHT'S  DISEASE.  883 

should  be  told  to  keep  the  bowels  regular,  the  skin  active  by  a  daily  tepid 
bath  with  friction,  and  the  urinary  secretion  free  by  drinking  daily  a  defi- 
nite amount  of  either  distilled  water  or  some  pleasant  mineral  water.  Alco- 
hol should  be  strictly  prohibited.    Tea  and  coffee  are  allowable. 

The  diet  should  be  light  and  nourishing,  and  the  patient  should  be 
warned  not  to  eat  excessively,  and  not  to  take  meat  more  than  once  a  day. 
Care  in  food  and  drink  is  probably  the  most  important  element  in  the  treat- 
ment of  these  early  cases. 

A  patient  in  good  circumstances  may  be  urged  to  go  away  during  the 
winter  months,  or,  if  necessary,  to  move  altogether  to  a  warm  equable  cli- 
mate, like  that  of  Southern  California.  There  is  no  doubt  of  the  value  in 
these  cases  of  removal  from  the  changeable,  irregular  weather  which  pre- 
vails in  the  temperate  regions  from  November  until  April. 

At  this  period  medicines  are  not  required  unless  for  certain  special 
symptoms.  Patients  derive  much  benefit  from  an  annual  visit  to  certain 
mineral  springs,  such  as  Poland,  Bedford,  Saratoga,  in  this  country,  and 
Vichy  and  others  in  Europe.  Mineral  waters  have  no  curative  influence 
upon  chronic  Bright's  disease;  they  simply  help  the  interstitial  circulation 
and  keep  the  drains  flushed.  In  this  early  stage,  when  the  patient's  con- 
dition is  good,  the  tension  not  high,  and  the  quantity  of  albumin  small, 
medicines  are  not  indicated,  since  no  remedies  are  known  to  have  the  slight- 
est influence  upon  the  progress  of  the  disease.  Sooner  or  later  symptoms 
arise  which  demand  treatment.  Of  these  the  following  are  the  most  im- 
portant: 

(a)  Greatly  Increased  Arterial  Tension. — It  is  to  be  remembered  that 
a  certain  increase  of  tension  is  not  only  necessary  but  unavoidable  in  chronic 
Bright^s  disease,  and  probably  the  most  serious  danger  is  too  great  lowering 
of  the  blood  tension.  The  happy  medium  must  be  sought  between  such 
heightened  tension  as  throws  a  serious  strain  upon  the  heart  and  risks  rup- 
ture of  the  vessels  and  the  low  tension  which,  under  these  circumstances, 
is  specially  liable  to  be  associated  with  serous  effusions.  In  cases  with  per- 
sistent high  tension  the  diet  should  be  light,  an  occasional  saline  purge 
should  be  given,  and  sweating  promoted  by  means  of  hot  air  or  the  hot 
bath.  If  these  measures  do  not  suffice,  nitroglycerin  may  be  tried,  begin- 
ning with  1  minim  of  the  1-per-cent  solution  three  times  a  day,  and  grad- 
ually increasing  the  dose  if  necessary.  Patients  vary  so  much  in  suscepti- 
bility to  this  drug  that  in  each  case  it  must  be  tested,  the  limit  of  dosage 
being  that  at  which  the  patient  experiences  the  physiological  effect.  As 
much  as  10  minims  of  the  1-per-cent  solution  may  be  given  three  times  a 
day.  In  many  case  I  have  given  't  in  much  larger  doses  for  weeks  at  a 
time.  I  have  never  seen  any  ill  effects  from  it.  If  the  dose  is  excessive  the 
patients  complain  at  once  of  flushing  or  headache.  Its  use  may  be  kept  up 
for  six  or  seven  Aveeks,  then  stopped  for  a  week  and  resumed.  Its  value 
is  seen  not  only  in  the  reduction  of  the  tension,  but  also  in  the  striking 
manner  in  which  it  relieves  the  headache,  dizziness,  and  dyspnoea. 

(b)  More  or  less  ancemia  is  present  in  advanced  cases,  and  is  best  met 
by  the  use  of  iron.  Weir  Mitchell,  who  has  had  a  unique  experience  in 
certain  forms  of  chronic  Bright's  disease,  gives  the  tincture  of  the  per- 


88i  DISEASES   OF   THE  KIDNEYS. 

chloride  of  iron  in  large  doses — from  half  a  drachm  to  a  drachm  three  times 
a  day.  He  thinks  that  it  not  only  benefits  the  angemia,  hut  that  it  also  is 
an  important  means  of  reducing  the  arterial  tension. 

(c)  Many  patients  with  Bright's  disease  present  themselves  for  treat- 
ment with  signs  of  cardiac  dilatation;  there  is  a  gallop  rhythm  or  the  heart 
sounds  have  a  foetal  character,  the  breath  is  short,  the  urine  scanty  and 
highly  albuminous,  and  there  are  signs  of  local  dropsy.  In  these  cases  the 
treatment  must  be  directed  to  the  heart.  A  morning  dose  of  salts  or  calo- 
mel may  be  given,  and  digitalis  in  10-minim  doses,  three  or  four  times  a 
day.  Strychnia  may  be  used  with  benefit  in  this  condition.  In  some  in- 
stances other  cardiac  tonics  may  be  necessary,  but  as  a  rule  the  digitalis  acts 
promptly  and  well. 

(d)  Urcemic  Symptoms. — ^Even  before  marked  manifestations  are  present 
there  may  be  extreme  restlessness,  mental  wandering,  a  heavy,  foul  breath, 
and  a  coated  tongue.  Headache  is  not  often  complained  of,  though  intense 
frontal  headache  may  be  an  early  symptom  of  ursemia.  In  this  condition, 
too,  the  patient  may  complain  of  palpitation,  feelings  of  numbness,  and 
sometimes  nocturnal  cramps.  For  these  symptoms  the  saline  purgatives 
should  be  ordered,  and  hot  baths,  so  as  to  induce  copious  sweating.  ,Grandin 
states  that  irrigation  of  the  bowel  with  water  at  a  temperature  from  120° 
to  150°  is  most  useful.  Nitroglycerin  also  may  be  freely  used  to  reduce  the 
tension.  For  the  ursemic  convulsions,  if  severe,  inhalations  of  chloroform 
may  be  used.  If  the  patient  is  robust  and  full-blooded,  from  13  to  30  ounces 
of  blood  should  be  removed.  The  patient  should  be  freely  sweated,  and  if 
the  conviilsions  tend  to  recur  chloral  may  be  given,  either  by  the  mouth  or 
per  rectum,  or,  better  still,  morphia.  Ursemic  coma  must  be  treated  by 
active  purgation,  and  sweating  should  be  promoted  by  the  use  of  pilocar- 
pine or  the  hot  bath.  For  the  restlessness  and  delirium  morphia  is  indis- 
pensable. Since  its  recommendation  in  ursemic  states  some  years  ago,  by 
Stephen  MacKenzie,  I  have  used  this  remedy  extensively  and  can  speak  of 
its  great  value  in  these  cases.  I  have  never  seen  ill  effects  or  any  tendency 
to  coma  follow.  It  is  of  special  value  in  the  dyspnoea  and  Cheyne-Stokes 
breathing  of  advanced  arterio-sclerosis  with  chronic  ursemia. 


VIII.    AMYLOID    DISEASE. 

Amyloid  (lardaceous  or  waxy)  degeneration  of  the  kidneys  is  simply  an 
event  in  the  process  of  chronic  Bright's  disease,  most  commonly  in  the 
chronic  parenchymatous  nephritis  following  fevers,  or  of  cachectic  states. 
It  has  no  claim  to  be  regarded  as  one  of  the  varieties  of  Bright's  disease. 
The  affection  of  the  kidneys  is  generally  a  part  of  a  widespread  amyloid 
degeneration  occurring  in  prolonged  suppuration,  as  in  disease  of  the  bone, 
in  syphilis,  tuberculosis,  and  occasionally  leuksemia,  lead  poisoning,  and 
gout.    It  varies  curiously  in  frequency  in  different  localities. 

Anatomically  the  amyloid  kidney  is  large  and  pale,  the  surface  smooth, 
and  the  venae  stellatse  well  marked.  On  section  the  cortex  is  large  and 
may  show  a  peculiar  glistening,  infiltrated  appearance,  and  the  glomeruli 


AMYLOID  DISEASE.  885 

are  very  distinct.  The  pyramids,  in  striking  contrast  to  the  cortex,  are  of 
a  deep  red  color.  A  section  soaked  in  dilute  tincture  of  iodine  shows  spots 
of  a  walnut  or  mahogany  brown  color.  The  Malpighian  tufts  and  the 
straight  vessels  may  be  most  affected.  In  lardaceous  disease  of  the  kidneys 
the  organs  are  not  always  enlarged.  They  may  be  normal  in  size  or  small, 
pale,  and  granular.  The  amyloid  change  is  first  seen  in  the  Malpighian 
tufts,  and  then  involves  the  afferent  and  efferent  vessels  and  the  straight 
vessels.  It  may  be  confined  entirely  to  them.  In  later  stages  of  the  dis- 
ease the  tubules  are  affected,  chiefly  the  membrane,  rarely,  if  ever,  the  cells 
themselves.  In  addition,  the  kidneys  always  show  signs  of  diffuse  nephritis. 
The  Bowman's  capsules  are  thickened,  there  may  be  glomerulitis,  and  the 
tubal  epithelium  is  swollen,  granular,  and  fatty. 

Symptoms. — The  renal  features  alone  may  not  indicate  the  presence 
of  this  degeneration.  Usually  the  associated  condition  gives  a  hint  of  the 
nature  of  the  process.  The  urine,  as  a  rule,  shows  important  changes; 
the  quantity  is  increased,  and  it  is  pale,  clear,  and  of  low  specific  gravity. 
The  albumin  is  usually  abundant,  but  it  may  be  scanty,  and  in  rare  in- 
stances absent.  Possibly  the  variations  in  the  situation  of  the  amyloid 
changes  may  account  for  this,  since  albumin  is  less  likely  to  be  present 
when  the  change  is  confined  to  the  vasa  recta.  In  addition  to  ordinary 
albumin  globulin  may  be  present.  The  tube-casts  are  variable,  usually 
hyaline,  often  fatty  or  finely  granular.  Occasionally  the  amyloid  reaction 
can  be  detected  in  the  hyaline  casts.  Dropsy  is  present  in  many  instances, 
particularly  when  there  is  much  anaemia  or  profound  cachexia.  It  is  not, 
however,  an  invariable  symptom,  and  there  are  cases  in  which  it  does  not 
develop.    Diarrhoea  is  a  common  accompaniment. 

Increased  arterial  tension  and  cardiac  hypertrophy  are  not  usually  pres- 
ent, except  in  those  cases  in  which  amyloid  degeneration  occurs  in  the 
secondary  contracted  kidney;  under  which  circumstances  there  may  be 
uraemia  and  retinal  changes,  which,  as  a  rule,  are  not  met  with  in  other 
forms. 

Diagnosis. — By  the  condition  of  the  urine  alone  it  is  not  possible  to 
recognize  amyloid  changes  in  the  kidney.  Usually,  however,  there  is  no 
difficulty,  since  the  Bright's  disease  comes  on  in  association  with  syphilis, 
prolonged  suppuration,  disease  of  the  bone,  or  tuberculosis,  and  there  is 
evidence  of  enlargement  of  the  liver  and  spleen.  A  suspicious  circum- 
stance is  the  existence  of  polyuria  with  a  large  amount  of  albumin  in  the 
urine,  or  when,  in  these  constitutional  affections,  a  large  quantity  of  clear, 
pale  urine  is  passed,  even  without  the  presence  of  albumin. 

The  prognosis  depends  rather  on  the  condition  with  which  the  nephritis 
is  associated.    As  a  rule  it  is  grave. 

Surgical  Treatment  of  Bright's  Disease. — It  had  been  noticed  by  Eegi- 
nald  Harrison  and  others  that  in  certain  conditions,  as  pain  and  ha?maturia, 
incision  of  the  capsule  of  the  kidney  gave  great  relief.  Edebohls  suggests, 
and  has  practised,  stripping  off  of  the  capsules  of  kidneys  in  Bright's  dis- 
ease with  a  view  of  establishing  new  vascular  connections  and  so  influencing 
the  nutrition  and  Work  of  the  organs.  Good  results  have  followed;  the 
cases  should  be  thoroughly  studied  beforehand. 


886  DISEASES  OF  THE  KIDNEYS. 

IX.  PYELITIS. 

{Consecutive  Nephritis  ;  Pyelonephritis  ;  Pyonephrosis^ 

Definition. — Inflammation  of  the  pelvis  of  the  kidney  and  the  con- 
ditions which  result  from  it. 

Etiology. — Pyelitis  in  almost  all  cases  is  induced  by  bacterial  invasion 
and  multiplication,  rarely  by  the  irritation  of  various  substances  such  as 
turpentine,  cubebs,  or  sugar  (diabetes).  N'ormally  the  kidney  can  eliminate 
without  harm  to  itself,  apparently,  various  bacteria  carried  to  it  by  the 
blood-current  from  the  intestinal  tract  or  some  focus  of  infection;  and  it 
probably  becomes  infected  only  where  its  resistance  is  lowered,  as  a  result 
of  some  general  cause,  as  anemia,  malnutrition,  or  intercurrent  disease, 
or  of  some  local  cause,  as  nephritis,  displacement,  congestion  due  to  pres- 
sure of  neoplasms  upon  the  ureter,  twisted  ureter  (Dietl's  crisis),  or  of 
operation,  or  where  the  number  or  virulence  of  the  micro-organisms  is  in- 
creased. These  same  factors  probably  play  an  important  role  also  in  the 
other  common  causes  of  pyelitis,  ascending  infection  from  an  infected  blad- 
der (cystitis),  and  tuberculous  infection.  Other  causes  described  are  vari- 
ous fevers,  cancer,  hydatids,  the  ova  of  certain  parasites,  cold,  and  over- 
exertion. Calculus  seems  not  to  be  a  common  cause,  as,  if  present  at  all, 
it  is  probably  consecutive  to  the  infection.  In  T.  E.  Brown's  series  of  20 
cases,  the  colon  bacillus  was  obtained  7  times,  the  tubercle  bacillus  6,  the 
proteus  bacillus  4,  a  white  staphylococcus  twice — all  in  pure  culture — while 
in  1  case  cultures  were  negative. 

Morbid  Anatomy. — In  the  early  stages  of  pyelitis  the  mucous  mem- 
brane is  turbid,  somewhat  swollen,  and  may  show  ecchymoses  or  a  grayish 
pseudo-membrane.  The  urine  in  the  pelvis  is  cloudy,  and,  on  examina- 
tion, numbers  of  epithelial  cells  are  seen. 

In  the  calculous  pyelitis  there  may  be  only  slight  turbidity  of  the  mem- 
brane, which  has  been  called  by  some  catarrhal  pyelitis.  More  commonly 
the  mucosa  is  roughened,  grayish  in  color,  and  thick.  Under  these  circum- 
stances there  is  almost  always  more  or  less  dilatation  of  the  calyces  and 
flattening  of  the  papillae.  Following  this  condition  there  may  be  (a)  ex- 
tension of  the  suppurative  process  to  the  kidney  itself,  forming  a  pyelo- 
nephritis; (&)  a  gradual  dilatation  of  the  calyces  with  atrophy  of  the  kidney 
substance,  and  finally  the  production  of  the  condition  of  pyonephrosis,  in 
which  the  entire  organ  is  represented  by  a  sac  of  pus  with  or  without  a 
thin  shell  of  renal  tissue,  (c)  After  the  kidney  structure  has  been  destroyed 
by  suppuration,  if  the  obstruction  at  the  orifice  of  the  pelvis  persists,  the 
fluid  portions  may  be  absorbed  and  the  pus  become  inspissated,  so  that  the 
organ  is  represented  l)y  a  series  of  sacculi  containing  grayish,  putty-like 
masses,  which  may  become  impregnated  with  lime  salts. 

Tuberculous  pyelitis,  as  already  described,  usually  starts  upon  the  apices 
of  the  pyramids,  and  may  at  first  be  limited  in  extent.  Ultimately  the 
condition  produced  may  be  similar  to  that  of  calculous  pyelitis.  Pyone- 
phrosis is  quite  as  frequent  a  sequence,  while  the  final  transformation  of 


PYELITIS.  887 

the  p-us  into  a  putty-like  material  impregnated  with  salts,  forming  the 
so-called  scrofulous  kidney,  is  even  commoner. 

The  pyelitis  consecutive  to  cystitis  is  generally  unilateral,  and  the  kidney 
is  sometimes  involved,  forming  the  so-called  surgical  kidney — acute  sup- 
purative nephritis.  There  are  lines  of  suppuration  extending  along  the 
pyramids,  or  small  abscesses  in  the  cortex,  often  just  beneath  the  capsule; 
or  there  may  be  wedge-shaped  abscesses.  The  pus  organisms  either  pass 
up  the  tubules  or,  as  Steven  has  shown,  through  the  lymphatics. 

Symptoms. — The  forms  associated  with  the  fevers  rarely  cause  any 
symptoms,  even  when  the  process  is  extensive.  In  mild  grades  there  is 
pain  in  the  back  or  there  may  be  tenderness  on  deep  pressure  on  the  af- 
fected side.  The  urine,  turbid  and  containing  pus  cells,  some  mucus,  and 
occasional  red  blood-cells,  is  acid  or  alkaline,  depending  on  the  infecting 
microbe;  usually  the  albuminuria  is  of  higher  grade  comparatively  than 
the  pyuria. 

Before  the  condition  of  pyuria  is  established  there  may  be  attacks  of 
pain  on  the  affected  side  (not  amounting  to  the  severe  agony  of  renal  colic), 
rigors,  high  fever,  and  sweats.  Under  these  circumstances  the  urine,  which 
may  have  been  clear,  becomes  turbid  or  smoky  from  the  presence  of  blood, 
and  may  contain  large  numbers  of  mucus  cells  and  transitional  epithelium. 
These  cases  are  not  common,  but  I  have  twice  had  opportunity  of  studying 
such  attacks  for  a  prolonged  period.  In  one  patient  the  occurrence  of  the 
rigor  and  fever  could  sometimes  be  predicted  from  the  change  in  the  con- 
dition of  the  urine.  Such  cases  occur,  I  believe,  in  association  with  calculi 
in  the  pelvis. 

The  statement  is  not  infrequently  made  that  the  epithelium  in  the 
urine  in  pyelitis  is  distinctive  and  characteristic.  This  is  erroneous,  as 
may  be  readily  demonstrated  by  comparing  scrapings  of  the  mucosa  of  the 
renal  pelvis  and  of  the  bladder.  In  both  the  epithelium  belongs  to  what  is 
called  the  transitional  variety,  and  in  both  regions  the  same  conical,  fusi- 
form and  irregular  cells  with  long  tails  are  found. 

When  the  pyelitis,  whether  calculous  or  tuberculous,  has  become  chronic 
and  discharges,  the  symptoms  are: 

(1)  Pyuria. — The  pus  is  in  variable  amount,  and  may  be  intermittent. 
Thus,  as  is  often  the  case  when  only  one  kidney  is  involved,  the  ureter 
may  be  temporarily  blocked,  and  normal  urine  is  passed  for  a  time;  then 
there  is  a  sudden  outflow  of  the  pent-up  pus  and  the  urine  becomes  puru- 
lent. Coincident  with  this  retention,  a  tumor  mass  may  be  felt  on  the 
side  affected.  The  pus  has  the  ordinary  characters,  but  the  transitional 
epithelium  is  not  so  abundant  at  this  stage  and  comes  from  the  bladder  or 
from  the  pelvis  of  the  healthy  side.  Occasionally  in  rapidly  advancing 
pyelonephritis,  portions  of  the  kidney  tissue,  particularly  of  the  apices  of 
the  pyramids,  may  slough  away  and  appear  in  the  urine;  or,  as  in  a  re- 
markable specimen  shown  to  me  by  Tyson,  solid  cheesy  moulds  of  the 
calyces  are  passed.  Casts  from  the  kidney  tulmlos  are  sometimes  present. 
The  reaction  of  the  urine  (leponds  entirely  upon  tlie  infecting  microbe, 
whether  the  condition  is  unilateral  or  bilateral,  and  whether  the  bladder 
is  also  infected,  when  vesical  irritability  and  frequent  micturition  may  be 
present.    Polyuria  is  usually  present  in  the  chronic  cases. 


888  DISEASES  OF   THE  KIDNEYS. 

(2)  Intermittent  fever  associated  with  rigors  is  usually  present  in  cases 
of  suppurative  pyelitis.  The  chills  may  recur  at  regular  intervals,  and 
the  cases  are  often  mistaken  for  malaria.  Owen-Eees  called  attention  to 
the  frequent  occurrence  of  these  rigors,  which  form  a  characteristic  feature 
of  hoth  calculous  and  tuberculous  pyelitis.  Ultimately  the  fever  assumes 
a  hectic  type  and  the  rigors  may  cease. 

(3)  The  general  condition  of  the  patient  often  indicates  prolonged 
suppuration.  There  is  more  or  less  wasting  with  anaemia  and  a  progressive 
failure  of  health.  Secondary  abscesses  may  develop  and  the  clinical  picture 
becomes  that  of  pyaemia.  In  some  instances,  particularly  of  tuberculous 
pyelitis,  the  clinical  course  may  resemble  that  of  typhoid  fever.  There  are 
instances  of  pyuria  recurring,  at  intervals,  for  many  years  without  impair- 
ment of  the  bodily  vigor.  Some  of  the  chronic  cases  have  practically  no 
discomfort. 

(4)  Physical  examination  in  chronic  pyelitis  usually  reveals  tenderness 
on  the  ajffected  side  or  a  definite  swelling,  which  may  vary  much  in  size 
and  ultimately  attain  large  dimensions  if  the  kidney  becomes  enormously 
distended,  as  in  pyonephrosis. 

(5)  Occasionally  nervous  symptoms,  which  may  be  associated  with 
dyspnoea,  supervene,  or  the  termination  may  be  by  coma,  not  unlike  that 
of  diabetes.  These  have  been  attributed  to  the  absorption  of  the  decom- 
posing materials  in  the  urine,  whence  the  so-called  ammoniaemia.  A  form 
of  paraplegia  has  been  described  in  connection  with  some  cases  of  abscess 
of  the  kidney,  but  whether  due  to  a  myelitis  or  to  a  peripheral  neuritis  has 
not  yet  been  determined. 

In  suppurative  nephritis  or  surgical  kidney  following  cystitis,  the  pa- 
tient complains  of  pain  in  the  back,  the  fever  becomes  high,  irregular,  and 
associated  with  chills,  and  in  acute  cases  a  typhoid  state  develops  in  which 
death  occurs. 

Diagnosis. — Between  the  tuberculous  and  the  calculous  forms  of 
pyelitis  it  may  be  difficult  or  impossible  to  distinguish,  except  by  the  de- 
tection of  tubercle  bacilli  in  the  pus.  The  examination  for  bacilli  shonld 
be  made  systematically,  and  in  suspicious  cases  intraperitoneal  injections 
of  guinea-pigs  should  also  be  made.  From  perinephric  abscess  p5^onephrosis 
is  distinguished  by  the  more  definite  character  of  the  tumor,  the  absence  of 
oedematous  swelling  in  the  lumbar  region,  and,  most  important  of  all,  the 
history  of  the  case.  The  urine,  too,  in  perinephric  abscess  may  be  free  from 
pus.  There  are  cases,  however,  in  which  it  is  difficult  indeed  to  make  a 
satisfactory  diagnosis.  A  patient,  whom  I  saw  with  Fussell,  had  had  cystitis 
through  her  pregnancy,  subsequently  pus  in  the  urine  for  several  months, 
and  then  a  large  fluctuating  abscess  developed  in  the  right  lumbar  region. 
It  did  not  seem  possible,  either  before  or  during  the  operation,  to  deter- 
mine whether  the  case  was  a  simple  pyonephrosis  or  whether  there  had  been 
a  perinephric  abscess  caused  by  the  pyelitis. 

Suppurative  pyelitis  and  cystitis  are  frequently  confounded.  I  have 
known  instances  of  the  former  in  which  perineal  section  was  performed  on 
the  supposition  of  the  existence  of  an  intractable  cystitis.  The  two  condi- 
tions may,  of  course,  coexist  and  prove  puzzling,  but  the  history,  the  higher 


HYDRONEPHROSIS.  880 

relative  grade  of  albuminuria  in  pyelitis  (Eosenfeld,  Goldberg,  T.  E. 
Brown),  the  polyuria,  the  mode  of  development,  the  local  signs  in  one  lum- 
bar region,  and  the  absence  of  pain  in  the  bladder,  should  be  sufficient  to 
differentiate  the  affections.  In  women,  by  catheterization  of  the  ureters, 
it  may  be  definitely  determined  whether  the  pus  comes  from  the  kidneys  or 
from  the  bladder.    The  cystoscope  may  be  used  for  this  purpose. 

Prognosis. — Cases  coming  on  during  the  fevers  usually  recover.  Tu- 
berculous pyelitis  may  terminate  favorably  by  inspissation  of  the  pus  and 
conversion  into  a  putty-like  substance  with  deposition  of  lime  salts.  When 
pyonephrosis  develops  the  dangers  are  increased.  Perforation  may  occur, 
the  patient  may  be  worn  out  by  the  hectic  fever,  or  amyloid  disease  may 
develop. 

Treatment. — In  mild  cases  fluids  should  be  taken  freely,  particularly 
the  alkaline  mineral  waters,  to  which  potassium  citrate  may  be  added. 

The  treatment  of  the  calculous  form  will  be  considered  later.  Practi- 
cally there  are  no  remedies  which  have  much  influence  upon  the  pyuria. 
Some  of  the  recently  described  urinary  antiseptics,  as  urotropin,  etc.,  seem 
to  be  of  value,  especially  in  the  acute  cases.  Tonics  should  be  given,  a 
nourishing  diet,  and  milk  and  butter-milk  may  be  taken  freely.  When"  the 
tumor  has  formed  or  even  before  it  is  perceptible,  if  the  symptoms  are 
serious  and  severe,  the  kidney  should  be  explored,  and,  if  necessary,  ne- 
phrotom-y  or  nephrectomy  should  be  performed. 


X.    HYDRONEPHROSIS. 

Definition. — Dilatation  of  the  pelvis  and  calyx  of  the  kidney  with 
atrophy  of  its  substance,  caused  by  the  accumulation  of  non-purulent  fluids, 
the  result  of  obstruction. 

Etiology. — The  condition  may  be  congenital,  owing  to  some  abnor- 
mality in  the  ureter  or  urethra.  The  tumor  produced  may  be  large  enough 
to  retard  labor.  Sometimes  it  is  associated  with  other  malformations.  There 
is  a  condition  of  moderate  dilatation,  apparently  congenital,  which  is  not 
connected  with  any  obstruction  in  the  ducts.  A  case  of  the  kind  was  shown 
at  the  Philadelphia  Pathological  Society  by  Daland. 

In  some  instances  there  has  been  contraction  or  twisting  of  the  ureter, 
or  it  has  been  inserted  into  the  kidney  at  an  acute  angle  or  at  a  high  level. 
In  adult  life  the  condition  may  be  due  to  lodgment  of  a  calculus,  or  to  a 
cicatricial  stricture  following  ulcer. 

New  growths,  such  as  tubercle  or  cancer,  occasionally  induce  hydro- 
nephrosis; more  commonly,  pressure  upon  the  ureter  from  without,  par- 
ticularly tumors  of  the  ovaries  and  uterus.  Occasionally  cicatricial  bands 
compress  the  ureter.  Obstruction  within  the  bladder  may  result  from  can- 
cer, from  hypertrophy  of  the  prostate  with  cystitis,  and  in  the  urethra  from 
stricture.  It  is  stated  that  slight  grades  of  ]iydr()ne])hrosis  have  been  found 
in  patients  with  excessive  polyuria. 

In  whatever  way  produced,  when  the  ureter  is  blocked  the  secretion  ac^ 
cumulates  in  the  pelvis  and  infundibula.  Sometimes  acute  inflammation 
follows,  but  more  commonly  the  slow,  gradual  pressure  causes  atrophy  of 
.5.5 


890  DISEASES  OP  THE  KIDNEYS. 

the  papillae  with  gradual  distention  and  wasting  of  the  organ.  In  acquired 
cases  from  pressure,  even  when  dilatation  is  extreme,  there  may  usually  be 
seen  a  thin  layer  of  renal  structure.  In  the  most  extreme  stages  the  kid- 
ney is  represented  by  a  large  cyst,  which  may  perhaps  show  on  its  inner 
surface  imperfect  septa.  The  fluid  is  thin  and  yellowish  in  color,  and  con- 
tains traces  of  urinary  salts,  urea,  uric  acid,  and  sometimes  albumin.  The 
secretion  may  be  turbid  from  admixture  with  small  quantities  of  pus. 

Total  occlusion  does  not  always  lead  to  a  hydronephrosis,  but  may  be 
followed  by  atrophy  of  the  kidney.  It  appears  that  when  the  obstruction 
is  intermittent  or  not  complete  the  greatest  dilatation  is  apt  to  follow.  The 
sac  may  be  enormous,  and  cause  an  abdominal  tumor  of  the  largest  size. 
The  condition  has  even  been  mistaken  for  ascites.  Enlargement  of  the 
other  kidney  may  compensate  for  the  defect.  Hypertrophy  of  the  left  side 
of  the  heart  usually  follows. 

Symptoms. — When  small,  it  may  not  be  noticed.  The  congenital 
cases  when  bilateral  usually  prove  fatal  within  a  few  days;  when  unilateral, 
the  tumor  may  not  be  noticed  for  some  time.  It  increases  progressively 
and  has  all  the  characters  of  a  tumor  in  the  renal  region.  In  adult  life 
many  of  the  cases,  due  to  pressure  by  tumors,  as  in  cancer  of  the  uterus 
and  enlargement  of  the  prostate,  etc.,  give  rise  to  no  symptoms. 

There  are  remarkable  instances  of  intermittent  hydronephrosis  in  which 
the  tumor  suddenly  disappears  with  the  discharge  of  a  large  quantity  of 
clear  fluid.  The  sac  gradually  refills,  and  the  process  may  be  repeated  for 
years.  In  these  cases  the  obstruction  is  unilateral;  a  cicatricial  stricture 
exists,  or  a  valve  is  present  in  the  ureter,  or  the  ureter  enters  the  upper 
part  of  the  pelvis.  Many  of  the  cases  are  in  women  and  associated  with 
movable  kidney. 

The  examination  of  the  abdomen  shows,  in  unilateral  hydronephrosis, 
a  tumor  occupying  the  renal  region.  When  of  moderate  size  it  is  readily 
recognized,  but  when  large  it  may  be  confounded  with  ovarian  or  other 
tumors.  In  young  children  it  may  be  mistaken  for  sarcoma  of  the  kidney 
or  of  the  retroperitoneal  glands,  the  common  cause  of  abdominal  tumor 
in  early  life.  Aspiration  alone  would  enable  us  to  differentiate  between 
hydronephrosis  and  tumor.  The  large  hydronephrotic  sac  is  frequently 
mistaken  for  ovarian  tumor.  The  latter  is,  as  a  rule,  more  mobile,  and 
rarely  fills  the  deeper  portion  of  the  lumbar  region  so  thoroughly.  The 
ascending  colon  can  often  be  detected  passing  over  the  renal  tumor,  and 
examination  per  vagi^am,  particularly  under  ether,  will  give  important 
indications  as  to  the  condition  of  the  ovaries.  In  doubtful  cases  the  sac 
should  be  aspirated.  The  fluid  of  the  renal  cyst  is  clear,  or  turbid  from  the 
presence  of  cell  elements,  rarely  colloid  in  character;  the  specific  gravity 
is  low;  albumin  and  traces  of  urea  and  uric  acid  are  u^^ually  present;  and 
the  epithelial  elements  in  it  may  be  similar  to  those  found  in  the  pelvis  of  the 
kidney.  In  old  sacs,  however,  the  fluid  may  not  be  characteristic,  since  the 
urinary  salts  disappear,  but  in  one  case  of  several  years'  duration  oxalates 
of  lime  and  urea  were  found. 

Perhaps  the  greatest  difficulty  is  offered  by  the  condition  of  hydro- 
nephrosis in  a  movable  kidney.     Here,  the  history  of  sudden  disappear- 


NEPHROLITHIASIS.  891 

ance  of  the  tumor  with  the  passage  of  a  large  quantity  t)f  clear  fluid  would 
be  a  point  of  great  importance  in  the  diagnosis.  In  those  rare  instances 
of  an  enormous  sac  filling  the  entire  abdomen,  and  sometimes  mistaken 
for  ascites,  the  character  of  the  fluid  might  be  the  only  point  of  difference. 
The  tumor  of  pyonephrosis  may  be  practically  the  same  in  physical  char- 
acteristics. Fever  is  usually  present,  and  pus  is  often  found  in  the  urine. 
In  these  cases,  when  in  doubt,  exploratory  puncture  should  be  made. 

The  outlook  in  hydronephrosis  depends  much  upon  the  cause.  When 
single,  the  condition  may  never  produce  serious  trouble,  and  the  intermit- 
tent cases  may  persist  for  years  and  finally  disappear.  Occasionally  the  cyst 
ruptures  into  the  peritonseum,  more  rarely  through  the  diaphragm  into  the 
lung.  A  remarkable  case  of  this  kind  was  under  the  care  of  my  colleague, 
Halsted.  A  man,  aged  twenty-one,  had,  from  his  second  year,  attacks  of 
abdominal  pain  in  which  a  swelling  would  appear  between  the  hip  and 
costal  margin  and  subside  with  the  passage  of  a  large  amount  of  urine. 
In  January,  1888,  the  sac  discharged  through  the  right  lung.*  Eeaccumu- 
lations  occurred  on  several  occasions,  and  on  June  9,  1891,  the  sac  was 
opened  and  drained.  He  remains  well,  though  there  is  still  a  sinus  through 
which  a  clear,  probably  urinous,  fluid  is  discharged. 

The  sac  may  discharge  spontaneously  through  the  ureter  and  the  fluid 
never  reaccumulate.  In  bilateral  hydronephrosis  there  is  a  danger  that 
ursemia  may  supervene.  There  are  instances,  too,  in  which  blocking  of 
the  ureter  on  the  sound  side  by  calculus  has  been  followed  by  ursemia. 
And,  lastly,  the  sac  may  suppurate,  and  the  condition  change  to  one  of 
pyonephrosis. 

Treatment. — Cases  of  intermittent  hydronephrosis  which  do  not  cause 
serious  symptoms  should  be  let  alone.  It  is  stated  that,  in  sacs  of  moderate 
size,  the  obstruction  has  been  overcome  by  shampooing.  If  practised,  it 
should  be  done  with  great  care.  When  the  sac  reaches  a  large  size  aspira- 
tion may  be  performed  and  repeated  if  necessary.  Puncture  should  be 
made  in  the  flank,  midway  between  the  ilium  and  the  last  rib.  If  the  fluid 
reaccumulates  and  the  sac  becomes  large,  it  may  be  incised  and  drained,  or, 
as  a  last  resort,  the  kidney  may  be  removed.  In  women  a  carefully  adapted 
pad  and  bandage  will  sometimes  prevent  the  recurrence  of  an  intermittent 
hydronephrosis.! 


XI.     NEPHROLITHIASIS  (Renal  Calculus). 

Definition. — The  formation  in  the  kidney  or  in  its  pelvis  of  con- 
cretions, by  the  deposition  of  certain  of  the  solid  constituents  of  the  urine. 

Etiology  and  Pathology. — In  the  kidney  substance  itself  the  sepa- 
ration of  the  urinary  salts  produces  a  condition  to  which,  unfortunately, 
the  term  infarct  has  been  applied.  Three  varieties  may  be  recognized:  (\) 
The  uric-acid  infarct,  usually  met  with  at  the  apices  of  the  pyramids  in 

*  Sowers,  New  York  Medical  Record,  1888. 

f  See  illustrative  cases  in  my  Lectures  on  Abdominal  Tumors,  1894. 


892  DISEASES  OF  THE  KIDNEYS. 

new-born  children  and  during  the  first  weeks  of  life.  The  priapism  and 
attacks  of  crying  in  the  new-born  have  been  attributed  to  the  passage  of 
these  infarcts  (Southworth);  (2)  the  sodium-urate  infarct,  sometimes  asso- 
ciated with  ammonium  urate,  which  forms  whitish  lines  at  the  apices  of 
the  pyramids  and  is  met  with  chiefly,  but  not  always,  in  gouty  persons;  and 
(3)  the  lime  infarcts,  forming  very  opaque  white  lines  in  the  pyramids, 
usually  in  old  people. 

In  the  pelvis  and  calyces  concretions  of  the  following  forms  occur:  {a) 
Small  gritty  particles,  renal  sand,  ranging  in  size  from  the  individual  grains 
of  the  uric-acid  sediment  to  bodies  1  or  2  mm.  in  diameter.  These  may  be 
passed  in  the  urine  for  long  periods  without  producing  any  symptoms,  since 
they  are  too  fine  to  be  arrested  in  their  downward  passage. 

(&)  Larger  concretions,  ranging  in  size  from  a  small  pea  to  a  bean,  and 
either  solitary  or  multiple  in  the  calyces  and  pelvis.  It  is  the  smaller  of 
these  calculi  which,  in  their  passage,  produce  the  attacks  of  renal  colic. 
They  may  be  rounded  and  smooth,  or  present  numerous  irregular  projec- 
tions. 

(c)  The  dendritic  form  of  calculus.  The  orifice  of  the  ureter  may  be 
blocked  by  a  Y-shaped  stone.  The  pelvis  itself  may  be  occupied  by  the 
concretion,  which  forms  a  more  or  less  distinct  mould.  These  are  the  re- 
markable coral  calculi,  which  form  in  the  pelvis  complete  moulds  of  in- 
fundibula  and  calyces,  the  latter  even  presenting  cup-like  depressions  cor- 
responding to  the  apices  of  the  papillae.  Some  of  these  casts  in  stone  of 
the  renal  pelvis  are  as  beautifully  moulded  as  HyrtFs  corrosion  prepara- 
tions. 

Chemically  the  varieties  of  calculi  are:  (1)  Uric  acid  and  urates,  most 
important,  and  forming  the  renal  sand,, the  small  solitary,  or  the  large 
dendritic  stones.  They  are  very  hard,  the  surface  is  smooth,  and  the  color 
reddish.  The  larger  stones  are  usually  stratified  and  very  dense.  Usually 
the  uric  acid  and  the  urates  are  mixed,  but  in  children  stones  composed  of 
urates  alone  may  occur. 

(2)  Oxalate  of  lime,  which  forms  mulberry-shaped  calculi,  studded  with 
points  and  spines.  They  are  often  very  dark  in  color,  intensely  hard,  and 
are  a  mixture  of  oxalate  of  lime  and  uric  acid. 

(3)  Phosphatic  calculi  are  composed  of  the  calcium  phosphate  and  the 
ammonio-magnesium  phosphate,  sometimes  mixed  with  a  small  amount  of 
calcium  carbonate.  They  are  quite  common,  although  the  phosphatic  salts 
are  often  deposited  about  the  uric  acid  or  the  calcium-oxalate  stones. 

(4)  Eare  forms  of  calculi  are  made  up  of  cystine,  xanthine,  carbonate  of 
lime,  indigo,  and  urostealith. 

The  mode  of  formation  of  calculi  has  been  much  discussed.  They  may 
be  produced  by  an  excess  of  a  sparingly  soluble  abnormal  ingredient,  such 
as  cystine  or  xanthine;  more  frequently  by  the  presence  of  uric  acid  in  a 
very  acid  urine  which  favors  its  deposition.  Sir  William  Roberts  thus 
briefly  states  the  conditions  which  lead  to  the  formation  of  the  uric-acid 
concretions:  high  acidity,  poverty  in  salines,  low  pigmentation,  and  high 
percentage  of  uric  acid.  Ord  suggests  that  albumin,  mucus,  blood,  and 
epithelial  threads  may  be  the  starting-point  of  stone.    The  demonatratiQii 


NEPHROLITHIASIS.  893 

of  organisms  in  the  centre  of  renal  calculi  renders  it  probable  that  in  many 
cases  the  nucleus  of  the  stone  is  an  agglutinated  mass  of  bacteria. 

Eenal  calculi  are  most  common  in  the  early  and  later  periods  of  life. 
They  are  moderately  frequent  in  this  country,  but  there  do  not  appear  to 
be  special  districts,  corresponding  to  the  "  stone  counties "  in  England. 
Men  are  more  often  afEected  than  women.  Sedentary  occupations  seem  to 
predispose  to  stone. 

The  effects  of  the  calculi  are  varied.  It  is  by  no  means  uncommon  to 
find  a  dozen  or  more  stones  of  various  sizes  in  the  calyces  without  any 
destruction  of  the  mucous  membrane  or  dilatation  of  the  pelvis.  A  tur- 
bid urine  fills  the  pelvis  in  which  there  are  numerous  cells  from  the  epi- 
thelial lining.  There  are  cases  of  this  sort  in  which,  apparently,  the  stones 
may  go  on  forming  and  are  passed  for  years  without  seriously  impairing 
the  health  and  without  inconvenience,  except  the  attacks  of  renal  colic. 
Still  more  remarkable  are  the  cases  of  coral-like  calculi,  which  may  occupy 
the  entire  pelvis  and  calyces  without  causing  pyelitis,  but  which  gradually 
lead  to  more  or  less  induration  of  the  kidney.  The  most  serious  effects 
are  when  the  stone  excites  a  suppurative  pyelitis  and  pyonephrosis. 

Symptoms.- — Patients  may  pass  gravel  for  years  without  having  an 
attack  of  renal  colic,  and  a  stone  may  never  lodge  in  the  ureter.  In  other 
instances,  the  formation  of  calculi  goes  on  year  by  year  and  the  patient  has 
recurring  attacks  such  as  have  been  so  graphically  described  by  Montaigne 
in  his  own  case.  A  patient  may  pass  an  enormous  number  of  calculi. 
Some  years  ago  I  was  consulted  by  a  commercial  traveller,  an  extremely 
vigorous  man,  who  for  many  years  had  had  repeated  attacks  of  renal  colic, 
and  had  passed  several  hundred  calculi  of  various  sizes.  His  collection  filled 
an  ounce  bottle.  A  patient  may  pass  a  single  calculus,  and  never  be  trou- 
bled again.  The  large  coral  calculi  may  excite  no  symptoms.  In  a  re- 
markable specimen  of  the  kind,  presented  to  the  McGill  Medical  Museum 
by  J.  A.  Macdonald,  the  patient,  a  middle-aged  woman,  died  suddenly  with 
ursemic  symptoms.     There  was  no  pyelitis,  but  the  kidneys  were  sclerotic. 

Benal  colic  ensues  when  a  stone  enters  the  ureter.  An  attack  may  set 
in  abruptly  without  apparent  cause,  or  may  follow  a  strain  in  lifting. 
It  is  characterized  by  agonizing  pain,  which  starts  in  the  flank  of  the 
affected  side,  passes  down  the  ureter,  and  is  felt  in  the  testicle  and  along 
the  inner  side  of  the  thigh.  The  pain  may  also  radiate  through  the  ab- 
domen and  chest,  and  be  very  intense  in  the  back.  In  severe  attacks  there 
are  nausea  and  vomiting  and  the  patient  is  collapsed.  The  perspiration 
breaks  out  upon  the  face  and  the  pulse  is  feeble  and  quick.  A  chill  may 
precede  the  outbreak,  and  the  temperature  may  rise  as  high  as  103°.  No 
one  has  more  graphically  described  an  attack  of  "  the  stone  "  than  Mon- 
taigne,* who  was  a  sufferer  for  many  years:  "Thou  art  seen  to  sweaft  with 
pain,  to  look  pale  and  red,  to  tremble,  to  vomit  well-nigh  to  blood,  to  suffer 
strange  contortions  and  convulsions,  by  starts  to  let  tears  drop  from  thine 
eyes,  to  urine  thick,  black,  and  frightful  water,  or  to  have  it  suppressed 
by  some  sharp  and  craggy  stone,  that  cruelly  pricks  and  tears  thee."     The 

*  Essays,  Book  III,  13. 


894  DISEASES  OF  THE  KIDNEYS. 

symptoms  persist  for  a  variable  period.  In  short  attacks  they  do  not  last 
longer  than  an  hour;  in  other  instances  they  continue  for  a  day  or 
more,  with  temporary  relief.  Micturition  is  frequent,  occasionally  painful, 
and  the  urine,  as  a  rule,  is  bloody.  There  are  instances  in  which  a  large 
amount  of  clear  urine  is  passed,  probably  from  the  other  kidney.  In  rare 
cases  the  secretion  of  urine  is  completely  suppressed,  even  when  the  kidney 
on  the  opposite  side  is  normal,  and  death  may  occur  from  ursemia.  This 
most  frequently  happens  when  the  second  kidney  is  extensively  diseased, 
or  when  only  a  single  kidney  exists.  A  number  of  cases  of  this  kind  have 
been  recorded.  The  condition  has  been  termed,  by  Sir  William  Eoberts, 
obstructive  suppression.  It  is  met  with  also  when  cancer  compresses  both 
ureters  or  involves  their  orifices  in  the  bladder.  The  patient  may  not  ap- 
pear to  be  seriously  ill  at  first,  and  ursemic  symptoms  may  not  develop  for 
a  week,  when  twitching  of  the  muscles,  great  restlessness,  and  sometimes 
drowsiness  supervene,  but,  strange  to  say,  neither  convulsions  nor  coma. 
Death  takes  place  usually  within  twelve  days  from  the  onset  of  the  ob- 
struction. 

After  the  attack  of  colic  has  passed  there  is  more  or  less  aching  on  the 
affected  side,  and  the  patient  can  usually  tell  from  which  kidney  the  stone 
has  come.  Examination  during  the  attack  is  usually  negative.  Very  rarely 
the  kidney  becomes  palpable.  Tenderness  on  the  affected  side  is  common. 
In  very  thin  persons  it  may  be  possible,  on  examination  of  the  abdomen, 
to  feel  the  stone  in  the  ureter;  or  the  patient  may  complain  of  a  grating 
sensation. 

When  the  calculi  remain  in  the  kidney  they  may  produce  very  definite 
and  characteristic  symptoms,  of  which  the  following  are  the  most  im- 
portant: 

(1)  Pain,  usually  in  the  back,  which  is  often  no  more  than  a  dull  sore- 
ness, but  which  may  be  severe  and  come  on  in  paroxysms.  It  is  usually  on 
the  si'de  affected,  but  may  be  referred  to  the  opposite  kidney,  and  there  are 
instances  in  which  the  pain  has  been  confined  to  the  sound  side.  Pains 
of  a  similar  nature  may  occur  in  movable  kidneys,  and  there  are  several 
instances  on  record  in  which  surgeons  have  incised  the  kidney  for  stone 
and  found  none.  In  an  instance  in  which  pain  was  present  for  a  couple 
of  years  the  exploration  revealed  only  a  contracted  kidney. 

(2)  Hcematuria. — Although  this  occurs  most  frequently  when  the  stone 
becomes  engaged  in  the  ureter,  it  may  also  come  on  when  the  stones  are 
in  the  pelvis.  The  bleeding  is  seldom  profuse,  as  in  cancer,  but  in  some 
instances  may  persist  for  a  long  time.  It  is  aggravated  by  exertion  and 
lessened  by  rest.  Frequently  it  only  gives  to  the  urine  a  smoky  hue.  The 
urine  may  be  free  for  days,  and  then  a  sudden  exertion  or  a  prolonged  ride 
may  cause  smokiness,  or  blood  may  be  passed  in  considerable  quantities. 

(3)  Pyelitis. — {a)  There  may  be  attacks  of  severe  pain  in  the  back,  not 
amounting  to  actual  colic,  which  are  initiated  by  a  heavy  chill  followed 
by  fever,  in  which  the  temperature  may  reach  104°  or  105°,  followed  by 
profuse  sweating.  The  urine,  Avhich  has  been  clear,  may  become  turbid 
and  smoky  and  contain  blood  and  abundant  epithelium  from  the  pelvis. 
Attacks  of  this  description  may  recur  at  intervals  for  months  or  even 


NEPHROLITHIASIS.  895 

years,  and  are  generally  mistaken  for  malaria,  unless  special  attention  is 
paid  to  the  urine  and  to  the  existence  of  the  pain  in  the  back.  This  renal 
intermittent  fever,  due  to  the  presence  of  calculi,  is  analogous  to  the  he- 
patic intermittent  fever,  due  to  gall-stones,  and  in  both  it  is  important  to 
remember  that  the  most  intense  paroxysms  may  occur  without  any  evi- 
dence of  suppuration. 

(h)  More  frequently  the  symptoms  of  purulent  pyelitis,  which  have  al- 
ready been  described,  are  present;  pain  in  the  renal  region,  recurring  chills, 
and  pus  in  the  urine,  with  or  without  indications  of  pyonephrosis. 

(4)  Pyuria. — There  are  instances  of  stone  in  the  kidney  in  which  pus 
occurs  continuously  or  intermittently  in  the  urine  for  many  years.  On 
many  occasions  between  1875  and  1884  I  examined  the  urine  of  a  physician 
who  had  passed  calculi  when  a  student  in  1845,  and  had  pus  in  the  urine 
at  intervals  to  1891.  In  spite  of  the  prolonged  suppuration  he  had  remark- 
able mental  and  bodily  vigor. 

Patients  with  stone  in  the  kidney  are  often  robust,  high  livers,  and 
gouty.  Attacks  of  dyspepsia  are  not  uncommon,  or  they  may  have  severe 
headaches. 

Diagnosis. — Renal  may  be  mistaken  for  intestinal  colic,  particularly 
if  the  distention  of  the  bowels  is  marked,  or  for  biliary  colic.  The  situa- 
tion and  direction  of  the  pain,  the  retraction  and  tenderness  of  the  testicle, 
the  occurrence  of  hsematuria,  and  the  altered  character  of  the  urine  are 
distinctive  features.  Attention  may  again  be  called  to  the  fact  that  at- 
tacks simulating  renal  colic  are  associated  with  movable  kidney,  or  even, 
it  has  been  supposed,  without  mobility  of  the  kidney,  with  the  accumu- 
lation of  the  oxalates  or  uric  acid  in  the  pelvis  of  the  kidney.  The  diag- 
nosis between  a  stone  in  the  kidney  and  stone  in  the  bladder  is  not  always 
easy,  though  in  the  latter  the  pain  is  particularly  about  the  neck  of  the 
bladder,  and  not  limited  to  one  side.  In  the  uric-acid  or  uratic  renal  stone, 
the  urine  is  acid,  thus  aiding  us  in  differentiating  it  from  a  bladder  stone, 
when  alkaline  urine  is  the  rule.  It  is  stated  that  certain  differences  occur 
in  the  symptoms  produced  by  different  sorts  of  calculi.  The  large  uric-acid 
calculi  less  frequently  produce  severe  symptoms.  On  the  other  hand,  as 
the  oxalate  of  lime  is  a  rougher  calculus,  it  is  apt  to  produce  more  pain 
(often  of  a  radiating  character)  than  the  lithic-acid  form,  and  to  cause 
hemorrhage.  In  both  these  forms  the  urine  is  acid.  The  phosphatic 
calculi  are  stated  to  produce  the  most  intense  pain,  and  the  urine  is  com- 
monly alkaline.  The  Roentgen  rays  are  becoming  of  more  and  more  value 
in  detorniining  the  presence  and  position  of  a  stone. 

Treatment. — In  the  attacks  of  renal  colic  great  relief  is  experienced 
by  the  hot  bath,  which  is  sometimes  sufficient  to  relax  the  spasm.  Wlien 
the  pain  is  very  intense  morphia  should  be  given  hypodermically,  and  in- 
halations of  chloroform  may  be  necessary  until  the  effects  of  the  anodyne 
are  manifest.  Local  applications  are  sometimes  grateful — hot  poultices, 
or  cloths  wrung  out  of  hot  water.  The  patient  may  drink  freely  of  hot 
lemonade,  soda  water,  or  barley  water.  Occasionally  change  in  posture  or 
inversion  will  give  great  relief.  Surgical  interference  should  be  consid- 
ered in  all  cases,  especially  when  the  stone  is  large  or  the  associated  pye- 
litis severe. 


89(3  DISEASES  OF  THE  KIDNEYS. 

In  the  intervals  the  patient  should,  as  far  as  possible,  live  a  quiet  life, 
avoiding  sudden  exertion  of  all  sorts.  The  essential  feature  in  the  treat- 
ment is  to  keep  the  urine  abundant  and,  in  the  uric-acid  or  uratic  cases, 
alkaline.  The  patient  should  drink  daily  a  large  but  definite  quantity  of 
mineral  waters  *  or  distilled  water,  which  is  just  as  satisfactory.  The 
citrate  or  bicarbonate  of  potash  may  be  added.  The  aching  pains  in  the 
back  are  often  greatly  relieved  by  this  treatment.  Many  patients  find 
benefit  from  a  stay  at  Saratoga,  Bedford,  Poland,  or  other  mineral  springs 
in  this  country,  or  at  Vichy  or  Ems  in  Europe. 

The  diet  should  be  carefully  regulated,  and  similar  to  that  indicated  in 
the  early  stages  of  gout.  Sir  William  Eoberts  recommends  what  is  known 
as  the  solvent  treatment  for  uric-acid  calculi.  The  citrate  of  potash  is 
given  in  large  doses,  half  a  drachm  to  a  drachm,  every  three  hours  in  a 
tumblerful  of  water.  This  should  be  kept  up  for  several  months.  I  have 
had  no  success  with  this  treatment,  nor,  when  one  considers  the  character 
of  the  uric-acid  stones  usually  met  with  in  the  kidney,  does  it  seem  likely 
that  any  solvent  action  could  be  exercised  upon  them  by  changes  in  the 
urine.  This  treatment  should  be  abandoned  if  the  urine  becomes  am- 
moniacal. 

The  value  of  piperazine  as  a  solvent  of  uric-acid  gravel  or  of  uric-acid 
stones  has  been  much  discussed  of  late.  While  outside  the  body  a  watery 
solution  of  the  drug  has  this  power  in  a  marked  degree,  the  amount  ex- 
creted in  the  urine  as  given  in  the  ordinary  doses  of  15  grains  daily  seems 
to  have  very  little  influence.  Several  observers  have  shown  that  the  per- 
centage of  piperazine  excreted  in  the  urine,  when  taken  in  doses  of  from 
1  to  2  grammes,  has,  when  tested  outside  of  the  body,  little  or  no  influence 
as  a  solvent  (Fawcett,  Gordon). 


XII.    TUMORS    OF   THE    KIDNEY. 

These  are  benign  and  malignant.  Of  the  benign  tumors,  the  most 
common  are  the  small  nodular  fibromata  which  occur  frequently  in  the 
pyramids,  the  aberrant  adrenals,  which  Grawitz  has  described,  and  occa- 
sionally lipoma,  angioma,  or  lymphadenoma.  The  adenomata  may  be  con- 
genital. In  one  of  my  cases  the  kidneys  were  greatly  enlarged,  contained 
small  cysts,  and  numerous  adenomatous  structures  throughout  both  organs. 

Malignant  growths — cancer  or  sarcoma — may  be  either  primary  or  sec- 
ondary. The  sarcomata  are  the  most  common,  either  alveolar  sarcoma  or 
the  remarkable  form  containing  striped  muscular  fibres — rhabdo-myoma. 
They  are  very  common  tumors  in  children.  G.  Walker  (Annals  of  Sur- 
gery, 1897)  has  analyzed  the  literature  of  the  subject  to  date.  Carcinoma 
is  less  frequent,  and  is  of  the  encephaloid  variety. 

The  tumors  attain  a  very  large  size.  In  one  of  my  cases  the  left  kidney 
weighed  12  pounds  and  almost  filled  the  abdomen.     In  children  they  may 

*  Some  of  these,  if  we  judge  by  the  laudatory  reports,  are  as  potent  as  the  waters  of 
Corsena,  declared  by  Montaigne  to  be  "  powerful  enough  to  break  stones." 


TUMORS  OF  THE  KIDNEY.  897" 

reach  an  enormous  size,  ilorris  states  that  in  a  boy  at  the  Middlesex  Hos- 
pital the  tumor  weighed  31  pounds.  They  grow  rapidly,  are  often  soft, 
and  hemorrhage  frequently  takes  place  into  them.  In  the  sarcomata,  in- 
vasion of  the  pelvis  or  of  the  renal  vein  is  common.  The  rhabdo-myomata 
rarely  form  very  large  tumors,  and  death  occurs  shortly  after  birth.  In  one 
of  my  cases  the  child  lived  to  the  age  of  three  years  and  a  half.  The  tumor 
grew  into  the  renal  vein  and  inferior  cava.  A  detached  fragment  passed 
as  an  embolus  into  the  pulmonary  artery,  and  a  portion  of  it  blocked  the 
tricuspid  orifice. 

Symptoms. — The  following  are  the  most  important:  (1)  Hsematuria. 
This  may  be  the  first  indication.  The 'blood  is  fluid  or  clotted,  and  there 
may  be  very  characteristic  moulds  of  the  pelvis  of  the  kidney  and  of  the 
ureter.  It  would  no  doubt  be  possible  for  such  to  form  in  the  ha3maturia 
from  calculus,  but  I  have  never  met  with  a  case  of  blood-casts  of  the  pelvis 
and  of  the  ureter,  either  alone  or  together,  except  in  cancer.  It  is  rare 
indeed  that  cancer  elements  can  be  recognized  in  the  urine. 

(2)  Pain  is  an  uncertain  symptom.  In  several  of  the  largest  tumors 
which  have  come  under  my  observation  there  has  been  no  discomfort  from 
beginning  to  close.  When  present,  it  is  of  a  dragging,  dull  character,  situ- 
ated in  the  flank  and  radiating  down  the  thigh.  The  passage  of  the  clots 
may  cause  great  pain.  In  a  recent  case  the  growth  was  at  first  upward, 
and  the  symptoms  for  some  months  were  those  of  pleurisy. 

(3)  Progressive  emaciation.  The  loss  of  flesh  is  usually  marked  and 
advances  rapidly.  There  may,  however,  be  a  very  large  tumor  without 
emaciation. 

Physical  Signs. — In  almost  all  instances  tumor  is  present.  Wlien 
small  and  on  the  right  side,  it  may  be  very  movable;  in  some  instances, 
occupying  a  position  in  the  iliac  fossa,  it  has  been  mistaken  for  ovarian 
tumor.  The  large  growths  fill  the  flank  and  gradually  extend  toward  the 
middle  line,  occupying  the  right  or  left  half  of  the  abdomen.  Inspection 
may  show  two  or  three  hemispherical  projections  corresponding  to  dis- 
tended sections  of  the  organ.  In  children  the  abdomen  may  reach  an 
enormous  size  and  the  veins  are  prominent  and  distended.  On  bimanual 
palpation  the  tumor  is  felt  to  occupy  the  lumbar  region  and  can  usually 
be  lifted  slightly  from  its  bed;  in  some  cases  it  is  very  movable,  even  when 
large;  in  others  it  is  flxed,  firm,  and  solid.  The  respiratory  movements 
have  but  slight  influence  upon  it.  Eapidly  growing  renal  tumors  are  soft, 
and  on  palpation  may  give  a  sense  of  fluctuation.  A  point  of  considerable 
importance  is  the  fact  that  the  colon  crosses  the  tumor,  and  can  usually  be 
detected  without  difficulty. 

Diagnosis. — In  children  very  large  abdominal  tumors  are  either  renal 
or  retroperitoneal.  The  retroperitoneal  sarcoma  (Lobstein's  cancer)  is  more 
central,  but  may  attain  as  large  a  size.  If  the  case  is  seen  only  toward  the 
end,  a  differential  diagnosis  may  be  impossible;  but  as  a  rule  the  sarcoma 
is  less  movable.  It  is  to  be  remembered  that  these  tumors  may  invade  the  ' 
kidney.  On  the  left  side  an  enlarged  spleen  is  readily  distinguished,  as 
the  edge  is  very  distinct  and  the  notch  or  notches  well  marked;  it  descends 
during  respiration,  and  the  colon  lies  behind,  not  in  front  of  it.  On  the 
56 


898  DISEASES   OF   THE  KIDNEYS. 

right  side  growths  of  the  liver  are  occasionally  confounded  with  renal 
tumors;  but  such  instances  are  rare,  and  there  can  usually  be  detected  a 
zone  of  resonance  between  the  upper  margin  of  the  renal  tumor  and  the 
ribs.  Late  in  the  disease,  however,  this  is  not  possible,  for  the  renal  tumor 
is  in  close  union  with  the  liver. 

A  malignant  growth  in  a  movable  kidney  may  be  very  deceptive  and 
may  simulate  cancer  of  the  ovary  or  myoma  of  the  uterus.  The  great  mo- 
bility upward  of  the  renal  growth  and  the  negative  result  of  examination 
of  the  pelvic  viscera  are  the  reliable  points. 

Medicinal  treatment  is  of  no  avail.  When  the  growth  is  small  and  the 
patient  in  good  condition  removal  of  the  organ  may  be  undertaken,  but  the 
percentage  of  cases  of  recovery  is  very  small,  only  5.4  per  cent  (G.  Walker). 


XIII.    CYSTIC    DISEASE    OF   THE    KIDNEY. 

The  following  varieties  of  cysts  are  met  with: 

(1)  The  small  cysts,  already  described  in  connection  with  the  chronic 
nephritis,  which  result  from  dilatation  of  obstructed  tubules  or  of  Bow- 
man's capsules.  There  are  cases  very  difficult  to  classify,  in  which  the 
kidneys  are  greatly  enlarged,  and  very  cystic  in  middle-aged  or  elderly 
persons,  and  yet  not  so  large  as  in  the  congenital  form. 

(2)  Solitary  cysts,  ranging  in  size  from  a  marble  to  an  orange,  or  even 
larger,  are  occasionally  found  in  kidneys  which  present  no  other  changes. 
In  e^eptional  cases,  they  may  form  tumors  of  considerable  size.  Newman 
operated  on  one  which  contained  35  ounces  of  blood.  They,  too,  in  all 
probability,  result  from  obstruction. 

(3)  The  polycystic  kidneys.  In  this  remarkable  condition  the  kidneys 
are  represented  by  a  conglomeration  of  cysts,  varying  in  size  from  a  pea 
to  a  marble.  The  organs  are  greatly  enlarged,  and  together  may  weigh 
6  or  more  pounds.  Little  or  no  renal  tissue  may  be  noticeable,  although  in 
microscopical  sections  it  is  seen  that  a  considerable  amount  remains  in 
the  interspaces.  The  cysts  contain  a  clear  or  turbid  fluid,  sometimes  red- 
dish brown  or  even  blackish  in  color,  and  may  be  of  a  colloidal  consistence. 
Albumin,  blood  crystals,  cholesterin,  with  triple  phosphates  and  fat  drops 
are  found  in  the  contents.  Urea  and  uric  acid  are  rarely  present.  The 
cysts  are  lined  by  a  flattened  epithelium.  They  occur  in  the  foetus,  and 
sometimes  are  of  such  a  size  as  to  obstruct  labor.  In  the  adult  they  are  usu- 
ally bilateral,  and  there  is  every  reason  to  believe  that  they  begin  in  early 
life  and  increase  gradually.  Indeed,  a  progressive  growth  has  been  noticed 
in  some  cases  (Alfred  King).  They  may  be  found  in  connection  with  cystic 
disease  of  the  liver  and  other  organs.  It  is  difficult  to  account  for  the 
origin  of  this  remarkable  condition,  which  some  regard  as  a  defect  of  de- 
velopment rather  than  a  pathological  change,  and  point  to  the  association 
in  the  fatal  cases  of  other  anomalies,  as  imperforate  anus.  Shattock  and 
Bland  Sutton  have  suggested  that  the  anomaly  of  development  is  in  the 
failure  of  complete  differentiation  of  the  Wolffian  bodies,  but  embryolo- 
gists  whom  I  have  consulted  on  this  point  tell  me  that  this  is  most  unlikely. 


CYSTIC  DISEASE  OF  THE  KIDNEY.  899 

Others  believe  the  condition  to  be  a  new  growth — a  sort  of  mucoid  endo- 
thelioma. 

It  is  interesting  to  note  that  several  members  of  a  family  may  be  affected, 
I  have  reported  an  instance  in  which  mother  and  son  were  the  subjects 
of  the  disease. 

Symptoms. — There  is  a  very  characteristic  group  of  symptoms  froiji 
which  the  diagnosis  can  be  made: 

(a)  Bilateral  tumors  in  the  renal  regions,  which  may  increase  in  size 
under  observation.  They  may  cause  great  enlargement  of  the  upper  zone 
of  the  abdomen.  The  colon  and  stomach  are  in  front  of  the  tumors,  on  the 
surface  of  which  in  very  thin  subjects  the  cysts  may  be  palpable. 

(&)  Hsematuria,  which  may  recur  at  intervals  for  years. 

(c)  The  general  features  of  a  chronic  interstitial  nephritis — (1)  pallor 
or  muddy  complexion;  in  rare  instances  a  bronzing  of  the  skin;  (2)  sclerosis 
of  the  arteries;  (3)  hypertrophy  of  the  heart  with  an  accentuated  second 
sound;  (4)  urine  abundant,  of  low  specific  gravity,  with  albumin,  hyaline, 
and  granular  tube  casts,  and  in  one  of  my  cases  there  were  cholesterin 
crystals.  Death  occurs  from  ursemia  or  the  cardio-vascular  complications 
of  chronic  Bright's  disease.  A  rare  event  is  rupture  of  a  cyst  with  the 
formation  of  a  perinephric  abscess  and  peritonitis. 

While  both  kidneys  are,  as  a  rule,  involved,  one  may  be  much  smaller 
than  the  other. 

Operation  is  rarely  indicated,  unless  the  condition  is  found  to  be  uni- 
lateral, in  which  case  Morris  has  removed  the  kidney  in  several  instances, 
and  the  patients  have  remained  well  for  years. 

(4)  Occasionally  the  kidneys  and  liver  present  numerous  small  cysts 
scattered  through  the  substance.  The  spleen  and  the  thyroid  also  may 
be  involved,  and  there  may  be  congenital  malformation  of  the  heart.  The 
cysts  in  the  kidney  are  small,  and  neither  so  numerous  nor  so  thickly  set 
as  in  the  conglomerate  form,  though  in  these  cases  the  condition  is  prob- 
ably the  result  of  some  congenital  defect.  There  are  cases,  however,  in 
which  the  kidneys  are  yery  large.  It  is  more  common  in  the  lower  ani- 
mals than  in  man.  I  have  seen  several  instances  of  it  in  the  hog;  in  one 
ease  the  liver  weighed  40  pounds,  and  was  converted  into  a  mass  of  simple 
cysts.  The  kidneys  were  less  involved.  Charles  Kennedy  *  states  that  he 
has  found  references  to  12  cases  of  combined  cystic  disease  of  the  liver  and 
kidneys. 

The  echinococcus  cysts  have  been  described  under  the  section  on  para- 
sites. Paranephric  cysts  (external  to  the  capsule)  are  rare;  they  may  reach 
a  large  size. 

*  Laboratory  Reports  of  the  Royal  College  of  Physicians,  Edinburgh,  vol.  iii. 


900  DISEASES  OF  THE  KIDNEYS. 


XIV.    PERINEPHRIC   ABSCESS. 

Suppuration  in  the  connective  tissue  about  the  kidney  may  follow  (1) 
blows  and  injuries;  (3)  the  extension  of  inflammation  from  the  pelvis  of 
tiie  kidney,  the  kidney  itself,  or  the  ureters;  (3)  perforation  of  the  bowel, 
most  commonly  the  appendix,  in  some  instances  the  colon;  (4)  extension 
of  suppuration  from  the  spine,  as  in  caries,  or  from  the  pleura,  as  in  em- 
pyema; (5)  as  a  sequel  of  the  fevers,  particularly  in  children. 

Post  mortem  the  kidney  is  surrounded  by  pus,  particularly  at  the  pos- 
terior part,  though  the  pus  may  lie  altogether  in  front,  between  the  kidney 
and  the  peritonaeum.  Usually  the  abscess  cavity  is  extensive.  The -pus 
is  often  offensive  and  may  have  a  distinctly  faecal  odor  from  contact  with 
the  large  bowel.  It  may  burrow  in  various  directions  and  burst  into  the 
pleura  and  be  discharged  through  the  lungs.  A  more  frequent  direction  is 
down  the  psoas  muscle,  when  it  appears  in  the  groin,  or  it  may  pass  along 
the  iliacus  fascia  and  appear  at  Poupart's  ligament.  It  may  perforate  the 
bowel  or  rupture  into  the  peritonaeum;  sometimes  it  penetrates  the  bladder 
or  vagina. 

Post  mortem  we  occasionally  find  a  condition  of  chronic  perinephritis 
in  which  the  fatty  capsule  of  the  kidney  is  extremely  firm,  with  numerous 
bands  of  fibrous  tissue,  and  is  stripped  off  from  the  proper  capsule  with  the 
greatest  difficulty.     Such  a  condition  probably  produces  no  symptoms. 

Symptoms. — There  may  be  intense  pain,  aggravated  by  pressure,  in 
the  lumbar  region.  In  other  instances,  the  onset  is  insidious,  without  pain 
in  the  renal  region;  on  examination  signs  of  deep-seated  suppuration  may  be 
detected.  On  the  affected  side  there  is  usually  pain,  which  may  be  referred 
to  the  neighborhood  of  the  hip-Joint  or  to  the  Joint  itself,  or  radiate  down 
the  thigh  and  be  associated  with  retraction  of  the  testis.  The  patient  lies 
with  the  thigh  flexed,  so  as  to  relax  the  psoas  muscle,  and  in  walking  throws, 
as  far  as  possible,  the  weight  on  the  opposite  leg.  He  also  keeps  the  spine 
immobile,  assumes  a  stooping  posture  in  walking,  and  has  great  difficulty 
in  voluntarily  adducting  the  thigh  (Gibney). 

There  may  be  pus  in  the  urine  if  the  disease  has  extended  from  the 
pelvis  or  the  kidney,  but  in  other  forms  the  urine  is  clear.  When  pus  has 
formed  there  are  usually  chills  with  irregular  fever  and  sweats.  On  ex- 
amination, deep-seated  induration  is  felt  between  the  last  rib  and  the  crest 
of  the  ilium.  Bimanual  palpation  may  reveal  a  distinct  tumor  mass. 
(Edema  or  puffiness  of  the  skin  is  frequently  present. 

The  diagnosis  is  usually  easy;  when  doubt  exists  the  aspirator  needle 
should  be  used.  We  cannot  always  differentiate  the  primary  forms  from 
those  due  to  perforation  of  the  kidney  or  of  the  bowel.  This,  however,  makes 
but  little  difference,  for  the  treatment  is  identical.  It  is  usually  possible  by 
the  history  and  examination  to  exclude  diseases  of  the  vertebra.  In  children 
hip-joint  disease  may  be  suspected,  but  the  pain  is  higher,  and  there  is  no 
fulness  or  tenderness  over  the  hip-joint  itself. 

The  treatment  is  clear — early,  free,  and  permanent  drainage. 


SECTION  X. 
DISEASES  OF  THE  l^fERYOUS  SYSTEM. 


I.    GENERAL  INTRODUCTION. 

In  diseases  of  the  nervous  system  it  is  of  the  greatest  importance  to 
know  accurately  the  position  of  the  morbid  process,  and  here,  even  more 
than  in  the  other  departments  of  medicine,  a  thorough  knowledge  of  anat- 
omy and  physiology  is  essential.  For  full  details  the  student  is  referred  to 
the  text-books  on  the  subject,  as  it  is  not  possible  to  do  more  than  touch  on 
the  subject  in  this  place. 

Recent  studies  have  modified  our  conceptions  of  the  fundamental  struc- 
ture of  the  nervous  system.  At  present  we  think  of  it  as  a  combination 
of  an  immense  number  of  units,  called  neurones,  all  having  an  essentially 
similar  structure.  Each  neurone  is  composed  of  a  cell  body,  the  protoplasmic 
processes  or  dendrites,  and  the  axis-cylinder  process  or  axone.  The  nutri- 
tion of  the  neurone  depends  in  large  part  upon  the  condition  of  the  cell 
body,  and  this  in  turn  in  all  probability  upon  the  activity  of  the  nucleus. 
If  the  cell  is  injured  in  any  manner  the  processes  degenerate,  or  if  the  pro- 
cesses are  separated  from  the  cell  they  degenerate.  Whether  or  not  the 
neurones  are  organically  connected  with  one  another  is  still  in  dispute.  The 
weight  of  evidence  is  in  favor  of  complete  anatomical  and  relative  physio- 
logical independence.  The  terminals  of  the  axone  of  one  neurone  are  re- 
lated to  the  dendrites  and  cell  bodies  of  other  neurones  by  contact  (Eamon 
y  Cajal)  or  by  concrescence  (Held).  It  is  generally  admitted,  however,  that 
occasional  coarse  anastomoses  exist  between  neighboring  dendrites  (accord- 
ing to  Dogiel),  especially  in  the  retina.  The  studies  of  Apathy  speak  in 
favor  of  a  general  interconnection  by  means  of  neurofibrils  and  protoplasmic 
bridges.  In  general,  it  may  be  stated  that  the  dendrites  or  protoplasmic 
processes  conduct  impulses  toward  the  cell  body  (cellulipetal  conduction), 
and  the  axis-cylinder  process  conducts  them  away  from  the  cell  (cellulifugal 
conduction).  The  axis-cylinder  process  after  leaving  the  cell  gives  off  at 
varying  intervals  lateral  branches  called  collaterals,  which  run  at  right 
angles  to  the  process.  The  collaterals  and  finally  the  axis-cylinder  process 
itself  at  their  terminations  split  up  into  many  fine  fibres,  forming  the  end- 
brushes.    These,  known  as  arborizations,  surround  the  body  of  one  or  more 

901 


902  "*-  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  the  many  other  cells,  or  interlace  with  their  protoplasmic  processes.  The 
cell  bodies  of  the  neurones  are  collected  more  or  less  closely  together  in 
the  gray  matter  of  the  brain  and  spinal  cord  and  in  the  ganglia  of  the  periph- 
eral nerves.  Their  processes,  especially  the  axis-cylinder  processes,  run  for 
the  most  part  in  the  white  tracts  of  the  brain  and  spinal  cord  and  in  the 
peripheral  nerves.  In  this  way  the  different  parts  of  the  central  nervous 
system  are  brought  into  relation  with  each  other  and  with  the  rest  of  the 
body.  In  many  cases  the  connections  are  extremely  complicated  and  have 
only  just  begun  to  be  unravelled,  but,  fortunately  for  the  clinician,  the 
nervous  mechanism  upon  which  motion  depends  is  the  best  understood 
and  is  the  simplest. 

A  voluntary  motor  impulse  starting  from  the  brain  cortex  must  pass 
through  at  least  two  neurones  before  it  can  reach  the  muscles,  and  we 
therefore  speak  of  the  motor  tract  as  being  composed  of  two  segments — 
an  upper  and  a  lower.  The  neurones  of  the  lower  segment  have  the  cell 
bodies  and  their  protoplasmic  processes  in  the  different  levels  of  the  ventral 
horns  of  the  spinal  cord  and  in  the  motor  nuclei  of  the  cerebral  nerves. 
The  axis-cylinder  processes  of  the  lower  motor  neurones  leave  the  spinal 
Gord  in  the  ventral  roots  and  run  in  the  peripheral  nerves,  to  be  distrib- 
uted to  all  the  muscles  of  the  body,  where  they  end  in  arborizations  in  the 
motor  end  plates.  These  neurones  are  direct — ^that  is,  their  cell  bodies, 
their  processes,  and  the  muscles  in  which  they  end  are  all  on  the  same  side 
of  the  body.* 

The  neurones  of  the  upper  motor  segment  have  their  cell  bodies  and 
protoplasmic  processes  in  the  cortex  of  the  brain  about  the  fissure  of  Eo- 
lando.  Their  axis-cylinder  processes  run  in  the  white  matter  of  the  brain 
through  the  internal  capsule  and  the  cerebral  peduncles  into  the  pons, 
medulla,  and  cord,  ending  in  arborizations  around  the  protoplasmic  pro- 
cesses and  cell  bodies  of  the  lower  motor  neurones.  .  The  upper  segment  is, 
in  the  main,  a  crossed  tract — that  is  to  say,  the  neurones  which  compose  it 
have  their  protoplasmic  processes  and  cell  bodies  on  one  side  of  the  body, 
whereas  their  axis-cylinder  processes  cross  the  middle  line,  to  end  about  cell 
bodies  of  the  lower  motor  neurones  on  the  opposite  side  of  the  body.  A 
certain  number  of  the  axones  of  the  pyramidal  tract,  however,  run^to  the 
lower  motor  neurones  of  the  same  side. 

Motor  impulses  starting  in  the  left  side  of  the  brain  cause  contractions 
of  muscles  on  the  right  side  of  the  body,  and  those  from  the  right  side  of 
the  brain  in  muscles  of  the  left  side  of  the  body.  Leaving  out  of  considera- 
tion the  exceptions  which  have  been  mentioned,  it  may  be  stated  as  a  gen- 
eral rule  that  the  motor  path  is  crossed,  and  that  tire  crossing  takes  place 
in  the  upper  segment  (Figs.  1  and  2).  Every  muscular  movement,  even  the 
simplest,  requires  the  activity  of  many  neurones.  In  the  production  of 
each  movement  special  neurones  are  brought  into  play  in  a  definite 
combination,  and  whenever  these  neurones  act  in  this  combination  that 
specific  movement  is  the  result.    In  other  words,  all  the  movements  of  the 

*  The  root  fibres  of  the  nervus  trochlearis  and  a  portion  of  the  root  fibres  of  the 
nervTis  oculomotorius  are  well-known  exceptions  to  this  rule. 


GENERAL  INTRODUCTION. 


903 


body  are  represented  in  the  central  nervous  system  by  combinations  of 
neurones — that  is,  they  are  localized.  Muscular  movements  are  localized  in 
every  part  of  the  motor  path,  so  that  in  cases  of  disease  of  the  nervous  sys- 
tem a  study  of  the  motor  defect  often  enables  one  to  fix  upon  the  site  of  the 
process,  and  it  would  be  hard  to  overesti- 
mate the  importance  of  a  thorough  knowl- 
edge of  such  localization. 

The  axis-cylinder  processes  of  the  lower 
motor  neurones  run  in  the  peripheral  nerves. 
Each  nerve  contains  processes  which  are 
supplied  to  definite  muscles,  and  we  have 
in  this  way  a  peripheral  localization.  (See 
sections  on  Diseases  of  the  Cerebral  and 
Spinal  Nerves.) 

The  axis-cylinder  processes  which  run  in 
the  peripheral  nerves  leave  the  central  nerv- 
ous system  from  its  ventral  aspect.  The 
ventral  roots  of  the  spinal  cord  are  from 
above  down,  collected  into  small  groups, 
which,  after  joining  with  the  dorsal  roots 
of  the  same  level  of  the  cord,  leave  the  spinal 
canal  between  the  vertebrae  as  the  spinal 
nerves.  That  part  of  the  cord  from  which 
the  roots  forming  a  single  spinal  nerve  arise 
is  called  a  segment,  and  corresponds  to  the 
nerve  which  arises  from  it  and  not  to  the 
vertebra  to  which  it  may  be  opposite.  The 
axis-cylinder  processes  which  go  to  make  up 
any  one  peripheral  nerve  do  not  neces- 
sarily arise  from  the  same  segment  of  the 
spinal  cord;  in  fact,  most  peripheral  nerves 
contain  processes  from  several  often  quite  widely  separated  segments,  and 
so  it  happens  that  the  movements  are  represented  in  the  spinal  cord  in  a 
different  manner — that  is,  there  is  spinal  localization,  or,  better,  lower  level 
localization,  since  it  also  includes  the  motor  nuclei  of  the  cerebral  nerves. 

Our  knowledge  of  the  localization  of  the  muscular  movements  in  the 
gray  matter  of  the  lower  motor  segment  is  far  from  complete,  but  enough 
is  known  to  aid  materially  in  determining  the  site  of  a  spinal  lesion.  A 
number  of  tables  have  been  prepared  by  different  observers  to  represent 
our  present  knowledge  of  this  subject.  They  differ  from  each  other  in 
minor  details,  but  agree  in  the  main.  The  following  is  the  table  prepared 
by  Starr,  in  which  the  names  of  the  muscles  are  given  whose  movements 
are  represented  in  each  of  the  spinal  segments.  Movements,  not  muscles, 
are  localized  in  the  central  nervous  system,  a  point  carefully  to  be  borne  in 
mind  by  the  student  (see  Wichmann's  Die  Eiickenmarksnerven,  etc.,  Berlin, 
1900). 


Fig.  1. — Diagram  of  motor  path, 
showing  the  crossing  of  the 
path,  which  takes  place  in 
the  upper  segment.  (Van  Gre- 
huchten,  colored.) 


904 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


t.EG 


Pig.  2.— Diagram  of  motor  path  from  right  brain.  The  upper  segment  is  black,  the  lower 
red.  The  nuclei  of  the  motor  cerebral  nerves  are  shown  on  the  left  side ;  on  the  right 
side  the  cerebral  nerves  of  that  side  are  indicated.  A  lesion  at  1  would  cause  upper 
segment  paralysis  in  the  arm  of  the  opposite  side — cerebral  monoplegia ;  at  2,  upper 
segment  paralysis  of  the  whole  opposite  side  of  the  body — hemiplegia ;  at  3,  upper 
segment  paralysis  of  the  opposite  face,  arm,  and  leg,  and  lower  segment  paralysis 
of  the  eye  muscles  on  the  same  side — crossed  paralysis ;  at  4,  upper  segment  paraly- 
sis of  opposite  arm  and  leg,  and  lower  segment  paralysis  of  the  face  and  the  external 
rectus  on  the  same  side — crossed  paralysis ;  at  5,  upper  segment  paralysis  of  all  mus- 
cles below  lesion,  and  lower  segment  paralysis  of  muscles  represented  at  level  of 
lesion — spinal  paraplegia ;  at  6,  lower  segment  paralysis  of  muscles  localized  at  seat 
of  lesion — anterior  poliomyelitis.     (Van  G-ehuchten,  modified.) 


GENERAL  INTRODUCTION. 
Localization  of  the  Functions  of  the  Segments  of  the  Spinal  Cord. 


905 


Segment. 

Muscles. 

Reflex. 

Sensation. 

II  and 

inc. 

Stern  o-mastoid. 
Trapezius. 
Scaleni  and  neck. 
Diaphragm. 

Hypochondrium  (?), 
Sudden   inspiration  pro- 
duced by  sudden  press- 
ure beneath  the  lower 
border  of  ribs. 

Back  of  head  to  ver- 
tex. 
Neck. 

IV  c. 

Diaphragm. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Supinator  longus. 

Rhomboid. 

Supra-  and  infra-spinatus. 

Pupil.     4th   to   7th  cer- 
vical. 

Dilatation  of    the  pupil 
produced  by  irritation 
of  neck. 

Neck. 

Upper  shoulder. 

Outer  arm. 

vc. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Brachialis  anticus. 

Supinator  longus. 

Supinator  brevis. 

Rhomboid. 

Teres  minor. 

Pectoralis  (clavicular  part). 

Serratus  magnus. 

Scapular. 

5th  cervical  to  1  st  thoracic. 

Irritation  of  skin  over  the 
scapula  produces   con- 
traction of  the  scapular 
muscles. 

Supinator  longus. 

Tapping    its    tendon   in 
wrist  produces  flexion 
of  forearm. 

Back  of  shoulder  and 

arm. 
Outer    side    of    arm 

and  forearm,  front 

and  back. 

VIC. 

Biceps. 

Brachialis  anticus. 

Pectoralis  (clavicular  part). 

Serratus  magnus. 

Triceps. 

Extensors    of    wrist     and 

fingers. 
Pronators. 

Triceps. 

5th  to  6th  cervical. 

Tapping     elbow    tendon 

produces    extension    of 

forearm. 
Posterior  wrist. 
6th  to  8th  cervical. 
Tapping  tendons  causes 

extension  of  hand. 

Outer  side  of  fore- 
arm, front  and 
back. 

Outer  half  of  hand. 

VII  c. 

Triceps  (long  head). 
Extensors     of     wrist     and 

fingers. 
Pronators  of  wrist. 
Plexors  of  wrist. 
Subscapular. 
Pectoralis  (costal  part). 
Latissimus  dorsi. 
Teres  major. 

Anterior  wrist. 
7th  to  8th  cervical. 
Tapping  anterior  tendons 

causes  flexion  of  wrist. 
Palmar.     7th  cervical  to 

1st  thoracic. 
Stroking     palm     causes 

closure  of  fingers. 

Inner  side  and  back 
of  arm  and  fore- 
arm. 

Radial  half  of  the 
hand. 

VIII  c. 

Flexors  of  wrist  and  fin- 
gers. 
Intrinsic  muscles  of  hand. 

Forearm    and    hand, 
inner  half. 

IT. 

Extensors  of  thumb. 
Intrinsic  hand  muscles. 
Thenar     and     hypothenar 
eminences. 

Forearm,  inner  half. 
Ulnar  distribution  to 
hand. 

II  to 
XII  T. 

Muscles  of  back  and  abdo- 
men. 
Erectores  spinae. 

Epigastric.     4th    to    7th 
thoracic. 

Tickling    mammary    re- 
gions causes  retraction 
of  epigastrium. 

Abdominal.     7th  to  11th 
thoracic. 

Stroking  side  of  abdomen 
causes      retraction     of 
belly. 

Skin  of  chest  and 
abdomen  in  bands 
running  aroiind 
and  downward,  cor- 
responding to  spi- 
nal nerves. 

Upper  gluteal  region. 

906 


DISEASES  OF   THE  NERVOUS  SYSTEM. 


Segment. 

Muscles. 

Reflex. 

SK>fSATION. 

IL. 

Ilio-psoas. 
Sartorius. 
Muscles  of  abdomen. 

Cremasteric.     1st   to  3d 

lumbar. 
Stroking      inner      thigh 

causes      retraction     of 

scrotum. 

Skin  over  groin  and 
front  of  scrotum. 

IIL. 

Ilio-psoas.     Sartorius. 
Flexors  of  knee  (Remak). 
Quadriceps  femoris. 

Patellar  tendon. 
Tapping    tendon    causes 
extension  of  leg. 

Outer  side  of  thigh. 

IIIL. 

Quadriceps  femoris. 
Inner  rotators  of  thigh. 
Abductors  of  thigh. 

- 

Front  and  inner  side 
of  thigh. 

IV  L. 

Abductors  of  thigh. 
Adductors  of  thigh. 
Flexors  of  knee  (Perrier). 
Tibialis  anticus. 

Gluteal.    4th  to  5th  lum- 
bar. 

Stroking  buttock  causes 
dimpling    in     fold     of 
buttock. 

Inner   side   of    thigh 

and  leg  to  ankle. 
Inner  side  of  foot. 

VL. 

Outward  rotators  of  thigh. 
Flexors  of  knee  (Ferrier). 
Flexors  of  ankle. 
Extensors  of  toes. 

Back  of  thigh,  back 
of    leg,   and    outer 
part  of  foot. 

I  to  II  S. 

Flexors  of  ankle. 

Long  flexor  of  toes. 

Peron^ei. 

Intrinsic  muscles  of  foot. 

Plantar. 

Tickling    sole     of     foot 
causes  flexion  -of    toes 
and  retraction  of  leg. 

Back  of  thigh. 
Leg  and  foot,  outer 
side. 

into 

VS. 

Perineal  muscles. 

Foot      reflex.       Achilles 

tendon. 
Overextension     of     foot 

causes    rapid    flexion ; 

ankle-clonus. 
Bladder  and  rectal  centres 

Skin  over  sacrum. 

Anus. 

Perinaeum.    Genitals. 

The  above  table  refers  only  to  localization  in  the  spinal  cord.  The 
manner  in  which  movements  are  represented  in  the  pons  and  medulla  is 
about  as  follows.  This  table  is  constructed  from  above  downward  in  refer- 
ence to  the  motor  nuclei  of  the  cranial  nerves: 


Nuclei. 
III. 

IV. 


'  Sphincter.     Ciliary  muscles. 
Levator  palpebrje  superioris.     Rectus  intemus  (in  convergence). 
Rectus  superior.     Rectus  inferior. 
Obliquus  inferior. 
Obliquus  superior. 
(Upper  facial  group.) 


XII. 


-y  j  (Associated  movement  of  levator  palpebrse.) 
■  (  Muscles  of  lower  jaw. 


r  Rectus  externus.    Rectus 
VI.  -<      inter,  of  opposite  side 
[^      in  lateral  movements. 


(Lower  facial  group). 
Muscles  of  tongue. 


VII. — Facial  muscles. 

IX,  r  Muscles  of  pharynx. 
X.  ■<  Muscles  of  oesophagus. 
XL  [  Muscles  of  larynx. 


GENERAL   INTRODUCTION. 


907 


Cerebral  Motor  Localization. — The  cell  bodies  of  the  upper  motor  neu- 
rones are  found  in  the  brain  cortex  anterior  to  the  fissure  of  Eolando,  and 
it  is  in  this  region  that  we  find  the  movements  of  the  body  again  repre- 
sented. 

The  clinical  studies  of  Hughlings  Jackson,  and  the  experiments  of 
Hitzig  and  Fritsch  and  of  Ferrier,  laid  the  foundation  for  the  great  mass 
of  most  excellent  work  which  has  been  done  upon  this  subject.     We  owe 


Fig.  3. — Diagrammatic  representation  of  cortical  localization  in  the  left  hemisphere, 
showing  the  speech  centres.  The  motor  areas  determined  by  unipolar  faradic  exci- 
tation of  the  anthropoid  cortex  (Sherrington  and  Griinbaum)  ai'e  here  shown  stip- 
pled in  red  and  lie  anterior  to  the  Rolandic  fissure.  The  sensory  areas  presumably 
lie  posterior  to  this  fissure  and  are  roughly  indicated  in  blue  without  accurate 
delineation. 


much  to  Victor  Horsley  and  his  associates  for  their  careful  researches  in 
this  direction.  More  recently  the  experimental  work  of  Sherrington  and 
Griinbaum  on  the  higher  apes  have  somewhat  modified  the  observations  of 
preceding  investigators,  and  with  the  result  of  more  accurately  delineating 
the  motor  territory.  They  have  shown  that  true  motor  response  is  only 
elicited  by  stimulation  anterior  to  the  Rolandic  fissure;  that  practically 


908 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


no  point,  over  the  ascending  frontal  convolution,  fails  to  respond  to  stimu- 
lation; that  there  is  but  slight  extension  of  the  motor  cortex  on  to  the 
paracentral  lobule  of  the  mesial  surface  of  the  brain;  that  movements  are 
obtainable  not  only  from  the  exposed  part  of  the  convolution,  but  also 
from  its  hidden  surface  to  the  very  depths  of  the  Eolandic  sulcus;  that 
there  is  an  area  of  representation  for  the  trunk  between  the  centres  for 
the  leg  and  arm,  and  also  for  the  neck  between  those  of  the  arm  and  face ; 
that  the  superior  and  inferior  genua  are  the  landmarks  which  indicate  the 

situation  of  these  small  areas  of  repre- 
sentation for  trunk  and  neck.  These  re- 
sults have  in  large  measure  been  con- 
firmed by  electrical  stimulation  of  the 
human  cortex  in  a  number  of  cases 
from  my  clinic.  From  above  down  the 
motor  areas  occur  in  the  following  order: 
leg,  trunk,  arm,  neck,  head  (Fig.  3). 
Those  of  the  leg  and  arm  occupy  the 
npper  half  of  the  convolution,  and  that  for 
the  head,  including  movements  of  the 
face,  jaws,  tongue,  and  larynx,  the  lower 
half. 

The  speech  centres  are  indicated  in  the 
diagram  (Fig.  3)  in  accordance  with  the 
generally  accepted  views:  that  for  motor 
speech  occupies  the  posterior  part  of  the 
left  third  frontal  or  Broca's  convolution. 
It  is  a  disputed  point  whether  or  not  there 
is  a  separate  centre  presiding  over  the 
movements  employed  in  writing.  Some 
have  assumed  such  a  centre  to  be  present 
in  the  second  frontal  convolution  as  indi- 
cated on  the  diagram.  The  conjugate 
movement  of  head  and  eyes  to  the  opposite 
side  has  commonly  been  found  to  follow 
stimulation  of  the  external  surface  of  the 
frontal  lobe.  Similarly  movements  of  the 
eyes  may  be  elicited  from  the  occipital  cortex,  but  probably  none  of  these 
reactions  are  comparable  to  the  more  simple  movements  which  follow  stimu- 
lation of  the  ascending  frontal  convolution. 

The  axis-cylinder  processes  of  the  upper  motor  neurones  after  leaving 
the  gray  matter  of  the  motor  cortex  pass  into  the  white  matter  of  the  brain 
and  form  part  of  the  corona  radiata.  They  converge  and  pass  between 
the  basal  ganglia  in  the  internal  capsule.  Here  the  motor  axis-cylinders 
are  collected  into  a  compact  bundle — the  pyramidal  tract — occupying  the 
knee  and  anterior  two  thirds  of  the  posterior  limb  of  the  internal  capsule. 
The  order  in  which  the  movements  of  the  opposite  side  of  the  body  are 
represented  here  is  given  in  Fig.  4. 

After  passing  through  the  internal  capsule  the  fibres  of  the  pyramidal 


Fig.  4. — Diagram  of  motor  and  sen- 
sory representation  in  the  inter- 
nal capsule.  NL.,  Lenticular 
nucleus.  NC,  Caudate  nucleus. 
THO.,  Optic  thalamus.  The 
motor  paths  are  red  and  black, 
the  sensory  are  blue. 


GENERAL  INTRODUCTION. 


909 


Fig.  5. — Diagram  of  motor  and  sensory  paths  in  Crura. 


tract  leave  the  hemisphere  by  the  crus,  in  which  they  occupy  about  the 
middle  three  fifths  (Fig.  5).  The  movements  of  the  tongue  and  lips  are 
represented  nearest  the  middle  line. 

As  soon  as  the  tract  enters  the  crus,  some  of  its  axis-cylinder  processes 
leave  it  and  cross  the 
middle  line  to  end  in 
arborizations  about  the 
ganglion  cells  in  the  nu- 
cleus of  the  third  nerve 
on  the  opposite  side;  and 
in  this  way,  as  the  py- 
ramidal tract  passes 
down,  it  gives  off  at  dif- 
ferent levels  fibres  which 
end  in  the  nuclei  of  all 
the  motor  cerebral  nerves 
on  the  opposite  side  of 
the  body.  Some  fibres, 
however,  go  to  the  nu- 
clei of  the  same  side 
(Hoche).  From  the  crus,  the  pyramidal  tract  runs  through  the  pons  and 
forms  in  the  medulla  oblongata  the  pyramid,  which  gives  its  name  to  the 
tract.  At  the  lower  part  of  the  medulla,  after  the  fibres  going  to  the  cere- 
bral nerves  have  crossed 
the  middle  line,  a  large 
proportion  of  the  remain- 
ing fibres  cross,  decussat- 
ing with  those  from  the 
opposite  pyramid,  and 
pass  into  the  opposite  side 
of  the  spinal  cord,  form- 
ing the  crossed  pyramidal 
tract  of  the  lateral  col- 
umn (fasciculus  cerebro- 
spinalis  lateralis)  (Fig.  6, 
1).^  The  smaller  number 
of  fibres  which  do  not  at 
this  time  cross,  descend 
in  the  ventral  column 
of  the  same  side,  form- 
ing the  direct  pyramidal 
tract,  or  Tiirck's  column 
(fasciculus  cerebrospinalis 
ventralis)  (Fig.  6,  2). 
At  every  level  of  the 
spinal  cord  axis-cylinder  processes  leave  the  crossed  pyramidal  tract  to  enter 
the  ventral  horns  and  end  about  the  cell  bodies  of  the  lower  motor  neurones. 
The  tract  diminishes  in  size  from  above  downward.    The  fibres  of  the  direct 


Fig.  6. — Diagram  of  cross-section  of  spinal  cord,  show- 
ing motor,  red,  and  sensory,  blue  paths.  1,  Lateral 
pyramidal  tract.  2,  Ventral  pyramidal  tract.  3, 
Dorsal  columns.  4,  Direct  cerebellar  tract.  5, 
Ventro-lateral  ground  bundles.  6,  Ventro-lateral 
ascending  tract  of  Gowers.  (Van  Gehuchten,  col- 
ored.) 


910 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


V  C  Til  - 


.-  C  VIII 


FiQ.  7. — Diagram  of  skin  areas  corresponding  to  the  different  spinal  segments. 
(Combined  from  Head's  diagrams.) 


GENERAL  INTRODUCTION. 


913 


c  vr -/- 


CTIII 


Fig.  8, — Diagram  of  skin  areas  corresponding  to  the  different  spinal  segments. 
(Combined  from  Head's  diagrams.) 


912  DISEASES  OF  THE  NERVOUS  SYSTEM. 

pyramidal  tract  cross  at  different  levels  in  the  ventral  white  commissure, 
and  also,  it  is  believed,  end  about  cells  in  the  ventral  horns  on  the  opposite 
side  of  the  cord.  This  tract  usually  ends  about  the  middle  of  the  thoracic 
region  of  the  cord. 

The  path  for  sensory  conduction  is  more  complicated  than  the  motor 
path,  and  in  its  simplest  form  is  composed  of  at  least  three  sets  of  neurones, 
one  above  the  other.  The  cell  bodies  of  the  lowest  neurones  are  in  the 
ganglia,  on  the  dorsal  roots  of  the  spinal  nerves,  and  the  ganglia  of 
the  sensory  cerebral  nerves.  These  ganglion  cells  have  a  special  form, 
having  apparently  but  a  single  process,  which,  soon  after  leaving  the  cell, 
divides  in  a  T-shaped  manner,  one  portion  running  into  the  central  nerv- 
ous system  and  the  other  to  the  periphery  of  the  body.  Embryological 
and  comparative  anatomical  studies  have  made  it  probable  that  the  periph- 
eral sensory  fibre,  the  process  which  conducts  toward  the  cell,  represents 
the  protoplasmic  processes,  while  that  which  conducts  away  from  the  cell 
is  the  axis-cylinder  process.  In  the  peripheral  sensory  nerves  we  have,  then, 
the  dendrites  of  the  lower  sensory  neurones.  These  start  in  the  periphery 
of  the  body  from  their  various  specialized  end  organs.  The  axis-cylinder 
processes  leave  the  ganglia  and  enter  the  spinal  cord  by  the  dorsal  roots  of 
the  spinal  nerves.  After  entering  the  cord  each  axis-cylinder  process  di- 
vides into  an  ascending  and  a  descending  branch,  which  run  in  the  dorsal 
fasciculi.  The  descending  branch  runs  but  a  short  distance,  and  ends  in 
the  gray  matter  of  the  same  side  of  the  cord.  It  gives  off  a  number  of 
collaterals,  which  also  end  in  the  gray  matter.  The  ascending  branch  may 
end  in  th.e  gray  matter  soon  after  entering,  or  it  may  run  in  the  dorsal  fas- 
ciculi as  far  as  the  medulla,  and  end  in  the  nuclei  of  these.  In  any  case  it 
does  not  cross  the  middle  line.    The  lower  sensory  neurone  is  direct. 

The  cells  about  which  the  axis-cylinder  processes  and  their  collaterals 
of  the  lower  sensory  neurone  end  are  of  various  kinds.  They  are  known 
as  sensory  neurones  of  the  second  order.  In  the  first  place,  some  of  them 
end  about  the  cell  bodies  of  the  lower  motor  neurones,  forming  the  path 
for  reflexes.  They  also  end  about  cells  whose  axis-cylinder  processes  cross 
the  middle  line  and  run  to  the  opposite  side  of  the  brain.  In  the  spinal 
cord  these  cells  are  found  in  the  different  parts  of  the  gray  matter,  and  their 
axis-cylinder  processes  run  in  the  opposite  ventro-lateral  ascending  tract 
of  Gowers  (Fig.  6,  6)  and  in  the  ground  bundles  (fasciculus  lateralis  pro- 
prius  and  fasciculus  ventralis  proprius). 

In  the  medulla  the  nuclei  of  the  dorsal  fasciculi  (nucleus  fasciculi  gra- 
cilis (Golli)  and  nucleus  fasciculi  cuneati  (Burdachi))  contain  for  the  most 
part  cells  of  this  character.  Their  axis-cylinder  processes,  after  crossing, 
run  toward  the  brain  in  the  medial  lemniscus  or  bundle  of  the  fillet;  certain 
of  the  longitudinal  bundles  in  the  formatio  reticularis  also  represent  sensory 
paths  from  the  spinal  cord  and  medulla  toward  higher  centres.  The  fibres 
of  the  medial  lemniscus  or  fillet  do  not,  however,  run  directly  to  the  cere- 
bral cortex.  They  end  about  cells  in  the  ventro-lateral  portion  of  the  optic 
thalamus,  and  the  tract  is  continued  on  by  way  of  another  set  of  neurones, 
which  send  processes  to  end  in  the  cortex  of  the  posterior  central  and  pari- 
etal convolutions.     This  is  the  most  direct  path  of  sensory  conduction, 


GENERAL  INTRODUCTION.  913 

but  by  no  means  the  only  one.  The  peripheral  sensory  neurones  may 
also  end  about  cells  in  the  cord  whose  axones  run  but  a  short  distance 
toward  the  brain  before  ending  again  in  the  gray  matter,  and  the  path,  if 
path  it  can  be  called,  is  made  up  of  a  series  of  these  superimposed  neurones. 
The  gray  matter  of  the  cord  itself  is  also  believed  to  offer  paths  of  sensory 
conduction.  All  these  paths  reach  the  tegmentum  and  optic  thalamus,  and 
from  thence  are  distributed  to  the  cortex  along  with  the  other  sensory  paths. 
There  may  also  be  paths  of  sensory  conduction  through  the  cerebellum  by 
way  of  the  direct  cerebellar  tract  and  Gowers'  bundle.  From  this  short 
summary  it  is  evident  that  the  possible  paths  of  sensory  conduction  are 
many,  and  that  our  knowledge  of  them  is  as  yet  very  indefinite;  for  this 
reason  disturbances  in  sensation  do  not  give  us  as  much  help  in  making 
a  local  diagnosis  as  do  those  of  motion.  Certain  facts  are  important  to  keep 
in  mind.  The  different  peripheral  nerves  contain  sensory  fibres  from  defi- 
nite areas  of  the  skin,  and  upon  this  depends  the  peripheral  sensory  repre- 
sentation.    (See  section  on  Diseases  of  the  Spinal  Nerves.) 

The  sensory  areas  of  the  skin  are  represented  in  the  spinal  cord  in  an 
entirely  different  manner  from  the  peripheral  representation,  just  as  is  the 
case  in  regard  to  motion.  The  surface  of  the  body  has  been  mapped  out 
into  areas  which  are  meant  to  correspond  to  the  different  dorsal  roots  or 
spinal  segments.  In  Starr's  table  the  third  column  indicates  his  belief. 
His  more  recent  division  of  the  sensory  areas  on  the  limbs  is  pictured  in 
the  American  Journal  of  the  Medical  Sciences,  June,  1895.  Figs.  7  and  8 
embody  the  result  of  Head's  work.  They  are  also  the  areas  in  which  the 
referred  pain  and  cutaneous  tenderness  in  visceral  diseases  make  their  ap- 
pearance. The  cutaneous  sensory  impressions  are  in  man  conducted  toward 
the  brain,  probably  on  the  opposite  side  of  the  cord — that  is,  the  path  crosses 
to  the  opposite  side  soon  after  entering  the  cord.  Muscular  sense,  on  the 
other  hand,  is  conducted  on  the  same  side  of  the  cord  in  the  fasciculi  of 
Goll,  to  cross  above  by  means  of  the  axones  of  sensory  neurones  of  the  second 
order  in  the  medulla. 

Tlie  localization  of  sensory  impressions  in  the  cortex  of  the  brain  is  not 
definitely  determined,  but  it  is  believed  to  be  posterior  to  the  motor  repre- 
sentation. Sensation  seems,  however,  to  be  more  widely  represented  than 
motion,  and  to  occupy  most  of  the  parietal  lobe  as  well  as  the  posterior  cen- 
tral convolutions  (Fig.  3). 

The  paths  for  the  conduction  of  the  stimuli  which  underlie  the  special 
senses  are  given  in  the  section  upon  the  cerebral  nerves,  and  it  is  only  neces- 
sary here  to  refer  to  what  is  known  of  the  cortical  representation  of  these 
senses. 

Visual  impressions  are  localized  in  the  occipital  lobes.  The  primary 
visual  centre  is  on  the  mesial  surface  in  the  cuneus,  especially  about  the 
calcarine  fissure,  and  here  are  represented  the  opposite  half-visual  fields. 
Some  authors  believe  that  there  is  another  higher  centre  on  the  outer  sur- 
face of  the  occipital  lobe,  in  which  tlie  vision  of  the  opposite  eye  is  chiefly 
represented.  However  this  may  be,  most  authors  hold  that  the  angular 
gyrus  of  the  left  hemisphere  is  a  part  of  the  brain  in  which  are  stored  the 
memories  of  the  meaning  of  letters,  words,  figures,  and  indeed  of  all  seen 

61 


914  DISEASES   OP   THE  NERVOUS  SYSTEM. 

objects.  This  is  designated  in  the  visual  speech  centre  on  the  diagram 
(Fig.  3).    Flechsig  and  Monakow  do  not  admit  this.     _ 

Auditory  impressions  are  localized  for  the  most  part  in  the  first  tem- 
poral convolution  and  the  transverse  temporal  gyri,  and  it  is  in  this  region 
in  the  left  hemisphere  that  the  memories  of  the  meanings  of  heard  words 
and  sounds  are  stored.  Musical  memories  are  localized  somewhat  in  front 
of  those  for  words  (Fig.  3).  The  cortical  centres  for  smell  include  a  part  of 
the  base  of  the  frontal  lobe,  the  uncus,  and  perhaps  the  gyrus  hippocampi. 
The  centres  for  taste  are  supposed  to  be  situated  near  those  for  smell,  but 
we  possess  as  yet  no  definite  information  about  them. 

Topical  Diagnosis. — The  successful  diagnosis  of  the  position  of 
a  lesion  in  the  nervous  system  depends  upon  a  careful  and  exhaustive 
examination  into  all  the  symptoms  that  are  present,  and  then  endeavoring 
with  the  help  of  anatomy  and  physiology  to  determine  the  place,  a  disturb- 
ance at  which  might  produce  these  symptoms. 

The  abnormalities  of  motion  are  usually  the  most  important  localizing 
symptoms,  both  on  account  of  the  ease  with  which  they  can  be  demon- 
strated, and  also  because  of  the  comparative  accuracy  of  our  knowledge  of 
the  motor  path. 

Lesions  in  any  part  of  the  motor  path  cause  disturbances  of  motion.  If 
destructive,  the  function  of  the  part  is  abolished,  and  as  the  result  there 
is  paralysis.  If,  on  the  other  hand,  the  lesion  is  an  irritative  one,  the 
structures  are  thrown  into  abnormal  activity,  which  produces  ahiormal 
muscular  contraction.  The  character  of  the  paralysis  or  of  the  abnormal 
muscular  contraction  varies  with  lesions  of  the  upper  and  lower  motor  seg- 
ment, the  variations  depending,  first,  upon  the  anatomical  position  of  the 
two  segments;  and,  secondly,  upon  the  symptoms  which  are  the  result  of 
secondary  degeneration  in  each  of  the  segments. 

{a)  Lesions  of  the  Lower  or  Spino-muscular  Segment. — Destructive 
Lesions. — It  has  been  stated  above  that  the  nutrition  of  all  parts  of  a  neu- 
rone depends  upon  their  connection  with  its  healthy  cell  body;  and  if  the 
cell  body  be  injured,  its  processes  undergo  degeneration,  or  if  a  portion 
of  a  process  be  separated  from  the  cell  body,  that  part  degenerates  along 
its  whole  length.  This  so-called  secondary  degeneration  plays  a  very  impor- 
tant role  in  the  symptomatology. 

In  the  lower  motor  segment  the  degeneration  not  only  affects  the  axis- 
cylinder  processes  which  run  in  the  peripheral  nerves,  but  also  the  muscle 
fibres  in  which  the  axis-cylinder  processes  end.  The  degeneration  of  the 
nerves  and  muscles  is  made  evident,  first,  by  the  muscles  becoming  smaller 
and  flabby,  and,  secondly,  by  change  in  their  reaction  to  electrical  stimula- 
tion. The  degenerated  nerve  gives  no  response  to  either  the  galvanic  or 
the  faradic  current,  and  the  muscle  does  not  respond  to  faradic  stimula- 
tion, but  reacts  in  a  characteristic  manner  to  the  galvanic  current.  The 
contraction,  instead  of  being  sharp,  quick,  lightning-like,  as  in  that  of  a 
normal  muscle,  is  slow  and  lazy,  and  is  often  produced  by  a  weaker  current, 
and  the  anode-closing  contraction  may  be  greater  than  the  cathode-closing 
contraction.  This  is  the  reaction  of  degeneration,  but  it  is  not  always  pres- 
ent in  the  classical  form.     Tlie  essential  feature  is  the  slow,  lazy  contrac- 


GENERAL  INTRODUCTION.  915 

tion  of  the  muscle  to  the  galvanic  current,  and  when  this  is  present  the 
muscle  is  degenerated. 

The  myotatic  irritability,  or  muscle  reflex,  and  the  muscle  tonus  de- 
pend upon  the  integrity  of  the  reflex  arc,  of  which  the  lower  motor  seg- 
ment is  the  efferent  limb,  and  in  a  paralysis  due  to  lesion  of  this  segment 
the  muscle  reflexes  (tendon  reflexes)  are  abolished  and  there  is  a  diminished 
muscular  tension. 

Lower  segment  paralyses  have  for  their  characteristics  degenerative 
atrophy  with  the  reaction  of  degeneration  in  the  affected  muscles,  loss  of 
their  reflex  excitability,  and  a  diminished  muscular  tension.  These  are 
the  general  characteristics,  but  the  anatomical  relations  of  this  segment 
also  give  certain  peculiarities  in  the  distribution  of  the  paralyses  which 
help  to  distinguish  them  from  those  which  follow  lesions  of  the  upper  seg- 
ment, and  which  also  aid  in  determining  the  site  of  the  lesion  in  the  lower 
segment  itself.  The  cell  bodies  of  this  segment  are  distributed  in  groups, 
from  the  level  of  the  peduncles  of  the  brain  throughout  the  whole  extent 
of  the  spinal  cord  to  its  termination  opposite  the  second  lumbar  vertebra, 
and  their  axis-cylinder  processes  run  in  the  peripheral  nerves  to  every  mus- 
cle in  the  body;  so  that  the  component  parts  are  more  or  less  widely  sepa- 
rated from  each  other,  and  a  local  lesion  causes  paralysis  of  only  a  few 
muscles  or  groups  of  muscles,  and  not  of  a  whole  section  of  the  body,  as 
is  the  case  where  lesions  affect  the  upper  segment.  The  muscles  which 
are  paralyzed  indicate  whether  the  disease  is  in  the  peripheral  nerves  or 
spinal  cord;  for,  as  we  have  seen  above,  the  muscles  are  represented  differ- 
ently in  the  peripheral  nerves  and  in  the  spinal  cord.  Sensory  symptoms, 
which  may  accompany  the  paralysis,  are  often  of  great  assistance  in  making 
a  local  diagnosis.  Thus,  in  a  paralysis  with  the  characteristics  of  a  lesion 
of  the  lower  motor  segment,  if  the  paralyzed  muscles  are  all  supplied  by 
one  nerve,  and  the  anesthetic  area  of  the  fkin  is  supplied  by  that  nerve, 
it  is  evident  that  the  lesion  must  be  in  the  nerve  itself.  On  the  other  hand, 
if  the  muscles  paralyzed  are  not  supplied  by  a  single  nerve,  but  are  repre- 
sented close  together  in  the  spinal  cord,  and  the  anaesthetic  area  corresponds 
to  that  section  of  the  cord  (see  table),  it  is  equally  clear  that  the  lesion  must 
be  in  the  cord  itself  or  in  its  nerve  roots. 

Irritative  Lesions  of  tlie  Lower  Motor  Segment. — Lesions  of  this  seg- 
ment cause  comparatively  few  symptoms  of  irritation,  and  our  knowledge 
on  the  point  is  neither  extensive  nor  accurate.  The  fibrillary  contractions 
which  are  so  common  in  muscles  undergoing  degeneration  are  probably 
due  to  stimulation  of  the  cell  bodies  in  their  slow  degeneration,  as  in  pro- 
gressive muscular  atrophy,  or  to  irritation  of  the  axis-cylinder  processes 
in  the  peripheral  nerves,  as  in  neuritis.  Lesions  which  affect  the  motor 
roots  as  they  leave  the  central  nervous  system  may  cause  spasmodic  con- 
tractions in  the  muscles  supplied  by  them.  Certain  convulsive  parox5'sms, 
of  which  1-aryngismus  stridulus  is  a  type,  and  to  which  the  spasms  of  tetany 
also  belong,  are  believed  to  be  due  to  abnormal  activity  in  the  lower  motor 
centres.  These  are  the  "lowest  level  fits"  of  Hughlings  Jackson.  Cer- 
tain poisons,  as  strychnia  and  that  of  tetanus,  act  particularly  upon  these 
centres. 


916  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  principle  diseases  in  whicli  the  lower  motor  segment  may  be  in- 
volved are:  all  diseases  involving  the  peripheral  nerves,  cerebral  and  spinal 
meningitis,  injuries,  hgemorrhages  and  tumors  of  the  medulla  and  cord  or 
their  membranes,  lesions  of  the  gray  matter  of  the  segment,  anterior  polio- 
myelitis, progressive  muscular  atrophy,  bulbar  paralysis,  ophthalmoplegia, 
syringo-myelia,  etc. 

[i)  Lesions  of  the  Upper  Motor  Segment. — Destructive  lesions  cause,  as 
in  the  lower  motor  segment,  paralysis,  and  here  again  the  secondary  degen- 
eration which  follows  the  lesion  gives  to  the  paralysis  its  distinctive  char- 
acteristics. In  this  case  the  paralysis  is  accompanied  by  a  spastic  condi- 
tion, shown  in  an  exaggeration  of  muscle  reflex  and  an  increase  in  the  ten- 
sion of  the  muscle.  It  is  not  accurately  known  how  the  degeneration  of 
the  pyramidal  fibres  causes  this  excess  of  the  muscle  reflex.  The  usual  ex- 
planation is,  that  under  normal  circumstances  the  upper  moto;:  centres 
are  constantly  exerting  a  restraining  influence  upon  the  activity  of  the 
lower  centres,  and  that  when  the  influence  ceases  to  act,  on  account  of  dis- 
ease of  the  pyramidal  fibres,  the  latter  take  on  increased  activity,  which  is 
made  manifest  by  an  exaggeration  of  the  muscle  reflex. 

We  have  seen  that  the  neurones  composing  each  segment  of  the  motor 
path  are  to  be  considered  as  nutritional  units,  and  therefore  the  secondary 
degeneration  in  the  upper  segment  stops  at  the  beginning  of  the  lower. 
For  this  reason  the  muscles  paralyzed  from  lesions  in  the  upper  segment  do 
not  undergo  degenerative  atrophy,  nor  do  they  show  any  marked  change 
in  their  electrical  reactions. 

The  separate  parts  of  the  upper  motor  segment  lie  much  more  closely 
together  than  do  those  of  the  lower  segment,  and  therefore  a  small  lesion 
may  cause  paralysis  in  many  muscles.  This  is  more  particularly  true  in 
the  internal  capsule,  where  all  the  axis-cylinder  processes  of  this  segment 
are  collected  into  a  compac^bundle — the  pyramidal  tract.  A  lesion  in 
this  region  usually  causes  paralysis  of  most  of  the  muscles  on  the  opposite 
side  of  the  body — that  is,  hemiplegia.  The  pyramidal  tract  continues  in  a 
compact  bundle,  giving  off  fibres  to  the  motor  nuclei  at  different  levels;  a 
lesion  anywhere  in  its  course  is  followed  by  paralysis  of  all  the  muscles 
whose  nuclei  are  situated  below  the  lesion.  ^\Tien  the  disease  is  above  the 
decussation,  the  paralysis  is  on  the  opposite  side  of  the  body;  when  below, 
the  paralyzed  muscles  are  on  the  same  side  as  the  lesion.  Above  the  in- 
ternal capsule  the  path  is  somewhat  more  separated,  and  in  the  cortex  the 
centres  for  the  movements  of  the  different  sections  of  the  body  are  com- 
paratively far  apart,  and  a  sharply  localized  lesion  in  this  region  may  cause 
a  more  limited  paralysis,  affecting  a  limb  or  a  segment  of  a  limb — the  cere- 
bral monoplegias;  but  even  here  the  paralysis  is  not  confined  to  an  indi- 
vidual muscle  or  group  of  muscles,  as  is  commonly  the  case  in  lower  seg- 
ment paralysis  (see  Fig.  2  and  explanation). 

To  sum  up,  the  paralyses  due  to  lesions  of  the  upper  motor  segment 
are  widespread,  often  hemiplegic;  the  paralyzed  muscles  are  spastic  (the 
tendon  reflexes  exaggerated),  they  do  not  undergo  degenerative  atrophy, 
and  they  do  not  present  the  degenerative  reaction  to  electrical  stimulation. 

There  is  an  exception  to  the  above  statement — that  is,  in  the  paralyses 


GENERAL  INTRODUCTION.  917 

which  follow  a  complete  transverse  lesion  of  the  spinal  cord.  Here  the 
limbs  are  of  course  completely  paralyzed,  but  instead  of  being  spastic  they 
are  flaccid  and  the  deep  reflexes  are  absent.  There  is,  however,  no  marked 
atrophy  in  the  muscles,  and  they  react  normally  to  electricity.  There  is 
no  satisfactory  explanation  of  why  the  reflexes  should  be  abolished  under 
these  conditions. 

Irritative  Lesions  of  the  Upper  Motor  Segment. — Our  knowledge  of 
such  lesions  is  confined  for  the  most  part  to  those  acting  on  the  motor  cor- 
tex. The  abnormal  muscular  contractions  resulting  from  lesions  so  situ- 
ated have  as  their  type  the  localized  convulsive  seizures  classed  under  Jack- 
sonian  or  cortical  epilepsy,  which  are  characterized  by  the  convulsion  begin- 
ning in  a  single  muscle  or  group  of  muscles  and  involving  other  muscles 
in  a  definite  order,  depending  upon  the  position  of  their  representation  in 
the  cortex.  For  instance,  such  a  convulsion,  beginning  in  the  muscles  of 
the  face,  next  involves  those  of  the  arm  and  hand,  and  then  the  leg.  The 
convulsion  is  usually  accompanied  by  sensory  phenomena  and  followed  by 
a  weakness  of  the  muscles  involved. 

A  majority  of  lesions  of  the  motor  cortex  are  both  destructive  and  irri- 
tative— i.  e.,  they  destroy  the  nerve  cells  of  a  certain  centre,  and  either  in 
their  growth  or  by  their  presence  throw  into  abnormal  activity  those  of  the 
surrounding  centres. 

The  upper  motor  segment  is  involved  in  nearly  all  the  diseases  of 
the  brain  and  spinal  cord,  especially  in  injuries,  tumors,  abscesses,  and 
haemorrhages;  transverse  lesions  of  the  cord;  syringomyelia,  progres- 
sive muscular  atrophy,  bulbar  paralysis,  etc.  One  lesion  often  involves 
both  the  upper  and  the  lower  motor  segments,  and  we  have  paralysis  in 
the  different  parts  of  the  body,  with  the  characteristics  of  each.  Such 
a  combination  enables  us  in  many  cases  to  make  an  accurate  local  diag- 
nosis. 

Lesions  in  the  optic  path,  and  in  the  different  speech  centres  also  give 
localizing  symptoms,  which  should  be  always  looked  for. 

(c)  Lesions  of  the  Sensory  Path. — Here  again  the  lesion  may  be  either 
irritative  or  destructive.  Irritative  lesions  cause  abnormal  subjective  sen- 
sory impressions — pargesthesia,  formication,  a  sense  of  cold  or  constriction, 
and  pain  of  every  grade  of  intensity.  The  character  of  the  sensory  symp- 
toms gives  very  little  indication  as  to  the  position  of  the  irritating  process. 
Intense  pain  is,  as  a  rule,  a  symptom  of  a  lesion  in  the  peripheral  sensory 
neurones,  but  it  may  be  caused  by  a  disease  of  the  sensory  path  within  the 
central  nervous  system. 

The  exact  distribution  of  symptoms  gives  us  more  accurate  data,  for  if 
they  are  confined  to  the  distribution  of  a  peripheral  nerve  or  of  a  spinal 
segment  the  indication  is  plain.  If  one  side  of  the  body  is  more  or  less 
completely  affected,  we  must  think  of  a  lesion  somewhere  within  the 
brain,  etc. 

Destructive  Lesions. — A  complete  destruction  of  the  sensory  paths  from 
any  part  of  the  body  would  of  course  deprive  that  part  of  sensation  in  all 
its  qualities.  This  occurs  most  frequently  from  injury  to  the  peripheral 
sensory  neurones  within  the  peripheral  nerves,  and  the  area  of  anaesthesia 


918 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


depends  upon  the  nerve  injured.     Complete  transverse  lesion  of  the  cord 
causes  complete  anassthesia  below  the  injury. 

Unilateral  lesions  of  the  cord,  medulla,  dorsal  part  of  the  pons,  teg- 
mentum, thalamus,  internal  capsule,  and  cortex  cause  disturbances  of  sensa- 
tion on  the  opposite  side  of  the  body;  here  again  the  extent  of  the  defect 
more  than  its  character  helps  us  to  determine  the  position  of  the  lesion. 
Hemiansesthesia  involving  the  face  as  well  as  the  rest  of  the  body  can  only 
occur  above  the  place  where  the  sensory  paths  from  the  fifth  nerve  have 
crossed  the  middle  line  on  their  way  to  the  cortex.     This  is  in  the  upper 
part  of  the  pons.     From  this  point  to  where  they  leave  the  internal  cap- 
sule the  sensory  paths  are  in  fairly  close  relation,  and  are  at  times  involved 
in  a  very  small  lesion.     Above  the  internal  capsule  the  paths   diverge 
quickly,  and  for  this  reason  only  an  extensive  lesion  can  involve  them  all, 
and  in  lesions  of  this  part  we  are  more  apt  to  have  the  sensory  disturbances 
confined  to  one  or  the  other  segments  of  the  body.     Unilateral  lesions  of 
the  pons,  medulla,  and  cord  usually  cause  sensory  disturbances  on  the  same 
side  of  the  body,  as  well  as  those  on  the  opposite  side.     These  are  due  to 
the  involvement  of  the  sensory. paths  as  they  enter  the  central  nervous  sys- 
tem at  or  a  little  below  the  site  of  the  lesion  and  before  the  axones  of  the 
sensory  neurones  of  the  second  order  have  crossed  the  middle  line.  The  area 
of  disturbed  sensation  on  the  same  side  is  limited  to  the  distribution  of  one 
or  more  spinal  segments  and  often  indicates  accurately  the  position  and  ex- 
tent of  the  diseased  process.    As  a  rule,  destructive  lesions  of  the  central 
nervous  system  do  not  involve  all  the  paths  of  sensory  conduction,  and  the 
loss  of  sensation  is  not  complete.  It  is  often  astonishing  how  very  slight  the 
sensory  disturbances  are  which  result  from  an  extensive  lesion  of  the  nerv- 
ous system.     Sensation  may  be  diminished  in  all  of  its  qualities,  or,  what  is 
more  common,  certain  qualities  may  be  affected  while  others  are  normal. 
These  cases  of  dissociation  of  sensation,  or  so-called  elective  sensory  paraly- 
sis, have  been  much  studied  of  late.     Thus  the  sense  of  pain  and  tempera- 
ture may  be  lost  while  that  of  touch  remains  normal,  as  is  often  the  case  in 
diseases  of  the  spinal  cord,  or  there  may  be  simply  a  loss  of  the  muscular 
sense  and  of  the  stereognostic  sense  (the  complex  sensory  impression  which 
enables  one  to  recognize  an  object  placed  in  the  hand),  as  occurs  frequently 
from  lesions  of  the  cortex.     Occasionally  pain  sensation  persists  with  loss 
of  tactile  and  thermic  sensations.     Almost  every  other  combination  has 
been  described.    It  is  the  distribution  more  than  the  character  of  the  sensory 
defect  that  is  of  importance,  and  often  the  distribution  gives  but  uncertain 
indication  of  the  position  of  the  lesion.     The  combination  of  the  sensory 
defect  with  different  forms  of  paralysis  gives  the  most  certain  diagnostic 
signs.     The  student  is  referred  to  the  sections  on  the  individual  parts  of 
the  nervous  system  for  a  more  detailed  consideration  of  the  subject. 


INTRODUCTION.  919 

II.    SYSTEM  DISEASES. 
I.    INTRODUCTION. 

There  are  certain  diseases  of  the  nervous  system  which  are  confined, 
if  not  absolutely,  still  in  great  part,  to  definite  tracts  (combinations  of 
neurones)  which  subserve  like  functions.  These  tracts  are  called  sys- 
tems, and  a  disease  which  is  confined  to  one  of  them  is  a  system  disease. 
If  more  than  one  system  is  involved,  the  process  is  called  a  combined  system 
disease.  Just  what  diseases  should  be  classed  under  these  names  has  given 
rise  to  much  discussion  but  to  very  little  agreement.  We  cannot  speak 
positively;  our  knowledge  is  as  yet  not  sufficiently  accurate,  either  in  regard 
to  the  exact  limits  of  the  systems  themselves,  or  to  the  nature  and  extent 
of  the  morbid  process  in  the  several  diseases.  In  the  classification  which 
has  been  adopted  in  this  edition  the  endeavor  has  been  to  make  the  arrange- 
ment as  simple  as  possible,  and,  while  it  is  based  upon  what  is  believed  to 
be  the  best  founded  views  of  the  systems  and  their  diseases,  there  has  been 
no  attempt  to  carry  the  classification  to  its  logical  conclusion,  nor  have  the 
limits  of  the  theory  been  always  respected. 

In  general  it  may  be  said  that  the  nervous  system  is  composed  of  two 
great  systems  of  neurones,  the  afferent  or  sensory  system  and  the  efferent 
or  motor  system,  and  the  connections  between  them.  (See  General  Intro- 
duction.) 

Locomotor  ataxia  is  a  disease  confined  to  the  afferent  S3^stem,  and  pro- 
gressive muscular  atrophy  is  one  of  the  efferent  system.  Representing  typ- 
ical system  diseases  as  we  now  understand  them,  they  have  been  taken  as 
the  basis  of  the  classification.  Several  theories  have  been  advanced  to  ex- 
plain why  a  disease  should  be  limited  to  a  definite  system  of  neurones.  One 
view  is  based  upon  the  idea  that  in  certain  individuals  one  or  the  other  of 
these  systems  has  an  innate  tendency  to  undergo  degeneration;  another  as- 
sumes that  neurones  with  a  similar  function  have  a  similar  chemical  con- 
struction (which  differs  from  that  of  neurones  with  a  different  function), 
and  this  is  taken  to  explain  why  a  poison  circulating  in  the  blood  should 
show  a  selective  action  for  a  single  functional  system  of  neurones. 

In  the  afferent  tract  locomotor  ataxia  stands  alone  as  a  system  disease. 
In  the  efferent  tract  progressive  (central)  muscular  atrophy  is  the  chief 
representative,  as  in  it  the  whole  motor  path  is  more  or  less  involved.  The- 
oretically, primary  lateral  sclerosis  is  a  disease  confined  to  the  upper  seg- 
ment of  the  efferent  tract,  while  anterior  poliomyelitis  involves  the  lower 
segment  of  the  tract. 

In  connection  with  progressive  (central)  muscular  atrophy,  the  other 
forms  of  muscular  atrophy  are  considered  as  a  matter  of  convenience.  In 
other  instances,  too,  diseases  are  arranged  in  positions  to  which  they  might 
not  be  entitled,  had  a  rigid  classification  of  system  diseases  been  maintained. 


920  DISEASES  OF  THE  NERVOUS  SYSTEM. 

II.   DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM. 

LocoMOTOE  Ataxia 
{Tabes  Dorsalis;  Posterior  Spinal  Sclerosis). 

Definition. — An  affection  characterized  clinically  by  incoordination, 
sensory  and  trophic  disturbances,  and  involvement  of  the  special  senses, 
particularly  the  eyes.  Anatomically  there  are  found  degeneration  of  the 
posterior  roots  and  of  the  dorsal  columns  of  the  cord;  sometimes  the  spinal 
ganglia  and  peripheral  nerves  are  affected.  Foci  of  degeneration  in  the 
basal  ganglia  and  degenerative  changes  in  the  cortex  cerebri  have  been 
described. 

Etiology. — It  is  a  widespread  disease,  more  frequent  in  cities  than  in 
the  country.  The  relative  proportion  may  be  judged  from  the  fact  that 
of  8,642  cases  in  the  neurological  dispensary  of  the  Johns  Hopkins  Hos- 
pital there  were  89  cases  of  locomotor  ataxia  (H.  M.  Thomas).  Males  are 
attacked  more  frequently  than  females,  the  proportion  being  at  least  10  to 
1.  Mitchell  has  called  attention  to  the  fact  that  it  is  a  rare  disease  in 
the  negro.  It  is  a  disease  of  adult  life,  a. majority  of  the  cases  occurring 
between  the  thirtieth  and  fortieth  years.  Occasionally  cases  are  seen  in 
young  men.  The  form  of  ataxia  which  occurs  in  children  is  a  different  dis- 
ease. Of  special  causes  syphilis  is  the  most  important.  According  to  the 
figures  of  Erb,  Fournier,  and  Gowers,  in  from  50  to  75  per  cent  of  all  cases 
there  is  a  history  of  this  disease.  Erb's  recent  figures  are  most  striking; 
of  300  cases  of  tabes  in  private  practice  89  per  cent  had  had  syphilis.  Moe- 
bius  goes  so  far  as  to  say,  "  The  longer  I  reflect  upon  it,  the  more  firmly  I 
believe  that  tabes  never  originates  without  S5'philis." 

Excessive  fatigue,  overexertion,  injury,  exposure  to  cold  and  wet,  and 
sexual  excesses  are  all  assigned  as  causes.  There  are  instances  in  which 
the  disease  has  closely  followed  severe  exposure.  James  Stewart  has  noted 
that  the  Ottawa  lumbermen,  who  live  a  very  hard  life  in  the  camps  during 
the  winter  months,  are  frequently  the  subjects  of  locomotor  ataxia.  Trauma 
has  been  noted  in  a  few  cases.  Alcoholic  excess  does  not  seem  to  predis- 
pose to  the  disease.  Among  patients  in  the  better  classes  of  life  I  do  not 
remember  one  in  which  there  had  been  a  previous  history  of  prolonged 
drunkenness.  There  are  now  a  good  many  cases  on  record  of  the  existence 
of  the  disease  in  both  husband  and  wife. 

Morbid  Anatomy  and  Pathology. — Our  conception  of  tabes 
dorsalis  has  undergone  radical  alteration,  and  the  studies  of  Leyden,  Red- 
lich,  Marie,  and  others  have  shown  that  it  can  no  longer  be  regarded  as  a 
primary  sclerosis  of  the  dorsal  columns.  These,  it  will  be  remembered,  are 
made  up.  in  great  part,  of  the  axis-cylinder  processes  of  the  spinal  ganglia, 
and  they,  with  their  branches,  represent  in  the  cord  the  paths  of  sensory 
conduction.  The  peripheral  sensory  nerves  represent  the  protoplasmic 
processes  of  the  spinal  ganglia,  which  important  structures  are  the  trophic 
centres  both  for  the  sensory  nerves  as  well  as  for  the  axis-cylinder  processes 
which  make  up  the  dorsal  columns  of  the  cord.     Marie  calls  attention  also 


DISEASES   OF  THE  AFFERENT   OR  SENSORY  SYSTEM.  921 

to  the  possibility  of  the  existence  of  peripheral  or  termiual  ganglion  cells 
which  are  found  in  different  organs — cells  from  which  certain  of  the  sensory 
fibres  are  derived  which  go  to  form  the  dorsal  nerve-roots.  According  to 
the  general  laws  of  nerve  physiology,  already  mentioned,  lesions  of  the  nerve 
ganglia  would  be  followed  by  degeneration  of  the  dorsal  root-fibres  and  of 
their  continuation  in  the  cord,  and  this  is  practically  what  the  recent  theory 
of  tabes  involves.  The  changes  in  the  dorsal  columns  are  merely  a  se- 
quence, and  not  the  primary  disease.  The  fibres  of  the  dorsal  root  are  di- 
vided into  three  sets: 

(1)  The  short  fibres,  which  pass  almost  directly  into  the  dorsal  cornu 
after  entering  the  cord. 

(2)  Fibres  of  moderate  length,  which  run  upward  in  the  cord;  some 
of  them  enter  the  dorsal  horn  at  its  middle  part,  while  others  pass  into 
Clarke's  column.  The  fibres  of  this  group  run  in  the  fasciculus  cuneatus 
of  Burdach. 

(3)  A  group  of  long  fibres,  which  are  derived  chiefly  from  the  roots  of 
the  Cauda  equina,  and  which  pass  the  whole  length  of  the  cord  to  enter 
certain  nuclei  in  the  medulla.  They  form  the  fasciculus  gracilis  of 
GoU. 

The  initial  cord  lesion  in  tabes  is  found  in  the  dorsal  root-zone  and 
in  the  zone  or  tract  of  Lissauer,  a  narrow  portion  situated  between  the 
margin  of  the  cord  and  the  apex  of  the  posterior  horn.  In  the  fasciculus 
of  Burdach  the  sclerosis  is  in  almost  direct  proportion  to  the  duration  of  the 
disease,  slight  at  first  and  centrally  placed,  and  becoming  widespread  as 
the  disease  advances.  The  fasciculus  of  Goll  is  afi^ected  slightly  in  the  early 
stages,  but  in  the  advanced  stage  there  is  extensive  sclerosis.  Marie  cor- 
relates the  sclerosis  of  these  different  parts  with  the  different  groups  of 
nerve-fibres  of  the  dorsal  root,  the  dorsal  root-zone  and  the  zone  of  Lis- 
sauer degenerating  from  the  involvement  of  the  short  fibres;  the  sclerosis 
of  the  fasciculi  of  Burdach  and  the  disappearance  of  the  network  of  the 
nerve-fibres  in  the  colunyLof  Clarke  being  due  to  the  degeneration  of  the 
second  group,  the  fibres  of  moderate  length;  while  the  sclerosis  of  the  fas- 
ciculi of  Goll  is  caused  by  the  degeneration  of  the  third  group,  namely,  the 
long  fibres.  He  suggests  also  that  groups  of  fibres  in  the  different  dorsal 
roots  are  not  simultaneously  affected,  and  the  lesions  may  be  in  an  ad- 
A^anced  stage  in  one  region  and  but  slight  in  the  other.  "  The  lesions  of  the 
spinal  cord  in  tabes  occur  hy  segments,  each  dorsal  root  bringing  into  the 
dorsal  column  a  fresh  contingent  of  degenerated  fibres." 

According  to  this  interesting  hypothesis  the  lesions  of  the  ganglia  of 
the  dorsal  roots  are  responsible,  in  part  at  least,  for  the  peripheral  neuritis, 
since  in  degeneration  of  the  spinal  ganglia  and  consequent  loss  of  trophic 
influence  there  would  necessarily  be  degeneration  in  the  peripheral  nerve- 
trunks.  Possibly,  too,  ]\Iarie  suggests,  the  degeneration  of  the  peripheral 
ganglion  cells  may  have  a  good  deal  to  do  with  the  neuritis  of  tabes. 

Obersteiner  and  Redlich,  while  agreeing  that  the  degeneration  of  the 

dorsal  columns  of  the  cord  is  dependent  upon  a  disease  in  the  dorsal  roots, 

believe,  at  least  for  most  cases,  that  the  change  in  the  latter  is  secondary  to 

a  chronic  inflammation  of  the  pia  mater,  which,  by  making  pressure  on  the 

58 


922  DISEASES  OF  THE  NERVOUS  SYSTEM. 

dorsal  root-fibres  just  where  they  are  poor  in  myeline;,  causes  them  to  de- 
generate. 

The  spinal  ganglia  have  been  found  diseased  in  certain  cases,  but  in 
other  cases  no  change  whatever  could  be  detected,  even  by  the  aid  of  the 
most  delicate  technique,  and  Marie  acknowledges  that  there  is  very  little 
anatomical  proof  for  his  theory  that  it  is  these  structures  that  are  primarily 
affected  in  tabes.     *" 

Trepinski  has  divided  the  dorsal  fasciculi  into  different  systeins  accord- 
ing to  the  time  of  the  development  of  their  myeline,  and  has  endeavored 
to  show  that  the  sclerosis  in  tabes  follows  these  systems. 

Symptoms. — These  are  best  considered  under  three  stages — the  in- 
cipient stage,  the  ataxic  stage,  and  the  paralytic  stage. 

The  Incipient  Stage. — This  is  sometimes  called  the  preataxic  stage. 
The  manner  in  which  tabes  makes  its  onset  differs  very  widely  in  the  dif- 
ferent cases,  and  mistakes  in  diagnosis  are  often  made  early  in  the  disease. 
The  following  are  the  most  characteristic  initial  sjonptoms: 

Pains,  usually  of  a  sharp  stabbing  character;  hence  the  term  lightning 
pains.  They  last  for  only  a  second  or  two  and  are  most  common  in  the  legs. 
They  may  be  associated  with  a  hot  burning  feeling.  Occasionally  herpes 
may  develop  at  the  site  of  the  pain.  They  may  occur  at  irregular  intervals, 
and  are  more  prone  to  follow  excesses  or  to  come  on  when  health  is  im- 
paired. The  gastric  crises  and  other  crises  may  occur  in  the  disease. 
Parsesthesia  may  also  be  among  the  first  symptoms.  Numbness  of  the  feet, 
tingling,  etc.,  and  at  times  a  sense  of  constriction  about  the  hodq.   ' 

Ocular  Symptoms. — (a)  Optic  atrophy.  This  occurs  in  about  10  per  cent 
of  the  eases,  and  is  often  an  early  and  even  the  first  symptom.  There  is 
a  gradual  loss  of  vision,  which  in  a  large  majority  of  cases  leads  to  total 
blindness,  (b)  Ptosis,  which  may  be  double  or  single,  (c)  Paralysis  of/the 
external  muscles  of  the  eye.  This  may  be  of  a  single  muscle  or  occasion- 
ally of  all  of  the  muscles  of  the  eye.  The  paralysis  is  often  transient,  the 
patient  merely  comjalaining  that  he  saw  double  for  a  certain  period.  (cZ) 
Argyll  Eobertson  pupil,  in  which  there  is  loss  of  the  iris  reflex  to  light 
but  contraction  during  accommodation.  The  pupils  are  often  very  small — 
spinal  myosis. 

Bladder  Symptoms. — The  first  warning  of  the  disease  which  the  patient 
has  may  be  a  certain  difficulty  in  emptying  the  bladder.  Incontinence  of 
urine  occurs  only  at  a  later  stage  of  the  disease.  Decrease  in  sexual  desire 
and  power  may  also  be  an  early  symptom. 

Trophic  Disturbances. — These  usually  occur  later  in  the  disease,  but  at 
times  they  are  very  early  symptoms  and  it  is  not  very  infrequent  to  have 
one's  attention  called  to  the  trouble  by  the  presence  of  a  perforating  ulcer 
or  of  a  characteristic  Charcot's  joint. 

Loss  of  the  Knee-jerTc. — This  early  and  most  important  symptom  may 
occur  years  before  the  development  of  ataxia.  Even  alone  it  is  of  great  mo- 
ment, since  it  is  very  rare  to  meet  with  individuals  in  whom  the  knee-jerk 
is  normally  absent.  The  combination  of  loss  of  the  knee-kick  with  one 
or  more  of  the  symptoms  mentioned  above,  especially  with  the  lightning 
pains  and  ptosis  or  Argyll  Eobertson  pupil,  is  practically  diagnostic.     The 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM.  923 

knee-jerk  is  not  lost  suddenly,  but  gradually  decreases,  often  disappearing 
in  one  leg  before  the  other. 

These  are  the  most  common  symptoms  of  the  initial  stage  of  tabes  and 
may  persist  for  years  without  the  development  of  incoordination.  The  pa- 
tient may  look  well  and  feel  well,  and  be  troubled  only  by  occasional 
attacks  of  lightning  pains  or  of  one  of  the  other  subjective  symptoms. 
Moebius  goes  so  far  as  to  state  that  the  typical  Argyll  Robertson  pupil 
means  either  tabes  or  general  paralysis,  and  that  paralysis  of  the  external 
muscles  of  the  eye  developing  in  adults  are  of  almost  equal  importance,  es- 
pecially if  they  develop  painlessly. 

The  time  between  the  syphilitic  infection  and  the  occurrence  of  the 
first  symptoms  of  locomotor  ataxia  varies  within  wide  limits.  About  one 
half  the  cases  occur  between  the  sixth  and  fifteenth  year,  but  many  begin 
even  later  than  this. 

The  disease  may  never  progress  beyond  this  stage,  and  when  optic 
atrophy  develops  early  and  leads  to  blindness,  ataxia  rarely,  if  ever,  super- 
venes. There  is  a  sort  of  antagonism  between  the  ocular  symptoms  and 
the  progress  of  the  ataxia.  Charcot  laid  considerable  stress  upon  this,  and 
both  Dejerine  and  Spiller  have  since  emphasized  the  point. 

Ataxic  S1a.ge. — Motor  Symptoms. — The  ataxia  is  believed  to  be  due  to 
a  disturbance  or  loss  of  the  afi^erent  impulses  from  the  muscles,  joints  and 
deep  tissues,  and  a  disturbance  of  the  muscle  sense  itself  can  usually  be 
demonstrated.  It  develops  gradually.  One  of  the  first  indications  to  the 
patient  is  inability  to  get  about  readily  in  the  dark  or  to  maintain  his  equi- 
librium when  washing  his  face  with  the  eyes  shut.  When  the  patient  stands 
with  the  feet  together  and  the  eyes  closed,  he  sways  and  has  difficulty  in 
maintaining  his  position  (Romberg's  symptom),  and  he  may  be  quite  un- 
able to  stand  on  one  leg.  He  does  not  start  off  promptly  at  the  word 
of  command.  On  turning  quickly  he  is  apt  to  fall.  He  descends  stairs 
with  more  difl&culty  than  he  ascends  them.  Gradually  the  characteristic 
ataxic  gait  develops.  The  patient,  as  a  rule,  walks  with  a  stick,  the  eyes 
are  directed  to  the  ground,  the  body  is  thrown  forward,  and  the  legf  are 
wide  apart.  In  walking,  the  leg  is  thrown  out  violently,  the  foot  is  raised 
too  high  and  is  brought  down  in  a  stamping  manner  with  the  heel  first,  or 
the  whole  sole  comes  in  contact  with  the  ground.  Ultimately  the  patient 
may  be  unable  to  walk  without  the  assistance  of  two  canes.  This  gait  is 
very  characteristic,  and  unlike  that  seen  in  any  other  disease.  The  inco- 
ordination is  not  only  in  walking,  but  in  the  performance  of  other  move- 
ments. If  the  patient  is  asked,  when  in  the  recumbent  posture,  to  touch 
the  knee  with  one  foot,  the  irregularity  in  the  movement  is  very  evident. 
Incoordination  of  the  arms  is  less  common,  but  usually  develops  in  some 
grade.  It  may  in  rare  instances  exist  before  the  incoordination  of  the  legs. 
It  may  be  tested  by  asking  the  patient  to  close  his  eyes  and  to  touch  the  tip 
of  the  nose  or  the  tip  of  the  ear  with  the  finger,  or  with  the  arms  thrust  out 
to  bring  the  tips  of  the  fingers  together.  The  incoordination  may  early  be 
noticed  by  a  difficult3»  which  the  patient  experiences  in  buttoning  his  collar 
or  in  performing  one  of  the  ordinary  routine  acts  of  dressing. 

One  of  the  most  striking  features  of  the  disease  is  that  with  marked 


924  DISEASES  OP   THE  NERVOUS  SYSTEM. 

incoordination  there  is  no  loss  of  muscular  power.  The  grip  of  the  hands 
may  be  strong  and  firm,  the  power  of  the  legs,  tested  by  trying  to  flex  them, 
may  be  unimpaired,  and  their  nutrition,  except  toward  the  close,  may  be 
unaffected. 

There  is  a  remarkable  muscular  relaxation  which  enables  the  joints  to 
be  placed  in  positions  of  hyperextension  and  hyperflexion.  It  gives  some- 
times a  marked  backward  curve  to  the  legs.  Frankel,  who  calls  the  condi- 
tion hypotonia,  says  it  may  be  an  early  symptom. 

Sensory  'Symptoms. — The  lightning  pains  may  persist.  They  vary 
greatly  in  different  cases.  Some  patients  are  rendered  miserable  by  the 
frequent  occurrence  of  the  attacks;  others  escape  altogether.  In  addition, 
common  symptoms  are  tingling,  pins  and  needles,  particularly  in  the  feet, 
and  areas  of  hyperaesthesia  or  of  anesthesia.  The  patient  may  complain  of 
a  change  in  the  sensation  in  the  soles  of  the  feet,  as  if  cotton  was  inter- 
posed between  the  floor  and  the  skin.  Sensory  disturbances  occur  lesS" 
frequently  in  the  hands.  Objective  sensory  disturbances  can  usually  be 
demonstrated,  and  indeed  almost  every  variety  of  sensory  disturbance  has 
been  described.  They  have  been  carefully  studied  in  this  country  by  Knapp 
and  by  Patrick,  and  in  Europe  by  many  observers.  Bands  about  the  chest 
of  a  moderate  grade  of  anaasthesia  are  not  uncommon;  they  are  apt  to 
follow  the  distribution  of  spinal  segments.  The  most  marked  disturbances 
are  usually  found  on  the  legs.  Eetardation  of  the  sense  of  pain  is  common, 
and  a  pin-prick  on  the  foot  is  first  felt  as  a  simple  tactile  impression,  and 
the  sense  of  pain  is  not  perceived  for  a  second  or  two  or  may  be  delayed  for 
as  much  as  ten  seconds.  The  pain  felt  may  persist.  A  curious  phenomenon 
is  the  loss  of  the  power  of  localizing  the  pain.  For  instance,  if  the  patient 
is  pricked  on  one  limb  he  may  say  that  he  feels  it  on  the  other  (allocheiria), 
or  a  pin-prick  on  the  foot  may  be  felt  on  both  feet.  The  muscular  sense 
which  is  usually  affected  early,  becomes  much  impaired  and  the  patient 
no  longer  recognizes  the  position  in  which  his  limbs  are  placed.  This  may 
be  present  in  the  pre-ataxic  stage. 

Eeflexes. — As  mentioned,  the  loss  of  the  knee-jerk  is  one  of  the  earliest 
symptoms  of  the  disease.  Occasionally  a  case  is  found  in  which  it  is  re- 
tained. The  skin  reflexes  may  at  first  be  increased,  but  later  are  usually 
involved  with  the  deep  reflexes. 

Special  Senses.— The  eye  symptoms  noted  above  may  be  present,  but, 
as  mentioned,  ataxia  is  rare  with  atrophy  of  the  optic  nerve.' 

Deafness  may  develop,  due  to  lesion  of  the  auditory  nerve.  There  may 
also  be  attacks  of  vertigo.     Olfactory  symptoms  are  rare. 

Visceral  Symptoms. — Among  the  most  remarkable  sensory  disturbances 
are  the  tabetic  crises,  severe  paroxysms  of  pain  referred  to  various  viscera; 
thus  laryngeal,  gastric,  nephric,  rectal,  urethral,  and  clitoral  crises  have 
been  described.  The  most  common  are  the  gastric  and  laryngeal.  In  the 
former  there  are  intense  pains  in  the  stomach,  vomiting,  and  a  secretion 
of  hyperacid  gastric  juice.  The  attack  may  last  for  several  days  or  even 
longer.  There  may  be  severe  pain  without  any  vomiting.  The  attacks  are 
of  variable  intensity  and  usually  require  morphia.  Paroxysms  of  rectal 
pain  and  tenesmus  are  described.     They  have  not  been   common   in  my 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM.  925 

experience.  Larj^ngeal  crises  also  are  rare.  There  may  be  true  spasm  with 
dyspnoea  and  noisy  inspiration.  In  one  instance  at  least  the  patient  has 
died  in  the  attack.   There  are  also  nasal  crises,  associated  with  sneezing  fits. 

The  sphincters  are  frequently  involved.  Early  in  the  disease  there  may 
be  a  retardation  or  hesitancy  in  making  water.  Later  there  is  retention, 
and  cystitis  may  occur.  Unless  great  care  is  taken  the  inflammation  may 
extend  to  the  kidneys.  Constipation  is  extremely  common.  Late  in  the 
disease  the  sphincter  ani  is  weakened.  The  sexual  power  is  usually  lost  in 
the  ataxic  stage. 

Trophic  Changes. — Skin  rashes  may  develop  in  the  course  of  the  light- 
ning pains,  such  as  herpes,  oedema,  or  local  sweating.  Alteration  in  the 
nails  may  occur.  A  perforating  ulcer  may  develop  on  the  foot,  usually 
beneath-the  great  toe.  A  perforating  buccal  ulcer  has  also  been  described. 
Onychia  may  prove  very  troublesome. 

The  arthropathies  or  Joint  lesions  afl'ect  chiefly  the  knees.  They  are 
unquestionably  associated  with  the  disease  itself,  and  are  not  necessarily  a 
.result  of  trauma.  The  condition,  known  as  Charcot's  joint,  is  anatomic- 
ally similar  to  that  of  chronic  arthritis  deformans.  The  effusion  may  be 
rapid  and  there  may  be  great  disintegration  and  destruction  of  the  carti- 
lages and  bones,  leading  to  dislocation  and  deformity.  Suppuration  may 
occur.  Spontaneous  fractures  may  occur.  Among  other  trophic  disturb- 
ances may  be  mentioned  atrophy  of  the  muscles,  which  is  usually  a  late 
manifestation,  but  may  be  localized  and  associated  with  neuritis.  In  any 
very  large  collection  of  cases  many  instances  of  atrophy  are  found,  due  either 
to  involvement  of  the  ventral  horns  or  to  peripheral  neuritis. 

Cerebral  Symptoms. — Hemiplegia  may  develop  at  any  stage  of  the  dis- 
ease, more  commonly  when  it  is  well  advanced.  It  may  be  due  to  hgemor- 
rhagic  softening  in  consequence  of  disease  of  the  vessels  or  to  progressive 
cortical  changes.  Hemianesthesia  is  sometimes  present.  Very  rarely  the 
hemiplegia  is  due  to  coarse  syphilitic  disease. 

Dementia  paralytica  frequently  exists  with  tabes,  and  it  may  be  ex- 
tremely difficult  to  determine  which  has  been  the  primary  affection;  indeed, 
some  authors  believe  that  these  two  diseases  are  simply  different  localizations 
of  the  same  morbid  process.  In  a  majority  of  the  cases  the  symptoms  of 
locomotor  ataxia  have  preceded  those  of  general  paresis.  In  other  instances 
melancholia,  dementia,  or  paranoia  develop. 

(c)  Paralytic  Stage.— After  persisting  for  an  indefinite  number  of  years 
the  patient  gradually  loses  the  power  of  walking  and  becomes  bedridden 
or  paralyzed.  In  this  condition  he  is  very  likely  to  be  carried  off  by  some 
intercurrent  affection,  such  as  pyelo-nephritis,  pneumonia,  or  tuberculosis. 

The  Course  of  the  Disease. — A  patient  may  remain  in  the  pre-ataxic 
stage  for  an  indefinite  period;  and  the  loss  of  knee-jerk  and  the  gray 
atrophy  of  the  optic  nerves  may  be  the  sole  indication  of  the  true  nature 
of  the  disease.  In  such  cases  incoordination  rarely  develops.  In  a  ma- 
jority of  cases  the  progress  is  slow,  and  after  six  or  eight  years,  sometimes 
less,  the  ataxia  is  well  developed.  The  symptoms  may  vary  a  good  deal; 
thus  the  pains,  which  may  have  been  excessive  at  first,  often  lessen.  Tlie 
disease  may  remain  stationary  for  years;  then  exacerbations  occur  and  it 


926  DISEASES  OF  THE  NERVOUS  SYSTEM. 

makes  rapid  progress.  Occasionally  the  process  seems  to  be  arrested.  There 
are  instances  of  what  may  be  called  acute  ataxia,  in  which,  within  a 
year  or  even  less,  the  incoordination  is  marked,  and  the  paralytic  stage 
may  develop  Avithin  a  few  months.  The  disease  itself  rarely  causes  death, 
and  after  becoming  bedridden  the  patient  may  live  for  fifteen  or  twenty 
years. 

Diagnosis. — In  the  initial  stage  the  combination  of  lightning  pains 
and  the  absence  of  knee-jerk  is  distinctive.  The  association  of  progressive 
atrophy  of  the  optic  nerves  with  loss  of  knee-jerk  is  also  characteristic. 
The  early  ocular  palsies  are  of  the  greatest  importance.  A  squint,  ptosis, 
*or  the  Argyll  Eobertson  pupil  may  be  the  first  symptom,  and  may  exist 
with  the  loss  only  of  the  knee-jerk.  Loss  of  the  knee-jerk  alone,  however, 
does  occasionally  occur  in  healthy  individuals.  A  history  of  preceding 
syphilis  lends  added  weight  to  the  symptoms,  and  its  presence  or  absence 
may  be  of  the  utmost  importance  in  determining  the  diagnosis.  If  the 
possibility  of  syphilitic  infection  can  be  excluded,  a  circumstance  but  too 
rarely  met  with,  only  the  most  unequivocal  combination  of  symptoms  can 
justify  the  diagnosis  of  locomotor  ataxia. 

The  diseases  most  likely  to  be  confounded  with  locomotor  ataxia  are: 
(1)  Peripheral  Neuritis. — The  steppage  gait  of  arsenical,  alcoholic,  or  dia- 
betic paralysis  is  quite  unlike  that  of  locomotor  ataxia.  In  these  forms 
there  is  a  paralysis  of  the  feet  and  the  leg  is  lifted  high  in  order  that  the 
toes  may  clear  the  floor.  The  use  of  the  word  ataxia  in  this  connection 
should  no  longer  be  continued.  In  the  rare  cases  in  which  the  muscle 
sense  nerves  are  particularly  affected  and  in  which  there  is  true  ataxia,  the 
absence  of  the  lightning  pains  and  eye  symptoms  and  the  history  will  suffice 
in  the  majority  of  cases  to  make  the  diagnosis  clear.  In  diphtheritic  paraly- 
sis the  early  loss  of  the  knee-jerk  and  the  associated  eye  symptoms  may  sug- 
gest tabes,  but  the  history,  the  existence  of  paralysis  of  the  throat,  and 
the  absence  of  pains  render  a  diagnosis  easy. 

(2)  Ataxic  Paraplegia. — Marked  incoordination  with  spastic  paralysis 
is  characteristic  of  the  condition  which  Gowers  has  termed  ataxic  paraplegia. 
In  a  majority  of  the  cases  this  affection  is  distinguished  also  by  the  ab- 
sence of  pains  and  of  eye  symptoms. 

(3)  Cerebral  Disease. — In  diseases  of  the  brain  involving  the  afferent 
tracts  ataxia  is  at  times  a  prominent  symptom.  It  is  usually  unilateral  or 
limited  to  one  limb;  this,  with  the  history  and  the  associated  s3-mptoms, 
excludes  tabes. 

(4)  Cerehellar  Disease. — The  cerebellar  incoordination  has  only  a  super- 
ficial resemblance  to  that  of  locomotor  ataxia,  and  is  more  a  disturbance 
of  equilibrium  than  a  true  ataxia;  the  knee-jerk  is  usually  present,  there 
are  no  lightning  pains,  no  sensory  disturbances;  while,  on  the  other  hand, 
there  are  headache,  optic  neuritis,  and  vomiting. 

(5)  Some  acute  affections  involving  the  dorsal  columns  of  the  cord  may 
be  followed  by  incoordination  and  resemble  tabes  very  closely.  In  a  case 
under  my  care,  the  gait  was  characteristic  and  Eomberg's  symptom  was 
present.  The  knee-jerk,  however,  was  retained  and  there  were  no  ocular 
symptoms.    The  condition  had_  developed  within  three  or  four  months,  and 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM.  927 

there  was  a  well-marked  history  of  syphilis.     Under  large  doses  of  iodide 
of  potassium  the  ataxia  and  other  symptoms  completely  disappeared. 

(6)  General  Paresis. — In  some  cases  this  offers  a  serious  difficulty.  In 
the  first  place,  in  general  paresis,  tabetic  symptoms  often  develop;  on  the 
other  hand,  there  are  cases  of  locomotor  ataxia  in  which,  toward  the  end, 
there  are  symptoms  of  general  paresis.  Cases  of  unusually  acute  ataxia 
with  mental  symptoms  belong,  as  a  rule,  to  the  former  disease.  The  ques- 
tion will  be  considered  under  general  paresis. 

(7)  Visceral  crises  and  neuralgic  symptoms  may  lead  to  error,  and  in 
middle-aged  men  with  severe,  recurring  attacks  of  gastralgia  it  is  always 
well  to  bear  in  mind  the  possibility  of  tabes,  and  to  make  a  careful  exam- 
ination of  the  eyes  and  of  the  knee-jerk. 

Prognosis. — Complete  recovery  cannot  be  expected,  but  arrest  of  the 
process  is  not  uncommon  and  a  marked  amelioration  of  the  symptoms  is 
frequent.  Optic-nerve  atrophy,  one  of  the  most  serious  events  in  the  dis- 
ease, has  this  hopeful  aspect — that  incoordination  rarely  follows  and  the 
progress  may  be  arrested.  The  optic  atrophy  itself  is  occasionally  checked. 
On  the  whole,  the  prognosis  in  tabes  is  bad.  The  experience  of  such  men 
as  Weir  Mitchell,  Charcot,  and  Gowers  is  distinctly  opposed  to  the  belief 
that  locomotor  ataxia  is  ever  completely  cured.*  No  such  instance  has 
come  under  my  personal  observation. 

Treatment. — To  arrest  the  progress  and  to  relieve,  if  possible,  the 
symptoms  are  the  objects  which  the  practitioner  should  have  in  view.  A 
quiet,  well-regulated  method  of  life  is  essential.  It  is  not  well,  as  a  rule, 
for  a  patient  to  give  up  his  occupation  so  long  as  he  is  able  to  keep  about 
and  perform  ordinary  work.  I  know  tabetics  who  have  for  years  conducted 
large  businesses,  and  there  have  been  several  notable  instances  in  our  pro- 
fession of  men  who  have  risen  to  distinction  in  spite  of  the  existence  of  this 
disease.  Excesses  of  all  sorts,  more  particularly' in  laccho  et  venere,  should 
be  carefully  avoided.     A  man  in  the  pre-ataxic  stage  should  not  marry. 

Care  should  be  taken  in  the  diet,  particularly  if  gastric  crises  have  oc- 
curred. To  secure  arrest  of  the  disease  many  remedies  have  been  em- 
ployed. Although  syphilis  plays  such  an  important  role  in  the  etiology, 
it  is  universally  acknowledged  that  neither  mercury  nor  the  iodide  of  po- 
tassium have  as  a  rule  the  slightest  influence  over  the  tabetic  lesions.  To 
this  there  is  but  one  exception — when  the  syphilis  is  comparatively  recent; 
when  the  symptoms  develop  within  two  years  of  the  primary  infection, 
there  is  then  a  possibility  of  arrest  by  mercury  and  iodide  of  potassium. 
However,  they  do  not  always  relieve.  In  two  cases  of  very  rapidly  pro- 
gressing tabes  following  syphilis  this  medication  was  of  no  avail.  Of  reme- 
dies which  may  be  tried  and  are  believed  by  some  writers  to  retard  the  pro- 
gress, the  following  are  recommended:  Arsenic  in  full  doses,  nitrate  of 
silver  in  quarter-grain  doses,  Calabar  bean,  ergot,  and  the  preparations 
of  gold. 

The  treatment  by  suspension  introduced  a  few  years  ago  has  already 
been  practically  abandoned.     Good  effects  certainly  have  followed  in  a  few 

♦  For  a  study  of  reputed  cures,  see  L.  C.  Gray,  N.  Y.  Medical  Journal,  November,  1889. 


928  DISEASES  OF  THE  NERVOUS  SYSTEM. 

cases,  but  it  was  unreasonable  from  the  outset,  either  on  tlierapeutic  or 
scientific  grounds,  to  hope  that  by  such  a  measure  permanent  changes  could 
be  induced  in  the  pathological  condition.  The  benefits  were  due  in  great 
part  to  suggestion  and  to  psychical  effects.  In  any  case  it  must  be  used 
with  caution. 

For  the  pains,  complete  rest  in  bed,  as  advised  by  Weir  Mitchell,  and 
counter-irritation  to  the  spine  (either  blisters  or  the  thermo-cautery)  may 
be  employed.  The  severe  spells  which  come  on  particularly  after  excesses 
of  any  kind  are  often  promptly  relieved  by  a  hot  bath  or  by  a  Turkish  bath. 
A  prolonged  course  of  nitrate  of  silver  seems  in  some  cases  to  allay  the 
pains  and  lessen  the  liability  to  the  attacks.  I  have  never  seen  ill  effects 
from  its  use  in  spinal  sclerosis.  Antipyrin  a-nd  antifebrin  may  be  em- 
ployed, and  occasionally  do  good,  but  their  analgesic  powers  in  this  disease 
have  been  greatly  overrated.  Cannabis  indica  is  sometimes  useful.  In 
the  severe  paroxysms  of  pain  hypodermics  of  morphia  or  of  cocaine  must 
be  used.  The  use  of  morphia  should  be  postponed  as  long  as  possible. 
Electricity  is  of  very  little  benefit.  For  the  severe  attacks  of  gastralgia, 
morphia  is  also  required.  The  laryngeal  crises  are  rarely  dangerous. 
An  application  of  cocaine  may  be  made  during  the  spasm,  or  a  few  whiffs 
of  chloroform  may  be  given,  or  nitrite  of  amyl.  In  all  cases  of  tabes  with 
increased  arterial  tension  the  prolonged  use  of  nitroglycerin,  given  in  in- 
creasing doses  until  the  physiological  effect  is  produced,  is  of  great  service 
in  allaying  the  neuralgic  pains  and  diminishing  the  frequency  of  the  crises. 
Its  use  must  be  guarded  when  there  is  aortic  insufficiency.  The  special 
indication  is  increased  tension.  The  bladder  symptoms  demand  constant 
care.  When  the  organ  cannot  be  perfectly  emptied  the  catheter  should  be 
used,  and  the  patient  may  be  taught  its  use  and  how  to  keep  it  thoroughly 
sterilized. 

Prankel's  method  of  re-education  often  helps  the  patient  to  regain  to  a 
considerable  extent  the  control  of  the  voluntary  movements  which  he  has 
lost.  By  this  method  the  patient  is  first  taught,  by  repeated  systematic 
efforts,  to  perform  simple  movements;  from  this  he  goes  to  more  and  more 
complex  movements.  The  treatment  should  be  directed  and  supervised  by 
a  trained  teacher,  as  the  result  depends  upon  the  skill  of  the  teacher  quite 
as  much  as  upon  the  perseverance  of  the  patient. 

III.    DISEASES    OF   THE    EFFE;RENT    OR    MOTOR    TRACT. 

A.    OP  THE  WHOLE  TRACT. 
1.  Peogeessive  (Centeal)  Musculae  Ateophy 

{Poliomyelitis  Anterior  Chronica ;  Amyotrophic  Lateral  Sclerosis;  Progressive  Bulbar 

Paralysis). 

Definition. — A  disease  characterized  by  a  chronic  degeneration  of  the 
motor  tract.  The  whole  tract  is  usually  involved,  but  at  times  the  degen- 
eration is  limited  to  the  lower  segments.  Associated  with  it  is  a  progressive 
atrophy  of  the  muscles,  combined  with  more  or  less  spastic  rigidity. 


DISEASES   OF  THE  EFFERENT   OR  MOTOR  TRACT.  929 

Three  afEections,  as  a  rule  described  apart,  belong  together  in  this 
category:  (a)  Progressive  muscular  atrophy  of  spinal  origin;  (b)  amyo- 
trophic lateral  sclerosis;  and  (c)  progressive  bulbar  paralysis.  A  slow 
atrophic  change  in  thd*  motor  neurones  is  the  anatomical  basis,  and  the  dis- 
ease is  one  of  the  whole  motor  path,  involving,  in  many  cases,  the  cortical, 
bulbar,  and  spinal  centres.  There  may  be  simple  muscular  atrophy  with 
little  or  no  spasm,  or  progressive  wasting  with  marked  spasm  and  great 
increase  in  the  reflexes.  In  others,  there  are  added  symptoms  of  involve- 
ment of  the  motor  nuclei  in  the  medulla — a  glosso-labio-laryngeal  paralysis; 
while  in  others,  again,  with  atrophy  (especially  of  the  arms),  a  spastic  con- 
dition of  the  legs  and  bulbar  phenomena,  tremors  develop  and  signs  of  cor- 
tical lesion.     These  various  stages  may  be  traced  in  the  same  case. 

For  convenience,  bulbar  paralysis  will  be  considered  separately,  and  I 
shall  here  take  up  together  progressive  muscular  atrophy  and  amyotrophic 
lateral  sclerosis. 

The  disease  is  known  as  the  Aran-Duchenne  type  of  progressive  muscular 
atrophy  and  as  Cruveilhier's  palsy,  after  the  French  physicians  who  early  de- 
scribed it.  Luys  and  Lockhart  Clarke  first  demonstrated  that  the  cells  of  the 
ventral  horns  of  the  spinal  cord  were  diseased.  Charcot  separated  two  types 
— one  with  simple  wasting  of  the  muscles,  due,  he  believed,  to  degeneration 
confined  to  the  ventral  horns  (and  to  this  he  restricted  the  name  progressive 
muscular  atrophy — ^type,  Aran-Duchenne);  the  other,'  in  which  there  was 
spastic  paralysis  of  the  muscles  followed  by  atrophy.  As  the  anatomical 
basis  for  this  he  assumed  a  primary  degeneration  of  the  pyramidal  tracts 
and  a  secondary  atrophy  of  the  ventral  horns.  To  this  he  gave  the  name 
of  amyotrophic  lateral  sclerosis.  There  is  but  little  evidence,  however,  to 
show  that  any  such  sharp  distinction  can  be  made  between  these  two  dis- 
eases, and  Leyden  and  Cowers  regard  them  as  identical. 

Etiology. — The  cause  of  the  disease  is  unknown.  It  is  more  frequent 
in  males  than  in  females.  It  affects  adults,  developing  after  the  thirtieth 
year,  though  occasionally  younger  persons  are  attacked.  A  large  majority 
of  all  cases  of  progressive  muscular  atrophy  under  twenty-five  years  of  age 
belong  to  the  dystrophies.  Cold,  wet,  exposure,  fright,  and  mental  worries 
are  mentioned  as  possible  causes.  Erb  has  lately  called  attention  to  cer- 
tain cases  following  injury.  Hereditary  influences  are  present  in  certain 
cases.  The  rare  form  which  occurs  in  infancy  usually  affects  several  mem- 
bers of  the  same  family.  Hereditary  and  family  influences,  however,  play 
but  a  small  part  in  the  etiology  of  this  disease,  and  in  this  it  is  in  contrast 
to  progressive  neural  muscular  atrophy  and  the ,  dystrophies.  Yet,  in  the 
Farr  family,  which  I  recorded  some  years  ago,  in  which  thirteen*  members 
were  affected  in  two  generations,  with  the  exception  of  two,  the  cases  oc- 
curred or  proved  fatal  above  the  age  of  forty,  and  the  late  onset  speaks 
rather  for  a  central  affection.  The  spastic  form  may  develop  late  in  life — 
after  seventy — as  a  senile  change. 

Morbid  Anatomy. — The  essential  anatomical  change  is  a  slow  de- 
generation of  the  motor  path,  involving  particularly  the  lower  motor  neu- 
rones. The  upper  neurones  are  also  involved,  either  first,  simultaneously, 
or  at  a  later  period.     Associated  with  the  degeneration  in  the  cells  of  the 


930 


DISEASES  OF   THE  NERVOUS  SYSTEM. 


ventral  horns  there  is  a  degenerative  atrophy  of  the  muscles.  The  following 
are  the  important  anatomical  changes:  (a)  The  gray  matter  of  the  cord 
shows  the  most  marked  alteration.  The  large  ganglion  cells  of  the  ventral 
horns  are  atrophied,  or,  in  places,  have  entirely  disappeared,  the  neuroglia 
is  increased,  and  the  medullated  fihres  are  much  decreased.  The  fihres  of 
the  ventral  nerve-roots  passing  through  the  white  matter  are  wasted,  (h) 
The  ventral  roots  outside  of  the  cord  are  also  atrophied,  (c)  The  muscles 
which  are  affected  show  degenerative  atrophy,  and  the  inter-muscular 
branches  of  the  motor  nerves  are  degenerated,  (d)  The  degeneration  of  the 
gray  matter  is  rarely  confined  to  the  cord,  but  extends  to  the  medulla,  where 
the  nuclei  of  the  motor  cerebral  nerves  are  found  extensively  wasted,  (e) 
In  a  majority  of  all  the  cases  there  is  sclerosis  in  the  ventro-lateral  white 
tracts,  the  lateral  pyramidal  tracts  particularly  are  diseased,  but  the  degener- 
ation is  not  confined  to  these  tracts,  and  extends  into  the  ventro-lateral 
ground  bundles.  The  direct  cerebellar  and  the  ventro-lateral  ascending 
tracts  are  spared.  The  degeneration  in  the  pyramidal  tracts  extends  toward 
the  brain  to  different  levels,  and  in  several  cases  has  been  traced  to  the 
motor  cortex,  the  cells  of  which  have  been  found  degenerated.  In  the 
medulla  the  medial  longitudinal  fasciculus  has  been  found  diseased. 
(/)  In  those  cases  in  which  no  sclerosis  has  been  found  in.  the  pyramidal 
tracts  there  has  been  a  sclerosis  of  the  ventro-lateral  ground  bundle  (short 
tracts). 

Symptoms. — Irregular  pains  may  precede  the  onset  of  the  wasting, 
and  cases  may  be  treated  for  chronic  rheumatism.     The  hands  are  usually 
first  affected,  and  there  is  difficulty  in  performing  delicate  manipulations. 
The  muscles  of  the  ball  of  the  thumb  waste  early,  then  the  interossei  and 
lumbricales,  leaving  marked  depressions  between  the  metacarpal  bones. 
Ultimately  the  contraction  of  the  flexor  and  extensor  muscles  and  the  ex- 
treme atrophy  of  the  thumb  muscles,  the  interossei,  and  lumbricales  pro- 
duces the  claw-hand — maifi  en  griff e  of  Duchenne.     The  flexors  of  the  fore- 
arm are  usually  involved  before  the  extensors.     In  the  shoulder-girdle  the 
deltoid  is  first  affected;  it  may  waste  even  before  the  other  muscles  of  the 
upper  extremity.     The  trunk  muscles  are  gradually  attacked;  the  upper 
part  of  the  trapezius  long  remains  unaffected.     Owing  to  the  feebleness  of 
the  muscles  which  support  it,  the  head  tends  to  fall  forward.     The  platysma 
myoides  is  unaffected  and  often  hypertrophies.     The  arms  and  the  trunk 
muscles  may  be  much  atrophied  before  the  legs  are  attacked.     The  face 
muscles  are  attacked  late.     Ultimately  the  intercostal  and  abdominal  mus- 
cles may  be  involved,  the  wasting  proceeds  to  an  extreme  grade,  and  the 
patient  may  be  actually  "  skin  and  bone,"  and,  as  "  living  skeletons,"  the 
cases  are  not  uncommon  in  "  museums  "  and  "  side-shows."     Deformities 
and  contractures  result,  and  lordosis  is  almost  always  present.     A  curious 
twitching  of  the  muscles  (fibrillation)  is  a  common  symptom,  and  may  occur 
in  muscles  which  are  not  yet  attacked.     It  is  a  most  important  symptom, 
but  is  not,  as  was  formerly  supposed,  a  characteristic  feature  of  the  disease. 
The  irritability  of  the  muscles  is  increased.     Sensation  is  unimpaired,  but 
the  patient  may  complain  of  numbness  and  coldness  of  the  affected  limbs. 
The  galvanic  and  faradic  irritability  of  the  muscles  progressively  dimin- 


DISEASES  OF  THE  EFFERENT  OR  MOTOR  TRACT.  931 

ishes  and  may  become  extinct;,  the  galvanic  persisting  for  the  longer  time. 
In  cases  of  rapid  wasting  and  paralysis  there  may  be  the  reaction  of  degen- 
eration. The  excitability  of  the  nerve-trunks  may  persist  after  the  mus- 
cles have  ceased  to  respond.  The  loss  of  power  is  usually  proportionate  to 
the  wasting. 

The  foregoing  description  applies  to  the  group  of  cases  in  which  the 
atrophy  and  paralysis  are  flaccid — atonic,  as  Gowers  calls  it.  In  other  cases, 
those  which  Charcot  describes  as  amyotrophic  lateral  sclerosis,  spastic  paraly- 
sis precedes  the  wasting.  This  ionic  atrophy  first  involves  the  arms  and 
then  the  legs.  The  reflexes  are  greatly  increased.  It  is  one  of  the  rare  con- 
ditions in  which  a  jaw  clonus  may  be  obtained.  The  most  typical  condition 
of  spastic  paraplegia  may  be  produced.  On  starting  to  walk,  the  patient 
seems  glued  to  the  ground  and  makes  ineffectual  attempts  to  lift  the  toes; 
then  four  or  five  short,  quick  steps  are  taken  on  the  toes  with  the  body 
thrown  forward;  and  finally  he  starts  off,  sometimes  with  great  rapidity. 
Some  of  the  patients  can  walk  up  and  down  stairs  better  than  on  the  level. 
The  wasting  is  never  so  extreme  as  in  the  atonic  form,  and  the  loss  of 
power  may  be  out  of  proportion  to  it.  The  sphincters  are  unaffected. 
Sexual  power  may  be  lost  early.  Cases  are  met  with  which  correspond  ac- 
curately to  the  clinical  picture  given  by  Charcot  of  amyotrophic  lateral 
sclerosis.  These  are  not  very  common,  and  it  is  much  more  usual  to  have 
a  combination  of  the  two  types,  A  flaccid  atrophic  paralysis  with  increased 
reflexes  is  often  met  with.  These  differences  depend  upon  the  relative  ex- 
tent of  the  involvement  of  the  upper  and  lower  motor  segments  and  the 
time  of  the  involvement  of  each.     The  condition  may  be  unilateral. 

As  the  degeneration  extends  upward  an  important  change  takes  place 
from  the  development  of  bulbar  symptoms,  which  may,  however,  precede 
the  spinal  manifestations.  The  lips,  tongue,  face,  pharynx,  and  larynx 
may  be  involved.  The  lips  may  be  affected  and  articulation  impaired  for 
years  before  serious  symptoms  occur.  In  the  final  stage  there  may  be 
tremor,  the  memory  fails,  and  a  condition  of  dementia  may  develop. 

Gowers  gives  the  following  useful  classification  of  the  varieties  of  this 
affection:  (1)  Atonic  atrophy,  becoming  extreme;  (2)  muscular  weakness 
with  spasm,  but  without  wasting  or  with  only  slight  wasting;  and  (3)  atonic 
atrophy,  rarely  extreme  in  degree,  with  exaggeration  of  the  reflexes.  These 
conditions  may  "  coexist  in  every  degree  and  combination — between  uni- 
versal atonic  atrophy  on  the  one  hand  and  universal  spastic  paralysis  with- 
out wasting  on  the  other." 

Diagnosis. — Progressive  (central)  muscular  atrophy  begins,  as  a  rule, 
in  adult  life,  without  hereditary  or  family  influences  (the  early  infantile 
form  being  an  exception),  and  usually  affects  first  the  muscles  of  the  thumb, 
and  gradually  involves  the  interossei  and  lumbricales.  Fibrillary  contrac- 
tions are  common,  electrical  changes  occur,  and  the  deep  reflexes  are  usu- 
ally increased.  These  characteristics  are  usually  sufficient  to  distinguisli 
it  from  the  other  forms  of  muscular  wasting. 

In  syringo-myelia  the  symptoms  may  be  very  similar  to  those  in  the 
spastic  form  of  muscular  atrophy.  The  sensory  disturbances  in  the  former 
disease  make,  as  a  rule,  the  diagnosis  clear,  but  when  these  are  absent  or 


932  DISEASES  OF  THE  NERVOUS  SYSTEM. 

but  little  developed  it  may  be  very  difficult  or  even  impossible  to  distinguish 
the  diseases. 

Treatment. — The  disease  is  incurable.  I  have  never  seen  the  slight- 
est benefit  from  drugs  or  electricity.  The  downward  progress  is  slow  but . 
certain,  though  in  a  few  cases  a  temporary  arrest  may  take  place.  With  a 
history  of  s'yphilis,  mercury  and  iodide  of  potassium  may  be  tried,  and 
Gowers  recommends  courses  of  arsenic  and  the  hypodermic  injection  of 
strychnine.  Probably  the  most  useful  means  is  systematic  massage,  partic- 
ularly in  the  spastic  cases. 

Bulbar  Paralysis  {Glosso-lahio-laryngeal  Paralysis). 

When  the  disease  affects  the  motor  nuclei  of  the  medulla  first  or  early, 
it  is  called  bulbar  paralysis,  but  it  has  practically  no  independent  existence, 
as  the  spinal  cord  is  sooner  or  later  involved. 

Symptoms. — The  disease  usually  begins  with  slight  defect  in  the 
speech,  and  the  patient  has  difficulty  in  pronouncing  the  dentals  and  Un- 
guals. The  paralysis  starts  in  the  tongue,  and  the  superior  lingual  muscle 
gradually  becomes  atrophied,  and  finally  the  mucous  membrane  is  thrown 
into  transverse  folds.  In  the  process  of  wasting  the  fibrillary  tremors  are 
seen.  Owing  to  the  loss  of  power  in  the  tongue,  the  food  is  with  difficulty 
pushed  back  into  the  pharynx.  The  saliva  also  may  be  increased,  and  is  apt 
to  accumulate  in  the  mouth.  When  the  lips  become  involved  the  patient 
can  neither  whistle  nor  pronounce  the  labial  consonants.  The  mouth  looks 
large,  the  lips  are  prominent,  and  there  is  constant  drooling.  The  food 
is  masticated  with  difficulty.  Swallowing  becomes  difficult,  owing  partly 
to  the  regurgitation  into  the  nostrils,  partly  to  the  involvement  of  the 
pharyngeal  muscles.  The  muscles  of  the  vocal  cords  waste  and  the  voice 
becomes  feeble,  but  the  laryngeal  paralysis  is  rarely  so  extreme  as  that  of 
the  lips  and  tongue. 

The  course  of  the  disease  is  slow  but  progressive.  Death  often  results 
from  an  aspiration  pneumonia,  sometimes  from  choking,  more  rarely  from 
involvement  of  the  respiratory  centres.  The  mind  usually  remains  clear. 
The  patient  may  become  emotional.  In  a  majority  of  the  cases  the  dis- 
ease is  only  part  of  a  progressive  atrophy,  either  simple  or  associated  with 
a  spastic  condition.  In  the  latter  stage  of  amyotrophic  lateral  sclerosis 
the  bulbar  lesions  may  paralyze  the  lips  long  before  the  pharynx  or  larynx 
becomes  affected. 

The  diagnosis  of  the  disease  is  readily  made,  either  in  the  acute  or 
chronic  form.  The  involvement  of  the  lips  and  tongue  is  usually  well 
marked,  while  that  of  the  palate  may  be  long  deferred.  A  condition  has 
been  described,  however,  which  may  closely  simulate  bulbar  paralysis. 
This  is  the  so-called  pseudo-lulbar  form  or  bulbar  palsy  of  cerebral  origin. 
Bilateral  disease  of  the  motor  cortex  in  the  lower  part  of  the  ascending 
frontal  convolution,  or  about  the  knee  of  the  internal  capsule,  may  cause 
paralysis  of  the  lips  and  tongue  and  pharynx,  which  closely  simulates  a 
lesion  of  the  medulla.  Sometimes  the  symjDtoms  appear  on  one  side,  but 
in  many  instances  they  develop  suddenly  on  both  sides.     A  bilateral  le- 


DISEASES   OP   THE  EFFERENT  OR  MOTOR  TRACT.  933 

sion  has  usually  been  found,  but  in  several  instances  the  disease  was  uni- 
lateral. 

The  so-called  acute  bulbar  paralysis  may  be  due  to  (a)  haemorrhagic  or 
embolic  softening  in  the  pons  and  medulla;  (b)  acute  inflammatory  softening, 
analogous  to  polio-myelitis,  occurring  occasionally  as  a  post-febrile  affection. 
It  usually  comes  on  very  suddenly,  hence  the  term  apoplectiform.  The 
symptoms  in  this  form  may  correspond  closely  to  those  of  an  advanced  case 
of  chronic  bulbar  paralysis.  The  sudden  onset  and  the  associated  symptoms 
make  the  diagnosis  easy.  In  these  acute  cases  there  may  be  loss  of  power 
in  one  arm,  or  hemiplegia,  sometimes  alternate  hemiplegia,  with  paralysis 
on  one  side  of  the  face  and  loss  of  power  on  the  other  side  of  the  body. 

3.  Progressive  Neural  Muscular  Atrophy. 

This  form,  known  also  as  the  peroneal  type,  or  by  the  names  of  the  men 
who  have  described  it  most  accurately  of  late — namely,  Charcot,  Marie,  and 
Tooth — occurs  either  as  a  hereditary  or  as  a  family  affection.  It  usually 
begins  in  early  childhood,  affecting  first  the  muscles  of  the  feet  and  the 
peroneal  group;  as  a  result  of  the  weakening  of  these  muscles,  club-foot, 
either  pes  equinus  or  pes  equino-varus  occurs.  In  rare  instances  the  dis- 
ease may  begin  in  the  hands,  but  the  upper  limbs,  as  a  rule,  are  not  affected 
for  some  years  after  the  legs  are  attacked,  and  the  trouble  then  begins  in 
the  small  muscles  of  the  hands.  Sensory  disturbances  are  frequently  present 
and  form  important  diagnostic  features.  Fibrillary  contractions  and  twitch- 
ings  also  occur.  The  electrical  reactions  are  altered;  there  is  either  a  loss  or 
a  very  great  decrease  of  the  excitability,  which  can  be  demonstrated  not 
only  in  the  atrophic  muscles,  but  also  in  muscles  and  nerved  which  are  ap- 
parently normal. 

This  form  of  muscular  atrophy  seems  to  stand  between  the  central  form 
and  the  muscular  dystrophies.  Occurring  in  families  and  beginning  in 
early  life,  it  resembles  the  latter,  but  it  is  more  like  the  former  in  that 
fibrillary  contractions  and  muscular  twitchings  are  common,  that  the  small 
muscles  of  the  hand  are  apt  to  be  involved,  and  that  electrical  changes  are 
present.  In  the  prominence  of  sensory  symptoms  it  differs  from  both.  In 
cases  of  acquired  double  club-foot  this  disease  should  be  suspected. 

3.  The  Muscular  Dystrophies 
(Dystrophia  muscularis  progressiva,  Erb). 

Definition. — Muscular  wasting,  with  or  without  an  initial  hypertro- 
phy, beginning  in  various  groups  of  muscles,  usually  progressive  in  char- 
acter, and  dependent  on  primary  changes  in  the  muscles  themselves.  A 
marked  hereditary  disposition  is  met  with  in  the  disease. 

Etiology. — No  etiological  factors  of  any  moment  are  known  other 
than  heredity.  The  influence  may  show  itself  by  true  heredity — the  dis- 
ease occurring  in  two  or  more  generations — or  several  members  of  the  same 
generation  may  be  affected,  showing  a  family  tendency.  Many  members 
of  the  same  family  may  be  attacked  through  several  generations.     Males, 


934  DISEASES  OF  THE  NERVOUS  SYSTEM. 

as  a  rule,  are  more  frequently  affected  than  females.  The  disease  is  usually 
transmitted  through  the  mother,  though  she  may  not  herself  be  affected. 
As  many  as  20  or  30  cases  have  been  described  in  five  generations.  In  Erb's 
cases  44  per  cent  showed  no  heredity.  The  disease  usually  sets  in  before 
puberty,  but  may  be  as  late  as  the  twentieth  or  twenty-fifth  year,  or  in  some 
instances  even  later. 

Symptoms. — The  first  symptom  noticed  is,  as  a  rule,  clumsiness  in 
the  movements  of  the  child,  and  on  examination  certain  muscles  or  groups 
of  muscles  seem  to  be  enlarged,  particularly  those  of  the  calves.  The 
extensors  of  the  leg,  the  glutei,  the  lumbar  muscles,  the  deltoid,  triceps 
and  infraspinatus,  are  the  next  most  frequently  involved,  and  may  stand 
out  with  great  prominence.  The  muscles  of  the  neck,  face,  and  forearm 
rarely  suffer.  Sometimes  only  a  portion  of  a  muscle  is  involved.  With  this 
hypertrophy  of  some  muscles  there  is  wasting  of  others,  particularly  the 
lower  portion  of  the  pectorals  and  the  latissimus  dorsi.  The  attitude  when 
standing  is  very  characteristic.  The  legs  are  far  apart,  the  shoulders  thrown 
back,  the  spine  is  greatly  curved,  and  the  abdomen  protrudes.  The  gait  is 
waddling  and  awkward.  In  getting  up  from  the  floor  the  position  assumed, 
so  well  known  now  through  Gowers'  figures,  is  pathognomonic.  The  pa- 
tient-first turns  over  in  the  all-fours  position  and  raises  the  trunk  with 
his  arms;  the  hands  are  then  moved  along  the  ground  until  the  knees  are 
reached;  then  with  one  hand  upon  a  knee  he  lifts  himself  up,  grasps  the 
other  knee,  and  gradually  pushes  himself  into  the  erect  posture,  as  it  has 
been  expressed,  by  climbing  up  his  legs.  The  striking  contrast  between  the 
feebleness  of  the  child  and  the  powerful-looking  pseudo-hypertrophic  mus- 
cles is  very  characteristic.  The  enlarged  muscles  may,  however,  be  rela- 
tively very  strong. 

The  course  of  the  disease  is  slow,  but  progressive.  Wasting  proceeds 
and  finally  all  traces  of  the  enlarged  condition  of  the  muscles  disappear. 
At  this  late  period  distortions  and  contractions  are  common. 

The  muscles  of  the  shoulder-girdle  are  nearly  always  affected  early  in 
the  disease,  causing  a  symptom  upon  which  Erb  lays  great  stress.  With 
the  hands  under  the  arms,  when  one  endeavors  to  lift  the  patient,  the 
shoulders  are  raised  to  the  level  of  the  ears,  and  one  gets  the  impression 
as  though  the  child  were  slipping  through.  These  "  loose  shoulders  "  are 
very  characteristic.  The  abnormal  mobility  of  the  shoulder-blades  gives 
them  a  winged  appearance,  and  makes  the  arms  seem  much  longer  than 
usual  when  they  are  stretched  out. 

The  patients  complain  of  no  sensory  symptoms.  The  atrophic  mus- 
cles do  not  show  the  reaction  of  degeneration  except  in  extremely  rare  in- 
stances. 

Clinical  rorm.s. — A  number  of  different  types  have  been  described, 
depending  upon  the  age  at  the  onset,  the  muscles  first  affected,  the  occur- 
rence of  hypertrophy,  the  prominence  of  heredity,  etc.  But  Erb  has  shown 
that  there  is  no  sharp  division  between  these  different  forms,  and  classes 
them  all  under  the  name  of  dystrophia  muscularis  progressiva.  For  con- 
venience of  description  he  subdivides  the  disease  into  two  large  groups: 

I.  Those  cases  which  occur  in  childhood. 


DISEASES  OF  THE  EFFERENT   OR  MOTOR  TRACT.  935 

II.  The  cases  occurring  in  youth  and  adult  life. 

The  first  division  is  subdivided  into  (1)  the  hypertrophic  and  (3)  the 
atrophic  form. 

Under  the  hypertrophic  form,  which  is  the  pseudo-hypertrophic  mus- 
.cular  paralysis  of  authors,  he  thinks  it  is  useful  to  distinguish  between 
the  cases  in  which  (a)  the  enlarged  muscles  have  undergone  lipomatosis — 
1.  e.,  pseudo-hypertrophy — from  those  (b)  in  which  there  is  a  real  hyper- 
trophy. 

The  atrophic  form  also  includes  two  subclasses:  (a)  Those  cases  in 
which  the  muscles  of  the  face  are  involved  early;  this  corresponds  to  the 
infantile  form  of  Duchenne — the  Landouzy-Dejerine  type,  (b)  Those  cases 
in  which  the  face  is  not  involved. 

I.  Dystrophia  muscularis  progressiva  infantum. 

1.  Hypertrophic  form. 

(a)  With  pseudo-hypertrophy. 

(b)  With  real  hypertrophy. 

2.  Atrophic  form. 

(ft)  With  primary  involvement  of  the  face  (infantile  form  of 

Duchenne). 
(b)  Without  involvement  of  the  face. 

II.  Dystrophia  muscularis  progressiva  juvenum  vel  aduUorum  (Erb's 
juvenile  form). 

Morbid  Anatomy. — According  to  Erb,  the  disease  consists  in  a 
change  in  the  muscles  themselves.  At  first  the  muscle-fibres  hypertrophy, 
and  become  round;  the  nuclei  increase,  and  the  muscle-fibres  may  become 
fissured.  At  the  same  time  there  is  a  slight  increase  in  the  connective  tissue. 
Sooner  or  later  the  muscle-fibres  begin  to  atrophy,  and  the  nuclei  become 
greatly  increased.  Vacuoles  and  fissures  appear,  and  the  fibres  finally  be- 
come completely  atrophic,  the  connective  tissue  becoming  markedly  in- 
creased. Fat  may  be  deposited  in  the  connective  tissue  to  such  an  extent  as 
to  cause  hypertrophic  lipomatosis — pseudo-hypertrophy.  The  different 
stages  of  these  changes  may  be  found  in  a  single  muscle  at  the  same  time. 

The  nervous  system  has  very  generally  been  found  to  be  without 
demonstrable  lesions,  but  in  certain  cases  changes  in  the  cells  of  the  ventral 
horn  have  been  described. 

Diagnosis.  ^ — The  muscular  dystrophies  can  usually  be  readily  distin- 
guished from  the  other  forms  of  muscular  atrophy. 

(ft)  In  the  cerebral  atrophy  loss  of  power  usually  precedes  the  atrophy, 
which  is  either  of  a  monoplegic  or  hemiplegic  type. 

(b)  From  progressive  (central)  muscular  atrophy  the  distinctions  are 
clearly  marked.  This  form  begins  in  the  small  muscles  of  the  hand,  a  situ- 
ation rarely  if  ever,  affected  by  the  dystrophies,  which  involve  first  those 
of  the  calves,  the  trunk,  the  face,  or  the  shoulder-girdle.  In  the  central 
atrophy  the  reaction  of  degeneration  is  present  and  fil)rillary  twitchings 
occur  in  both  the  atrophied  and  non-atrophied  muscles.  In  many  cases,  in 
addition  to  the  wasting  in  the  arms,  there  is  a  spastic  condition  in  the  legs 
and  increase  in  the  reflexes.  The  central  atrophies  come  on  late  in  life; 
the  dystrophies  develop,  as  a  rule,  early.     In  the  progressive  muscular  dys- 


936  DISEASES   OF   THE  NERVOUS  SYSTEM. 

trophies  heredity  plays  an  important  role,  which  in  the  central  form  is  quite 
subsidiary.  In  the  rare  cases  of  early  infantile  spinal  muscular  atrophy 
occurring  in  families  the  symptoms  are  so  characteristic  of  a  central  disease 
that  the  diagnosis  presents  no  difficulty. 

(c)  In  the  neuritic  muscular  atrophies,  whether  due  to  lead  or  to  trauma, 
the  general  characters  and  the  mode  of  onset  are  distinctive.  In  the  cases 
of  multiple  neuritis  seen  for  the  first  time  at  a  period  when  the  wasting  is 
marked  there  is  often  difficulty,  but  the  absence  of  family  history  and  the 
distribution  are  important  features.  Moreover,  the  paralysis  is  out  of  pro- 
portion to  the  atrophy.  Sensory  symptoms  may  be  present,  and  in  the  cases 
in  which  the  legs  are  chiefly  involved  there  is  usually  the  steppage  gait  so 
characteristic  of  peripheral  neuritis. 

{d)  Progressive  neural  muscular  atrophy.  Here  heredity  is  also  a  factor, 
and  the  disease  usually  begins  in  early  life,  but  the  distribution  of  atrophy 
and  paralysis,  which  in  this  aifection  is  at  first  confined  to  the  periphery 
of  the  extremities,  helps  to  distinguish  it  from  the  dystrophies;  while  the 
occurrence  of  sensory  symptoms,  fibrillary  contractions,  and  the  marked 
decrease  in  the  electrical  escitability  usually  make  the  distinction  clear. 

The  outlook  in  the  primary  muscular  dystrophies  is  bad.  The  wasting 
progresses  uniformly,  uninfluenced  by  treatment.  Erb  holds  that  by  elec- 
tricity and  massage  the  progress  is  occasionally  arrested.  The  general  health 
should  be  carefully  looked  after,  moderate  exercise  allowed,  frictions  with 
oil  applied  to  the  muscles,  and  when  the  patient  becomes  bedfast,  as  is  in- 
evitable sooner  or  later,  care  should  be  taken  to  prevent  contractures  in 
awkward  positions. 

The  three  forms  of  progressive  muscular  wasting — progressive  (central) 
muscular  atrophy,  progressive  neural  muscular  atrophy,  and  the  muscular 
dystrophies — have  been  considered  as  distinct  diseases,  but  certain  recent 
writings  make  it  probable  that  the  distinction  may  not  be  so  sharp  as  we 
believe.  Certain  cases  occur  which  seem  not  to  belong  to  any  one  of  the 
forms  but  to  stand  between  them.  The  changes  in  the  muscles  which  were 
thought  to  be  characteristic  of  the  dystrophies  have  been  found  in  the 
other  forms.  The  central  form  occurs  as  a  family  disease  in  infancy,  and 
the  nervous  system  has  been  found  diseased  in  the  dystrophies. 

The  whole  question  is  in  a  chaotic  state,  and  it  is  at  present  better  to 
keep  to  the  old  divisions.  Even  if  it  should  turn  out  to  be  true,  as  Striimpell 
suggests,  that  all  the  forms  depend  upon  a  congenital  tendency  of  the 
motor  system  to  degenerate,-  they  represent  well-defined  clinical  types,  into 
which  the  cases  can,  as  a  rule,  be  grouped  without  difficulty,  while  corre- 
sponding to  each  there  is  a  fairly  well-determined  anatomical  basis. 

B.    SYSTEM  DISEASES  OF  THE  UPPER  MOTOR  SEGMENT. 

The  question  of  an  uncomplicated  primary  degeneration  of  the  upper 
motor  neurones  has  not  been  decided.  Cases  with  a  clinical  picture  corre- 
sponding to  this  lesion  are  not  uncommon,  and  they  may  persist  for  a  long 
time  without  change.  Unfortunately  the  cases  which  have  come  to  autopsy 
have  shown  various  conditions.     In  only  two  or  three  has  the  disease  been 


DISEASES  OF  THE  EFFERENT   OR  MOTOR  TRACT.  937 

so  nearly  confined  to  the  pyramidal  tract  that  they  can  be  used  as  an  argu- 
ment for  the  independence  of  this  condition.  The  cases  of  Minlvowski, 
Dreschfeld,  and  Striimpell  are  not  absolutely  conclusive,  as  they  are  not 
quite  pure,  although  they  go  far  to  prove  that  a  degeneration  in  the  pyram- 
idal tract  may  be  uncomplicated,  at  least  for  a  long  time.  The  same 
may  be  said  for  the  group  of  cases  described  by  Bernhardt  and  Striimpell 
under  the  name  hereditary  spastic  spinal  paralysis,  in  which  the  extensive 
systemic  degeneration  of  the  pyramidal  tracts  is  combined  with  slight  de- 
generation in  other  tracts  of  the  cord. 

1.  Spastic  Paralysis  of  Adults 

{Tabes  dorsalis  spasmodique  ;  Primary  Lateral  Sclerosis). 

Definition. — A  gradual  loss  of  power  with  spasm  of  the  muscles  of  the 
body,  the  lower  extremities  being  first  and  most  affected,  unaccompanied 
by  muscular  atrophy,  sensory  disturbance,  or  other  symptoms.  The  patho- 
logical anatomy  is  undetermined,  but  a  systemic  degeneration  of  the  pyram- 
idal tracts  is  assumed. 

Symptoms. — The  general  symptoms  of  spastic  paraplegia  in  adults  are 
very  distinctive.  The  patient  complains  of  feeling  tired,  of  stiffness  in  the 
legs,  and  perhaps  of  pains  of  a  dull  aching  character  in  the  back  or  in  the 
calves.  *  There  may  be  no  definite  loss  of  power,  even  when  the  spastic  con- 
dition is  well  established.  In  other  instances  there  is  definite  weakness.  The 
stiffness  is  felt  most  in  the  morning.  In  a  well-developed  case  the  gait  is 
most  characteristic.  The  legs  are  moved  stifRy  and  with  hesitation,  the 
toes  drag  and  catch  against  the  ground,  and,  in  extreme  cases,  when  the 
ball  of  the  foot  rests  upon  the  ground  a  distinct  clonus  develops.  The 
legs  are  kept  close  together,  the  knees  touch,  and  in  certain  cases  the  ad- 
ductor spasm  may  cause  cross-legged  progression.  On  examination,  the  legs 
may  at  first  appear  tolerably  supple,  perhaps  flexed  and  extended  readily. 
In  other  cases  the  rigidity  is  marked,  particularly  when  the  limbs  are  ex- 
tended. The  spasm  of  the  adductors  of  the  thigh  may  be  so  extreme  that 
the  legs  are  separated  with  the  greatest  difficulty.  In  cases  of  this  extreme 
rigidity  the  patient  usually  loses  the  power  of  walking.  The  nutrition  is 
well  maintained,  the  muscles  may  be  hypertrophied.  The  reflexes  are 
greatly  increased.  The  slightest  touch  upon  the  patellar  tendon  produces 
an  active  knee-jerk.  The  rectus  clonus  and  the  ankle  clonus  are  easily  ob- 
tained. In  some  instances  the  slightest  touch  may  throw  the  legs  into  vio- 
lent clonic  spasm,  the  condition  to  which  Brown-Sequard  gave  the  name  of 
spinal  epilepsy.  The  superficial  reflexes  are  also  increased.  The  arms  may 
be  unaffected  for  years,  but  occasionaHy  they  become  weak  and  stiff  at  the 
same  time  as  the  legs.  This  was  the  case  m  a  colored  boy  who  was  in  my 
wards  for  several  years.  He  presented  a  degree  of  general  spastic  rigidity 
that  I  have  never  seen  equalled.  The  disease  had  begun  after  puberty, 
developed  gradually,  and  remained  quite  stationary  for  more  than  a  year 
before  he  left  the  wards.    There  were  no  other  symptoms. 

The  course  of  the  disease  is  progressively  downward.  Years  may  elapse 
before  the  patient  is  bedridden.  Involvement  of  the  sphincters,  as  a  rule, 
no 


9^8  DISEASES  OF  THE  KERVOUS  SYSTEM. 

is  late;  occasionally,  however,  it  is  early.  The  sensory  symptoms  rarely 
progress,  and  the  patients  may  retain  their  general  nutrition  and  enjoy  ex- 
cellent health.    Ocular  symptoms  are  rare. 

The  diagnosis,  so  far  as  the  clinical  picture  is  concerned,  is  readily  made, 
but  it  is  often  very  difficult  to  determine  accurately  the  nature  of  the  under- 
lying pathological  condition.  A  history  of  syphilis  is  present  in  many  of 
the  cases.  Cases  which  have  run  a  fairly  typical  clinical  course  upon  com- 
ing to  autopsy  have  been  found  to  have  been  due  to  very  different  condi- 
tions— transverse  myelitis,  multiple  sclerosis,  cerebral  tumor,  etc.  General 
paralysis  of  the  insane  may  begin  with  symptoms  of  spastic  paraplegia,  and 
Westphal  believed  that  it  was  only  in  relation  to  this  disease  that  a  primary 
sclerosis  of  the  pyramidal  tracts  ever  occurred.  In  any  case  the  diagnosis 
of  primary  systemic  degeneration  of  the  pyramidal  tract  is,  to  say  the  least, 
doubtful. 

2.  Spastic  Paealtsis  of  Infants — Spastic  Diplegia — Bieth  Palsies 

{Paraplegia  cerehralis  spastica  {Heine) ;  Little's  Disease). 

In  this  condition  there  is  a  paralysis  with  spasm  of  all  extremities,  dating 
from  or  shortly  succeeding  birth,  more  rarely  following  the  fevers  or  an 
attack  of  convulsions.  The  legs  are  usually  more  involved  than  the  arms; 
there  is  no  wasting,  no  disturbance  of  sensation.  The  reflexes  are  increased. 
The  mental  condition  is  usually  much  disturbed.  The  patients  are  often 
imbeciles  or  idiots,  helpless  in  mind  and  body.  Ataxic  and  athetoid  move- 
ments of  the  most  exaggerated  kind  may  occur. 

While  a  limited  number  only  of  cases  of  infantile  hemiplegia  are  con- 
genital, on  the  other  hand,  in  spastic  diplegia  and  paraplegia  a  large  pro- 
portion of  the  cases  results  from  injury  at  birth.  The  arms  may  be  so 
slightly  affected  as  to  make  it  difficult  to  determine  whether  it  is  a  case  of 
diplegia  or  paraplegia.  The  disease  usually  dates  from  birth,  and  a  ma- 
jority of  the  children  are  born  in  first  labors  or  are  forceps  cases,  and  are 
at  birth  asphyxiated  blue  babies.  Eoss  suggests  that  in  feet  presentations 
there  may  be  laceration  or  tearing  of  the  cerebro-spinal  membranes.  Pre- 
mature birth  is  also  given  as  a  cause. 

Morbid  Anatomy. — The  birth  palsies  which  ultimately  induce  the 
spastic  diplegias  or  paraplegias  are  most  frequently  the  result  of  meningeal 
haemorrhage.  The  importance  of  this  condition  has  been  shown  by  the 
studies  of  Litzmann  and  Sarah  J.  McNutt.  The  bleeding  may  come  from 
the  veins,  or,  as  in  one  case  which  I  saw  with  Hirst,  from  the  longitudinal 
sinus.  The  haemorrhage  has  in  many  cases  been  thickest  over  the  motor 
areas,  and  it  seems  probable  that  the  sclerosis  found  in  these  cases  may  re- 
sult from  compression  by  the  blood-clot.  In  other  instances  the  condition 
may  be  due  to  a  foetal  meningo-encephalitis.  In  16  autopsies  collected  in 
the  literature,  in  which  the  patients  died  at  ages  varying  from  two  to  thirty, 
the  anatomical  condition  was  either  a  diffuse  atrophy,  which  was  most  com- 
mon, or  porencephalus.  From  the  fact  that  certain  of  the  cases  are  born 
prematurely,  before  the  pyramidal  tracts  are  developed,  it  has  been  as- 
sumed by  some  that  a  non-development  of  these  tracts  is  the  cause  of  the 


DISEASES  OP  THE  EFFERENT  OR  MOTOR  TRACT.  939 

disease.  This  hypothesis  has  been  urged  by  Marie,  who  limits  the  name 
spastic  paraplegia  to  that  group  of  the  infantile  cases  in  which  there  is  no 
evidence  of  involvement  of  the  brain — intellectual  disturbances,  epilepsy, 
etc.,  and  it  is  in  these  cases  that  he  believes  the  pyramidal  tract  has  re- 
mained undeveloped. 

Symptoms. — At  first  nothing  abnormal  may  be  noticed  about  the 
child.  In  some  instances  there  have  been  early  and  frequent  convulsions; 
then  at  the  age  when  the  child  should  begin  to  walk  it  is  noticed  that  the 
limbs  are  not  used  readily,  and  on  examination  a  stiffness  of  the  legs  and 
arms  is  found.  Even  at  the  age  of  two  the  child  may  not  be  able  to  sit 
up,  and  often  the  head  is  not  well  supported  by  the  neck  muscles.  The 
rigidity,  as  a  rule,  is  more  marked  in  the  legs,  and  there  is  adductor  spasm. 
When  supported  on  the  feet,  the  child  either  rests  on  its  toes  and  the  inner 
surface  of  the  feet,  with  the  knees  close  together,  or  the  legs  may  be  crossed. 
The  stiffness  of  the  upper  limbs  varies.  It  may  be  scarcely  noticeable  or 
the  rigidity  may  be  as  marked  as  in  the  legs.  When  the  spastic  condition 
affects  the  arms  as  well  as  the  legs,  we  speak  of  the  condition  as  diplegia; 
when  the  legs  alone  are  involved,  as  paraplegia.  There  seems  to  be  no  suf- 
ficient reason  for  considering  them  separately.  Constant  irregular  move- 
ments of  the  arms  are  not  uncommon.  The  child  has  great  difficulty  in 
grasping  an  object.  The  spasm  and  weakness  may  be  more  evident  on  one 
side  than  the  other.  The  mental  condition  is,  as  a  rule,  defective  and  con- 
vulsive seizures  are  common. 

Associated  with  the  spastic  paralysis  are  two  allied  conditions  of  con- 
siderable interest,  characterized  by  spasm  and  disordered  movements.  A 
child  with  spastic  diplegia  may  present,  in  an  unusual  degree,  irregular 
movements  of  the  muscles.  In  attempting  to  grasp  an  object  the  fingers 
may  be  thrown  out  in  a  stiff,  spasmodic,  irregular  manner,  or  there  may  be 
constant  irregular  movements  of  the  shoulders,  arms,  and  hands,  with 
slight  incoordination  of  the  head.  Cases  of  this  description  have  been  de- 
scribed as  chorea  spastica,  and  they  may  be  difficult  to  separate  from  mul- 
tiple sclerosis  and  from  Friedreich's  ataxia. 

A  still  more  remarkable  condition  is  that  of  bilateral  athetosis,  in  which 
there  is  a  combination  of  spasm  more  or  less  marked  with  the  most  extraor- 
dinary bizarre  movements  of  the  muscles.  The  condition,  as  a  rule,  dates 
from  infancy.  The  patient  may  not  be  able  to  walk.  The  head  is  turned 
from  side  to  side;  there  are  continual  irregular  movements  of  the  face  mus- 
cles, and  the  mouth  is  drawn  and  greatly  distorted.  The  extremities  are 
more  or  less  rigid,  particularly  in  extension.  On  the  slightest  attempt  to 
move,  often  spontaneously,  there  are  extraordinary  movements  of  the  arms 
and  legs,  particularly  of  the  arms,  somewhat  like  though  much  more  exag- 
gerated than  athetosis.  The  patients  are  often  unable  to  help  themselves 
on  account  of  these  movements.  The  reflexes  are  increased.  The  mental 
condition  is  variable.  The  patient  may  be  idiotic,  but  in  3  of  the  6  cases 
which  I  have  seen  the  patients  were  intelligent.  Massalongo,  who  has  care- 
fully studied  this  condition,  describes  3  cases  in  one  family.  I  have  col- 
lected 53  cases  from  the  literature,  33  of  which  occurred  in  males  and  20 
in  females. 


940  DISEASES  OP  THE  NERVOUS  SYSTEM. 

3.  Heeeditary  Spastic  Paeaplegia 

{Hereditary  Spastic  Spinal  Paralysis  ;  Family  form  of  Spastic  Spinal  Paralysis), 

Much  interest  has  been  aroused  in  this  type,  cases  of  which  have  been 
described  by  Gee,  Striimpell,  Bernhardt,  Latimer,  Newmark,  Erb,  Tooth, 
Sachs,  and  others.  Apparently  we  have  to  distinguish  in  this  form  two 
groups  of  cases.  In  one  tlie  disease  develops  in  infancy  or  childhood,  and 
the  cases  have  all  the  characters  of  a  paraplegia  spastica  cerebralis.  In  these 
cases,  however,  the  symptoms  pointing  to  disease  of  the  brain,  mental  dis- 
turbances, epilepsy,  etc.,  may  be  entirely  wanting,  and  it  was  in  relation  to 
them  that  Erb  made  the  suggestion  that  possibly  too  much  stress  had  been 
laid  upon  the  cerebral  .disease.  He  thought  that  a  systemic  degeneration 
of  the  lower  part  of  the  pyramidal  tract  accounted  for  the  symptoms.  The 
cases  of  amaurotic  family  idiocy  described  by  Sachs,  Peterson,  Hirsch,  and 
others  do  not  belong  here,  although  in  them  there  is  also  a  sclerosis  of  the 
pyramidal  tract. 

In  the  other  group  of  cases,  described  by  Bernhardt  and  Striimpell,  the 
disease  develops  later,  usually  between  twenty  and  thirty.  The  progress 
is  very  slow,  extending  over  many  years.  At  first  there  is  no  paralysis,  only 
a  spastic  condition  of  the  legs.  The  arms  are  affected  later.  Toward  the 
end  there  may  be  a  true  paralysis,  sensation  may  be  affected,  and  the  bladder 
may  be  slightly  involved.  In  a  fatal  case  of  Striimpell's  there  was  an  ex- 
tensive degeneration  of  the  pyramidal  tract  and  slight  disease  of  the  col- 
umns of  Goll  and  of  the  direct  cerebellar  tract. 

Amaurotic  Family  Idiocy. — A  remarkable  form  of  infantile  paralysis 
has  been  described  by  Sachs,  Peterson,  and  Hirsch.  The  symptoms  as  sum- 
marized by  Sachs  are:  1.  Psychic  disturbances  that  appear  in  early  life 
(first  or  second  year)  and  progress  to  total  idiocy.  2.  Paresis,  and  ulti- 
mately complete  paralysis  of  the  extremities,  which  may  be  either  flaccid 
or  spastic.  3.  Increased,  decreased,  or  normal  tendon  reflexes.  4.  Partial, 
followed  by  total,  blindness  (macular  changes,  with  subsequent  atrophy  of 
the  optic  nerve).  5.  Marasmus  and  death,  usually  before  the  second 
year.  6.  Distinct  familial  type.  Occasional  symptoms  are  nystagmus, 
strabismus,  hyperacusis,  or  impairment  of  hearing.  The  pathological 
changes  are  primitive  type  of  the  cerebral  convolutions,  macrogyria,  de- 
generative changes  in  the  large  pyramidal  cells,  absence  of  the  tangential 
fibres,  and  decrease  of  the  fibres  of  the  white  matter.  The  blood-vessels 
are  normal.  There  is  also  degeneration  of  the  pyramidal  columns  of  the 
cord.  Of  27  cases  collected  by  Sachs,  17  occurred  in  six  families;  all  in 
Jews. 

4.  Eeb's  Syphilitic  Spinal  Paralysis. 

Erb  has  described  a  symptom  group  under  the  term  syphilitic  spinal 
paralysis,  to  which  much  attention  has  been  given.  The  points  upon  which 
he  lays  stress  are  a  very  gradual  onset  with  a  development  finally  of  the 
features  of  a  spastic  paresis;  the  tendon  reflexes  are  greatly  increased,  but 
the  muscular  rigidity  is  slight  in  comparison  with  the  exaggerated  deep 
reflexes.    There  is  rarely  much  pain,  and  the  sensory  disturbances  are  trivial, 


DISEASES  OP  THE  EFFERENT   OR  MOTOR  TRACT.  94I 

but  there  may  be  paraesthesia  and  the  girdle  sensation.  The  bladder  and 
rectum  are  usually  involved,  and  there  is  sexual  failure  or  impotence.  And, 
lastly,  improvement  is  not  infrequent.  A  majority  of  instances  of  spastic 
paralysis  of  adults  not  the  result  of  slow  compression  of  the  cord  are  asso- 
ciated with  syphilis  and  belong  to  this  group. 

Erb  thought  the  lesion  to  be  a  special  form  of  transverse  myelitis,  but 
perhaps  it  should  be  classed  with  the  system  diseases,  under  the  name  toxic 
spastic  spinal  paralysis. 

5.  Secondary  Spastic  Paealysis. 

Following  any  lesion  of  the  pyramidal  tract  we  may  have  spastic  paraly- 
sis; thus,  in  a  transverse  lesion  of  the  cord,  whether  the  result  of  slow  com- 
pression (as  in  caries),  chronic  myelitis,  the  pressure  of  tumor,  chronic 
meningo-myelitis,  or  multiple  sclerosis,  degeneration  takes  place  in  the 
pyramidal  tracts,  below  the  point  of  disease.  The  legs  soon  become  stiff  and 
rigid,  and  the  reflexes  increase.  Bastian  has  shown  that  in  compression  para- 
plegia if  the  transverse  lesion  is  complete,  the  limbs  may  be  flaccid,  without 
increase  in  the  reflexes — paraplegie  flasque  of  the  French.  The  condition 
of  the  patient  in  these  secondary  forms  varies  very  much.  In  chronic  mye- 
litis or  in  multiple  sclerosis  he  may  be  able  to  walk  about,  but  with  a  char- 
acteristic spastic  gait.  In  the  compression  myelitis,  in  fracture,  or  in  caries, 
there  may  be  complete  loss  of  power  with  rigidity. 

It  may  be  difficult  or  even  impossible  to  distinguish  these  cases  from 
those  of  primary  spastic  paralysis.  Eeliance  is  to  be  placed  upon  the  asso- 
ciated symptoms;  when  these  are  absent  no  definite  diagnosis  as  to  the  cause 
of  the  spastic  paralysis  can  be  given. 

6.  Hysteeical  Spastic  Paeaplegia. 

There  is  no  spinal-cord  disease  which  may  be  so  accurately  mimicked  as 
spastic  paraplegia.  In  the  hysterical  form  there  is  wasting,  the  sensory 
symptoms  are  not  marked,  the  loss  of  power  is  not  complete,  and  there  is  not 
that  extensor  spasm  so  characteristic  of  organic  disease.  The  reflexes  are, 
as  a  rule,  increased.  The  knee-jerk  is  present,  and  there  may  be  a  well- 
developed  ankle  clonus.  Gowers  calls  attention  to  the  fact  that  it  is  usually 
a  spurious  clonus,  "  due  to  a  half-voluntary  contraction  in  the  calf  muscles." 
A  true  clonus  does  occur,  however,  and  there  may  be  the  greatest  difficulty 
in  determining  whether  or  not  the  case  is  one  of  hysterical  paraplegia.  The 
hysterical  contracture  will  be  considered  later. 

C.    SYSTEM   DISEASES  OP  THE  LOWER  MOTOR  SEGMENT. 
1.  Chronic  Anterior  Polio-myelitis 

(Progressive  Muscular  Atrophy — Aran-Dtichenne). 

This  disease  has  been  considered  as  one  of  the  types  making  up  the 
progressive  (central)  muscular  atrophies.  In  certain  rare  cases  the  process 
is  confined  to  the  lower  motor  segments.     They,  however,  differ  so  little 


942  DISEASES  OF  THE  NERVOUS  SYSTEM. 

clinically  from  many  of  the  cases  in  which  the  pyramidal  tracts  are  in- 
volved that  it  seems  better  to  make  no  sharp  distinction  between  them. 
The  same  may  be  said  of  chronic  bulbar  paralysis. 

2.  Ophthalmoplegia. 

This  disease  is  at  times  due  to  a  chronic  degeneration  of  the  nuclei  of 
the  motor  nerves  of  the  eyeballs,  and  so  is  a  system  disease  of  the  lower 
motor  segment.  It  is  treated  of  in  connection  with  the  other  ocular  palsies 
for  the  sake  of  simplicity  and  because  all  ophthalmoplegias  are  not  due  to 
nuclear  disease. 


3.  Acute  Anteeioe  Polio-myelitis 

{Atrophic  Spinal  Paralysis;  Infantile  Paralysis). 

This  disease  was  formerly  believed  to  be  due  to  an  acute  inflammation 
of  the  cells  of  the  ventral  horns,  depending  upon  a  selective  action  of  the 
poison  for  these  cells,  and  Avould  on  this  theory  have  properly  been  classed 
as  a  system  disease  of  the  lower  motor  neurones.  Later  observations  indi- 
cate that  the  distribution  of  the  inflammation  depends  upon  the  blood  sup- 
ply, and  possibly  that  a  thrombotic  or  an  embolic  process  may  act  as  the 
exciting  cause  of  the  inflammation.  Just  why  this  process  should  always 
act  through  the  arteries  supplying  the  ventral  horns  has  not  been  explained. 
In  any  case  the  disease  appears  to  be  a  focal  inflammation,  and  not  a  system 
disease.  The  symptoms  are  confined  to  the  motor  system,  and  for  this 
reason  it  is  considered  here  and  not  with  the  focal  lesions  of  the  spinal  cord. 

Definition. — An  afi^ection  occurring  most  commonly  within  the  first 
three  years  of  life,  characterized  by  fever,  loss  of  power  in  certain  muscles, 
and  rapid  atrophy. 

Etiology. — The  cause  of  the  disease  is  unknown.  It  has  been  at- 
tributed to  cold,  to  the  irritation  from  dentition,  or  to  overexertion.  Since 
the  days  of  Mephibosheth,  parents  have  been  inclined  to  attribute  this  form 
of  paralysis  to  the  carelessness  of  nurses  in  letting  the  children  fall,  but  very 
rarely  is  the  disease  induced  by  traumatism,  and  in  perhaps  a  majority  of 
the  cases  the  child  is  attacked  while  in  full  health.  As  Sinkler  has  pointed 
out,  the  cases  are  more  common  in  the  warm  months.  Boys  are  more 
liable  to  be  affected  than  girls.  Several  instances  of  the  occurrence  of 
numerous  cases  together  in  epidemic  form  have  been  described.  Medin  re- 
ports from  Stockholm  an  epidemic  in  which  from  the  9th  of  August  to  the 
23d  of  September  29  cases  came  under  observation.  In  two  instances  two 
children  in  the  same  family  were  attacked  within  a  few  days. 

The  most  remarkable  epidemic  is  that  which  occurred  in  the  vicinity 
of  Eutland,  Vt.,  and  which  has  been  recorded  by  Caverly  (New  York  Med- 
ical Record,  1894,  ii).  One  hundred  and  nineteen  cases  occurred  during 
the  summer  of  1894;  85  were  under  six  years  of  age;  18  died.  Additional 
small  outbreaks  have  been  recorded  of  late  years  in  New  York  and  in 
London,  Ontario. 


DISEASES  OP  THE  EFFERENT  OR  MOTOR  TRACT.  943 

Although  most  frequent  in  cliildren  in  the  second  to  fourth  years,  it 
develops  occasionally  in  young  adults,  or  even  in  middle-aged  persons. 

Morbid  Anatomy. — The  disease  is  oftenest  seen  in  either  the  cer- 
vical or  lumbar  enlargements.  In  very  early  cases,  such  as  those  de- 
scribed by  David  Drummond  and  Charlewood  Turner,  the  lesion  has  been 
that  of  an  acute  hemorrhagic  myelitis  with  degeneration  and  rapid  de- 
struction of  the  large  ganglion  cells.  The  condition  may  be  strictly  con- 
fined to  the  ventral  cornua;  in  some  instances  there  is  slight  meningeal 
involvement.  The  investigations  of  Goldscheider,  Siemerling,  and  others 
have  demonstrated  the  arterial  origin  of  the  disease,  which  is  localized 
in  the  parts  supplied  by  the  ventral  median  branch  of  the  ventral  spinal 
artery.  Occasionally  the  changes  are  found  in  the  region  of  distribution 
of  the  ventral  radicular  arteries.  Marie  thinks  that  the  initial  process  is 
embolism  or  thrombosis  of  the  arteries  of  the  ventral  horns,  the  result 
of  an  acute  infection.  In  cases  in  which  the  examination  is  not  made 
for  some  months  or  years  the  changes  are  very  characteristic.  The  ven- 
tral cornu  in  the  affected  region  is  greatly  atrophied  and  the  large  motor 
cells  are  either  entirely  absent  or  only  a  few  remain.  The  affected  half  of 
the  cord  may  be  considerably  smaller  than  the  other.  The  ventro-lateral 
column  may  show  slight  sclerotic  changes,  chiefly  in  the  pyramidal  tract. 
The  corresponding  ventral  nerve  roots  are  atrophied,  and  the  muscles  are 
wasted  and  gradually  undergo  a  fatty  and  sclerotic  change. 

Symptoms. — In  a  majority  of  the  cases,  after  slight  indisposition 
and  feverishness,  the  child  is  noticed  to  have  lost  the  use  of  one  limb. 
Convulsions  at  the  outset  are  rare,  not  constant  as  in  the  acute  cerebral 
palsies  of  children.  Fever  is  usually  present,  the  temperature  rising  to 
101°,  sometimes  to  103°.  Pain  is  often  complained  of  in  the  early  stages. 
This  may  be  localized  in  the  back  or  between  the  shoulders;  any  pressure 
on  the  paralyzed  limbs  may  be  painful,  causing  the  patient  to  cry  out  when 
he  is  moved  in  bed.  The  paralysis  is  abrupt  in  its  onset  and,  as  a  rule, 
is  not  progressive,  but  reaches  its  maximum  in  a  very  short  time,  even 
within  twenty-four  hours.  It  is  rarely  generalized.  The  suddenness  of 
onset  is  remarkable  and  suggests  a  primary  affection  of  the  blood-vessels, 
a  view  which  the  hsemorrhagic  character  of  the  early  lesion  supports.  The 
distribution  of  the  paralysis  is  very  variable.  Its  irregularity  and  lack  of 
symmetry  is  quite  characteristic  of  the  disease.  One  or  both  arms  may  be 
affected,  one  arm  and  one  leg,  or  both  legs;  or  it  may  be  a  crossed  paralysis, 
the  right  leg  and  the  left  arm.  In  the  upper  extremities  the  paralysis  is 
rarely  complete  and  groups  of  muscles  may  be  affected.  As  Eemak  has 
pointed  out,  there  is  an  upper-arm  and  a  lower-arm  type  of  palsy.  The  del- 
toid, the  biceps,  brachialis  anticus,  and  supinator  longus  may  l)e  affected 
in  the  former,  and  in  the  latter  the  extensors  or  flexors  of  the  fingers  and 
wrists.  This  distribution  is  due  to  the  fact  that  muscles  acting  functionally 
together  are  represented  near  each  other  in  the  spinal  cord. 

In  the  legs  the  tibialis  anticus  and  extensor  groups  of  muscles  are  more 
affected  than  the  hamstrings  and  glutei.  The  muscles  of  the  face  are 
very  rarely,  the  sphincters  hardly  ever  involved.  While  the  rule  is  for 
the  paralysis  to  be  abrupt  and  sudden,  there  are  cases  in  which  it  comes 


944: 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


on  slowly  and  takes  from  three  to  five  days  for  its  development.  At  first 
the  afi:ected  limb  looks  natural,  and  as  children  between  two  and  three 
are  usually  fat,  very  little  change  may  be  noticed  for  some  time;  but  the 
atrophy  proceeds  rapidly,  and  the  limb  becomes  flaccid  and  feels  soft  and 
flabby.  Usually  as  early  as  the  end  of  the  first  week  the  reaction  of  de- 
generation is  present.  The  nerves  are  found  to  have  lost  their  irritability. 
The  muscles  do  not  react  to  the  induced  current,  but  to  the  constant  cur- 
rent they  respond  by  a  sluggish  contraction,  usually  to  a  weaker  current 
than  is  normal.  The  paralysis  remains  stationary  for  a  time,  and  then 
there  is  gradual  improvement.  Complete  recovery  is  rare,  and,  when  the 
anatomical  condition  is  considered,  is  scarcely  to  be  expected.  The  large 
motor  cells  of  the  cornua,  when  thoroughly  disintegrated,  cannot  be  re- 
stored. In  too  many  cases  the  improvement  is  only  slight  and  permanent 
paralysis  remains  in  certain  groups.  Sensation  is  unaffected;  the  skin  re- 
flexes are  absent,  and  the  deep  reflexes  in  the  affected  muscles  are  usu- 
ally lost. 

When  the  paralysis  persists  the  wasting  is  extreme,  the  growth  of  the 
bones  of  the  affected  limb  is  arrested,  or  at  any  rate  retarded,  and  the 
joints  may  be  very  relaxed;  as,  for  instance,  when  the  deltoid  is  affected, 
the  head  of  the  humerus  is  no  longer  kept  in  contact  with  the  glenoid 
cavity.  In  the  later  stages  very  serious  deformities  are  produced  by  the 
contracture  of  the  muscles. 

Diagnosis. — The  condition  is  only  too  evident  in  the  majority  of 
cases.  There  is  a  flaccid,  flabby  paralysis  of  one  or  more  limbs  which  has 
set  in  abruptly.  The  rapid  wasting,  the  lax  state  of  the  muscles,  the 
electrical  reactions,  and  the  absence  of  reflexes  distinguish  it  from  the 
cerebral  palsies.  In  multiple  neuritis,  a  rare  disease  in  childhood,  the 
paralysis  is  bilaterally  symmetrical,  affects  the  muscles  at  the  periphery  of 
the  limbs,  and  is  combined  with  sensory  symptoms.  The  pseudo-paresis 
of  rickets  is  a  condition  to  be  carefully  distinguished.  In  this  the  loss  of 
power  is  in  the  legs,  rapid  atrophy  is  not  present,  certain  movements  are 
possible  but  painful.  The  general  hypersesthesia  of  the  skin,  the  charac- 
teristic changes  in  the  bones,  and  the  diffuse  sweats  are  present.  Disease 
of  the  hip  or  knee  may  produce  a  pseudo-paralysis  which  can  with  care  be 
readily  distinguished.     Limp  chorea  may  also  be  confused. 

Prognosis. — The  outlook  in  any  case  for  complete  recovery  is  bad. 
The  natural  course  of  the  disease  must  be  borne  in  mind;  the  sudden  onset, 
the  rapid  but  not  progressive  loss  of  poAver,  a  stationary  period,  then  marked 
improvement  in  certain  muscle  groups,  and  finally  in  many  cases  contrac- 
tures and  deformities.  There  is  no  other  disease  in  which  the  physician 
is  so  often  subject  to  unjust  criticism,  and  the  friends  should  be  told  at  the 
outset  that  in  the  severe  and  extensive  paralysis  complete  recovery  should 
not  be  expected.  The  best  to  be  hoped  for  is  a  gradual  restoration  of  power 
in  certain  muscle  groups.  In  estimating  the  probable  grade  of  permanent 
paralysis,  the  electrical  examination  is  of  great  value. 

Treatment. — The  treatment  of  acute  infantile  paralysis  has  a  bright 
and  a  dark  side.  In  a  case  of  any  extent  complete  recovery  cannot  be  ex- 
pected; on  the  other  hand,  it  is  remarkable  how  much  improvement  may 


DISEASES  OF  THE  EFFERENT   OR  MOTOR  TRACT.  945 

finally  take  place  in  a  limb  which  is  at  first  completely  flaccid  and  helpless. 
The  following  treatment  may  be  pursued:  If  seen  in  the  febrile  stage,  a 
brisk  laxative  and  a  fever  mixture  may  be  given.  The  child  should  be  in 
bed  and  the  afl'ected  limb  or  limbs  wrapped  in  cotton.  As  in  the  great 
majority  of  cases  the  damage  is  already  done  when  the  physician  is  called 
and  the  disease  makes  no  further  progress,  the  application  of  blisters  and 
other  forms  of  counter-irritation  to  the  back  is  irrational  and  only  cruel  to 
the  child. 

The  general  nutrition  should  be  carefully  maintained  by  feeding  the 
child  well,  and  taking  it  out  of  doors  every  day.  As  soon  as  the  child  can 
bear  friction  the  affected  part  should  be  carefully  rubbed;  at  first  once  a 
day,  subsequently  morning  and  evening.  Any  intelligent  mother  can  be 
taught  systematically  to  rub,  knead,  and  pinch  the  muscles,  using  either 
the  bare  hand  or,  better  still,  sweet  oil  or  cod-liver  oil.  This  is  worth  all  the 
other  measures -advised  in  the  disease,  and  should  be  systematically  prac- 
tised for  months,  or  even,  if  necessary,  a  year  or  more.  Electricity  has  a 
much  more  limited  use,  and  cannot  be  compared  with  massage  in  main- 
taining the  nutrition  of  the  muscles.  The  faradic  current  should  be  applied 
to  those  muscles  which  respond.  The  essence  of  the  treatment  is  in  main- 
taining the  nutrition  of  the  muscles,  so  that  in  the  gradual  improvement 
which  takes  place  in  parts,  at  least,  of  the  affected  segments  of  the  cord 
the  motor  impulses  may  have  to  deal  with  well-nourished,  not  atrophied 
muscle  fibres. 

Of  medicines,  in  the  early  stage  ergot  and  belladonna  have  been  warmly 
recommended,  but  it  is  unlikely  that  they  have  the  slightest  influence. 
Later  in  the  disease  strychnia  may  be  used  with  advantage  in  one  or  two 
minim  doses  of  the  liquor  strychnise,  which,  if  it  has  no  other  effect,  is  a 
useful  tonic. 

The  most  distressing  cases  are  those  which  come  under  the  notice  of 
the  physician  six,  eight,  or  twelve  months  after  the  onset  of  the  paralysis, 
when  one  leg  or  one  arm  or  both  legs  are  flaccid  and  have  little  or  no 
motion.  Can  nothing  be  done?  A  careful  electrical  test  should  be  made 
to  ascertain  which  muscles  respond.  This  may  not  be  apparent  at  first, 
and  several  applications  may  be  necessary  before  any  contractility  is  no- 
ticed. With  a  few  lessons  an  intelligent  mother  can  be  taught  to  use  the 
electricity  as  well  as  to  apply  the  massage.  If  in  a  case  in  which  the  paraly- 
sis has  lasted  for  six  or  eight  months  no  observable  improvement  takes  place 
in  the  next  six  months  with  thorough  and  systematic  treatment,  little  or  no 
hope  can  be  entertained  of  further  change. 

In  the  later  stage  care  should  be  taken  to  prevent  the  deformities  re- 
sulting from  the  contractions.  Great  benefit  results  from  a  carefully  ap- 
plied apparatus.  The  tendon  transplantation  introduced  by  Goldthwaite 
seems  to  be  a  distinct  advantage  in  many  cases.  Eulenberg  has  recently 
reported  a  case  (1898)  in  which  the  pes  equinus  was  marked;  he  was  able 
to  afford  notable  relief  by  tendon  implantation.  Half  of  the  tendo- 
Achillcs  and  a  part  of  the  tendon  of  the  soleus  were  implanted  upon  the 
tendons  of  the  peroneus  longus  et  brevis,  the  remaining  half  of  the  tendo- 
Achilles  being  divided.     The  transference  of  the  functions  from  the  flexors 


946  DISEASES  OF  THE  NERVOUS  SYSTEM. 

to  the  pronators  was  satisfactorily  accomplished,  and  the  results  were  sur- 
prisingly beneficial. 

4.  Acute  and  Subacute  Polio-myelitis  in  Adults. 

An  acute  polio-myelitis  in  adults^,  the  exact  counterpart  of  the  disease 
in  children,  is  recognized.  A  majority,  however,  of  the  cases  described 
under  this  heading  have  been  multiple  neuritis;  but  the  suddenness  of 
onset,  the  rapid  wasting,  and  the  marked  reaction  of  degeneration  are 
thought  by  some  to  be  distinguishing  features.  Multiple  neuritis  may, 
however,  set  in  with  rapidity;  there  may  be  great  wasting  and  the  reaction 
of  degeneration  is  sometimes  present.  The  time  element  alone  may  deter- 
mine the  true  nature.  Eecovery  in  a  case  of  extensive  multiple  paralysis 
from  polio-myelitis  will  certainly  be  with  loss  of  power  in  certain  groups 
of  muscles;  whereas,  in  multiple  neuritis  the  recovery,  while  slow,  may  be 
perfect. 

The  subacute  form,  the  paralysie  generate  s'pinale  anterieure  subaigue 
of  Duchenne,  is  in  all  probability  a  peripheral  palsy.  The  paralysis  usually 
begins  in  the  legs  with  atrophy  of  the  muscles,  then  the  arms  are  involved, 
but  not  the  face.     Sensation  is,  as  a  rule,  not  involved. 

5.  Acute  Ascending  (Landey's)  Pakalysis. 

Definition. — An  ascending  flaccid  paralysis,  beginning  in  the  legs, 
rapidly  extending  to  the  trunk  and  arms,  and  finally  involving  the  muscles 
of  respiration.  Sensation  and  electrical  reactions  are  normal,  and  there 
is  retention  of  sphincter  control. 

Etiology  and  Pathology. — This  disease  occurs  most  commonly  in 
males  between  the  twentieth  and  thirtieth  years.  It  has  sometimes  fol- 
lowed the  specific  fevers.  The  recent  careful  studies  by  Mills  and  Spiller, 
Thomas  and  Knapp,  Bailey  and  Ewing,  and  Greene  have  not  solved  the 
problem  of  this  remarkable  disease.  There  are  two  views:  first,  that  it  is 
a  peripheral  neuritis  (Eoss,  Neuwerk,  Barth,  and  many  others).  Spiller 
found  in  a  rapidly  fatal  case  destructive  changes  in  the  peripheral  nerves 
and  corresponding  alterations  in  the  cell  bodies  of  the  ventral  horns.  He 
suggests  that  the  toxic  agent  acts  on  the  lower  motor  neurones  as  a  whole, 
and  that  possibly  the  reason  why  no  lesions  were  found  in  some  of  the  cases 
is  that  the  more  delicate  histological  methods  were  not  used.  Secondly, 
that  it  is  a  functional  disorder  without  a  recognizable  anatomical  basis. 
Eecent  negative  autopsies  support  this  view.  While  waiting  for  additional 
light,  we  may  regard  the  disease  as  an  acute  poisoning  of  the  lower  motor 
neurones. 

Symptoms. — Weakness  of  the  legs,  gradually  progressing,  often  with 
tolerable  rapidity,  is  the  first  symptom.  In  some  cases  within  a  few  hours 
the  paralysis  of  the  legs  becomes  complete.  The  muscles  of  the  trunk  are 
next  affected,  and  within  a  few  days,  or  even  less  in  more  acute  cases,  the 
arms  are  also  involved.  The  neck  muscles  are  next  attacked,  and  finally 
the  muscles  of  respiration,  deglutition,  and  articulation.    The  reflexes  are 


COMBINED  SYSTEM  DISEASES.  .  947 

lost,  but  the  muscles  neither  waste  nor  show  electrical  changes.  The  sen- 
sory symptoms  are  variable;  in  some  cases  tingling,  numbness,  and  hyper- 
esthesia have  been  present.  In  the  more  characteristic  cases  sensation  is 
intact  and  the  sphincters  are  uninvolved.  Enlargement  of  the  spleen  has 
been  noticed  in  several  cases.  The  course  of  the  disease  is  variable.  It 
may  prove  fatal  in  less  than  two  days.  Other  cases  persist  for  a  week  or 
for  two  weeks.  In  a  large  proportion  of  the  cases  the  disease  is  fatal."  One 
patient  was  kept  alive  for  41  days  by  artificial  respiration  (C.  L.  Greene). 
The  diagnosis  is  difficult,  particularly  from  certain  forms  of  multiple 
neuritis,  and  if  we  include  in  Landry's  paralysis  the  cases  in  which  sensa- 
tion is  involved,  distinction  between  the  two  afEections  is  impossible.  We 
apparently  have  to  recognize  the  existence  of  a  rapidly  advancing  motor 
paralysis  without  involvement  of  the  sphincters,  without  wasting  or  elec- 
trical changes  in  the  muscles,  without  trophic  lesions,  and  without  fever — 
features  sufficient  to  distinguish  it  from  either  the  acute  central  myelitis 
or  the  polio-myelitis  anterior.  It  is  doubtful,  however,  whether  these 
characters  always  suffice  to  enable  us  to  differentiate  the  cases  of  multiple 
neuritis. 

6.  Myasthenia  Geavis 

{Asthenic  Bulbar  Paralysis ;  Erb-Goldflani's  Symptom-complex). 

Some  sixty  cases  are  on  record  and  have  been  analyzed  by  Harry  Camp- 
bell and  Edwin  Bramwell  (Brain,  1900).  Tlie  etiology  is  unknown.  Young 
persons  are  chiefly  affected.  The  muscles  innervated  by  the  bulb  are  first 
affected — those  of  the  eyes,  the  face,  of  mastication,  and  of  the  neck.  All 
the  voluntary  muscles  may  become  involved.  After  rest  the  power  is  re- 
covered. In  severe  cases  paralysis  may  persist.  The  myasthenic  reaction 
of  Jolly  is  the  rapid  exhaustion  of  the  muscles,  by  faradism,  not  by  gal- 
vanism. There  are  marked  remissions  and  fluctuations  in  the  severity  of 
the  symptoms.  The  affected  muscles  in  a  few  cases  have  atrophied.  Of 
17  autopsies,  in  only  6  was  anything  abnormal  found  (C.  and  B.),  and  the 
significance  of  the  changes  is  doubtful. 

The  diagnosis  is  easy — from  the  ptosis,  the  facial  expression,  the  nasal 
speech,  the  rapid  fatigue  of  the  muscles,  the  myasthenic  reaction,  the  ab- 
sence of  atrophy,  tremors,  etc.,  and  the  remarkable  variations  in  the  in- 
tensity of  the  symptoms.  Of  the  60  cases,  23  ended  fatally.  The  patient 
may  live  many  years;  recovery  may  take  place.  Eest,  strychnia  in  full 
doses,  massage,  alternate  courses  of  iodide  of  potassium  and  mercury  may 
be  tried. 

IV.    COMBINED    SYSTEM    DISEASES. 

When  the  disease  is  not  confined  within  the  limits  of  either  the  afferent 
or  efferent  systems, but  affects  both,  it  is  known  as  a  cnmJnned  system  disease. 
Some  authors  contend  that  the  diseases  usually  classed  under  this  head  are 
not  really  system  diseases,  but  are  diffuse  processes.  This  is  the  view  taken 
by  Leyden  and  Goldsclieidor,  who  limit  the  term  system  disease  to  loco- 
motor ataxia  and  progressive  muscular  atrophy. 


948  DISEASES  OF  THE  NERVOUS  SYSTEM. 

In  certain  cases  of  locomotor  ataxia  which  have  run  a  fairly  typical 
course  there  may  be  found  after  death,  besides  the  anatomical  picture  corre- 
sponding to  this  disease,  a  moderate  degeneration  of  the  pyramidal  tracts 
and  of  the  ventral  horns.  In  progressive  muscular  atrophy,  on  the  other 
hand,  there  may  be  degeneration  in  the  dorsal  column.  During  life  these 
secondary  involvements  of  other  systems,  as  they  may  be  termed,  may  or 
may  not  be  accompanied  by  demonstrable  symptoms,  and  when  such  do 
occur  they  make  their  appearance  late  in  the  disease. 

There  is  another  group  of  cases  in  which  from  the  very  first  the  symp- 
toms point  to  an  involvement  of  both  the  afferent  and  efferent  systems,  and 
it  is  to  these  that  the  term  primary  combined  system  disease  is  usually 
limited. 

1.  Ataxic  Paeaplegia. 

This  name  is  applied  by  Gowers  to  a  disease  characterized  clinically  by 
a  combination  of  ataxia  and  spastic  paraplegia,  and  anatomically  by  in- 
volvement of  the  dorsal  and  lateral  columns. 

The  disease  is  most  common  in  middle-aged  males.  Exposure  to  cold 
and  traumatism  have  been  occasional  antecedents.  In  striking  contrast  to 
ordinary  tabes  a  history  of  syphilis  is  rarely  to  be  obtained. 

The  anatomical  features  are  a  sclerosis  of  the  dorsal  columns,  which 
is  not  more  marked  in  the  lumbar  regioa  and  not  specially  localized  in 
the  root  zone  of  the  cuneate  fasciculi.  The  involvement  of  the  lateral  col- 
umns is  diffuse,  not  always  limited  to  the  pyramidal  tracts,  and  there  may 
be  an  annular  sclerosis.  Marie  believes  that  in  many  eases  the  distribution 
of  the  sclerosis  is  due  to  the  arterial  supply  and  not  to  a  true  systemic  de- 
generation, the  vessels  involved  being  branches  of  the  dorsal  spinal  artery. 

The  symptoms  are  well  defined.  The  patient  complains  of  a  tired  feel- 
ing in  the  legs,  not  often  of  actual  pain.  The  sensory  symptoms  of  true 
tabes  are  absent.  An  unsteadiness  in  the  gait  gradually  develops  with 
progressive  weakness.  The  reflexes  are  increased  from  the  outset,  and 
there  may  be  well-developed  ankle  clonus.  Eigidity.of  the  legs  slowly  comes 
on,  but  it  is  rarely  so  marked  as  in  the  uncomplicated  cases  of  lateral 
sclerosis.  From  the  start  incoordination  is  a  well-characterized  feature, 
and  the  difficulty  of  walking  in  the  dark  or  swaying  when  the  eyes  are 
closed  may,  as  in  true  tabes,  be  the  first  symptom  to  attract  attention. 
In  walking  the  patient  uses  a  stick,  keeps  the  eyes  fixed  on  the  ground, 
the  legs  far  apart,  but  the  stamping  gait,  with  elevation  and  sudden  descent 
of  the  feet,  is  not  often  seen.  The  incoordination  may  extend  to  the  arms. 
Sensory  symptoms  are  rare,  but  Gowers  calls  attention  to  a  dull,  aching 
pain  in  the  sacral  region.  The  sphincters  usually  become  involved.  Eye 
symptoms  are  rare.  Late  in  the  disease  mental  symptoms  may  develop, 
similar  to  those  of  general  paresis. 

In  well-marked  cases  the  diagnosis  is  easy.  The  combination  of  marked 
incoordination  with  retention  of  the  reflexes  and  more  or  less  spasm  are 
characteristic  features.  The  absence  of  ocular  and  sensory  symptoms  is 
an  important  point. 


COMBINED  SYSTEM  DISEASES.  949 

2.  Peimary  Combined  Sclerosis  (Putnam). 

The  studies  of  J.  J.  Putnam,  Dana,  Bastianelli,  Eisien  Russell,  Collier, 
and  Batten  have  separated  from  among  the  lesions  of  the  cord  a  fairly 
well  defined  disease,  characterized  anatomically  by  a  diffuse  degeneration, 
often  in  discrete  patches.  The  dorsal  and  lateral  columns  are  constantly 
involved,  chiefly  in  the  thoracic  and  cervical  regions.  The  nerve  roots  and 
the  gray  matter  show  no  changes.  The  lesions  have  the  "  appearance  of  a 
non-systemic  primary  neurone  degeneration,  not  dependent  upon  antece- 
dent inflammation  "  (E.  W.  Taylor). 

Of  Putnam's  50  cases,  31  were  women,  all  but  5  above  thirty  years  old. 
A  majority  of  the  patients  were  of  small  stature  and  slender  frame,  and 
in  many  there  had  been  a  general  lack  of  vigor  and  a  chronic  pallor  and 
debility;  7  presented  profound  ansemia.  There  was  no  luetic  history.  The 
relation  of  this  group  to  anaemia  is  interesting.  Russell,  Batten,  and  Col- 
lier make  three  groups:  (1)  cases  of  profound  anaemia  (and  one  may  add  of 
cachexia),  in  which  during  life  no  symptoms  were  present,  but  in  which 
there  were  found  combined  scleroses  of  the  cord  post-mortem;  (2)  cases  of 
progressive  pernicious  anaemia,  in  which  spinal  symptoms  have  occurred; 
(3)  cases  of  chronic  sclerosis  of  the  cord,  in  which  there  occurs,  as  a  sec- 
ondary feature,  a  severe  anaemia. 

The  symptoms  are  both  sensory  and  motor.  The  onset  is  usually  with 
numbness  in  the  extremities,  progressive  loss  of  strength,  and  emaciation. 
Paraplegia  gradually  develops,  before  which  there  have  been,  as  a  rule, 
spastic  symptoms  with  exaggerated  knee-jerk.  The  arms  are  affected  less 
than  the  legs.  Mental  symptoms  suggestive  of  dementia  paralytica  may 
develop  toward  the  close. 

3.  Hereditary  Ataxia  (Friedreich's  Ataxia). 

In  1861  Friedreich  reported  6  cases  of  a  form  of  hereditary  ataxia,  and 
the  affection  has  usually  gone  by  his  name.  Unfortunately,  paramyoclonus 
multiplex  is  also  called  Friedreich's  disease;  so  it  is  best,  if  his  name  is  used 
in  connection  with  this  affection,  to  term  it  Friedreich's  ataxia.  It  is  a  very 
different  disease  in  many  respects  from  ordinary  tabes.  It  may  or  may  not 
be  hereditary.  It  is  really  a  family  disease,  several  brothers  and  sisters 
being,  as  a  rule,  affected.  The  143  cases  analyzed  by  Griffith  occurred  in 
71  unrelated  families.  In  his  series  inheritance  of  the  disease  itself  occurred 
in  only  33  cases.  Various  influences  in  the  parents  have  been  noted;  alco- 
holism in  only  7  cases.  Syphilis  has  rarely  been  present.  Of  the  143  cases, 
86  were  males  and  57  females.  The  disease  sets  in  early  in  life,  and  in  Grif- 
fith's series  15  occurred  before  the  age  of  two  years,  39  before  the  sixth 
year,  45  between  the  sixth  and  tenth  years,  20  between  the  eleventh  and 
fifteenth  years,  18  between  the  sixteenth  and  twentieth  years,  and  5  be- 
tween the  twentieth  and  twenty-fifth  years. 

The  morlicl  anatomy  shows  an  extensive  sclerosis  of  the  dorsal  and 
lateral  columns  of  the  spinal  cord.  The  periphery,  and  the  cerebellar  tracts 
are  usually  involved.  The  observations  of  Dejerine  and  Letulle  are  of  spe- 
cial interest,  since  they  seem  to  indicate  tlint  tlic  change  in  this  disease  is 


950  DISEASES  OF  THE  NERVOUS  SYSTEM. 

a  neuroglial  (ectodermal)  sclerosis,  differing  entirely  from  the  ordinary- 
spinal  sclerosis.  According  to  this  view,  Friedreich's  disease  is  a  gliosis  of 
the  dorsal  columns  due  to  developmental  errors;  but  the  question  is  still 
unsettled. 

Symptoms. — The  ataxia  differs  somewhat  from  the  ordinary  form. 
The  incoordination  begins  in  the  legs,  but  the  gait  is  peculiar.  It  is  sway- 
ing, irregular,  and  more  like  that  of  a  drunken  man.  There  is  not  the  char- 
acteristic stamping  gait  of  the  true  tabes.  Eomberg's  symptom  may  or 
may  not  be  present.  The  ataxia  of  the  arms  occurs  early  and  is  very 
marked;  the  movements  are  almost  choreiform,  irregular,  and  somewhat 
swaying.  In  making  any  voluntary  movement  the  action  is  overdone,  the 
prehension  is  claw-like,  and  the  fingers  may  be  spread  or  overextended 
just  before  grasping  an  object.  The  hand  frequently  moves  about  an  object 
for  a  moment  and  then  suddenly  pounces  upon  it.  There  are  irregular, 
swaying  movements,  some  of  which  are  choreiform,  of  the  head  and  shoul- 
ders. There  is  present  in  many  cases  what  is  known  as  static  ataxia,  that  is 
to  say,  ataxia  of  quiet  action.  It  occurs  when  the  body  is  held  erect  or  when 
a  limb  is  extended — irregular,  oscillating  movements  of  the  head  and  body 
or  of  the  extended  limb. 

Sensory  symptoms  are  not  usually  present.     The  deep  reflexes  are  lost 
"early  in  the  disease,  and,  next  to  the  ataxia,  this  is  the  most  constant  and 
important  symptom  (Striimpell).     The  skin  reflexes  are  usually  normal, 
and  the  pupillary  reflex  to  light  is  practically  never  affected. 

Nystagmus  is  a  characteristic  symptom.  Atrophy  of  the  optic  nerve 
rarely  occurs.  A  striking  feature  is  early  deformity  of  the  feet.  There 
is  talipes  equinus,  and  the  patient  walks  on  the  outer  edge  of  the  feet. 
The  big  toe  is  flexed  dorsally  on  the  first  phalanx.  Lateral  curvature  of 
the  spine  is  very  common. 

Trophic  lesions  are  rare.  As  the  disease  advances  paralysis  comes  on 
and  may  u,ltimately  be  complete.     Some  of  the  patients  never  walk. 

Disturbance  of  speech  is  common.  It  is  usually  slow  and  scanning; 
the  expression  is  often  dull;  the  mental  power  is,  as  a  rule,  maintained,  but 
late  in  the  disease  becomes  impaired. 

The  diagnosis  of  the  disease  is  not  difficult  when  several  members  of 
a  family  are  affected.  The  onset  in  childliood,  the  curious  form  of  inco- 
ordination, the  loss  of  knee-kicks,  the  early  talipes  equinus,  the  posi- 
tion of  the  great  toe,  the  scoliosis,  the  nystagmus,  and  scanning  speech  make 
up  an  unmistakable  picture.  The  disease  is  often  confounded  with  chorea, 
with  the  ordinary  form  of  which  it  has  nothing  in  common.  "With  hered- 
itary chorea  it  has  certain  similarities,  but  usually  this  disease  does  not  set 
in  until  after  the  thirtieth  year. 

The  affection  lasts  for  many  years  and  is  incurable.  Care  should  be 
taken  to  prevent  contractures. 

Cerebellar  Type. — There  is  a  form  of  hereditary  ataxia,  described  by 
Marie  as  cerebellar  heredo-ataxia,  which  starts  later  in  life,  after  the  age  of 
twenty,  with  disability  in  the  legs,  but  the  gait  is  less  ataxic  than  "  groggy." 
The  knee-jerks  are  retained,  and  a  spastic  condition  of  the  legs  ultimately 
develops.    There  is  no  scoliosis,  nor  does  club-foot  develop.    Sanger  Brown's 


AFFEGTIONS  OF  THE  MENINGES.  951 

cases,  25  in  one  family,  and  J.  H.  NefE's,  13,  appear  to  belong  to  this  type. 
The  cerebellum  has  been  found  atrophied  in  2  cases. 

4.  Progeessive  Inteestitial  Htperteophic  Neueitis  of  Infants. 

Under  this  imposing  title  Dejerine  and  Sottas  described  a  rare  and  inter- 
esting affection.  It  is  a  family  disease,  and  begins  in  early  life.  The  symp- 
toms are  those  typical  of  locomotor  ataxia,  to  which  is  added  progressive 
muscular  atrophy,  with  involvement  of  the  face  and  a  hypertrophy  and 
hardening  of  the  peripheral  nerves.  As  the  name  indicates,  it  is  an  inter- 
stitial hypertrophic  neuritis  with  secondary  involvement  of  the  dorsal  col- 
umns of  the  cord.  This  disease  has  been  associated  with  progressive  neural 
muscular  atrophy,  but  Dejerine  has  shown  that  it  is  quite  distinct. 

5.  Toxic  Combined  Scleeosis. 

Certain  poisons  cause  changes  in  the  lateral  and  dorsal  columns  of  the 
cord  that  resemble  those  of  the  combined  system  disease^s.  They  have  been 
demonstrated  in  pellagra  and  in  ergotism,  and  have  already  been  described. 
In  pernicious  antemia  and  many  chronic  wasting  disease  these  scleroses 
occur,  and  are  believed  to  be  due  to  the  action  of  poisons  produced  within 
the  system. 


m.    DIFFUSE  DISEASES   OF  THE  TnTERYOUS   SYSTEM. 

I.   AFFECTIONS   OF   THE    MENINGES. 

Diseases  of  the  Dura  Mater  {Pachymeningitis). 

Pachymeningitis  Externa. — Cerebral — Hemorrhage  often  occurs  as  a 
result  of  fracture.  Inflammation  of  the  external  layer  of  the  dura  is  rare. 
Caries  of  the  bone,  either  extension  from  middle-ear  disease  or  due  to 
syphilis,  is  the  principal  cause.  In  the  syphilitic  cases  there  may  be  a 
great  thickening  of  the  inner  table  and  a  large  collection  of  pus  between 
the  dura  and  the  bone. 

Occasionally  the  pus  is  infiltrated  between  the  two  layers  of  the  dura 
mater  or  may  extend  through  and  cause  a  dura-arachnitis. 

The  symptoms  of  external  pachymeningitis  are  indefinite.  In  the  syi:ih- 
ilitic  cases  there  may  be  a  small  si^us  communicating  with  the  exterior. 
Compression  symptoms  may  occur  with  or  without  paralysis. 

Spinal — An  acute  form  may  occur  in  syphilitic  affections  of  the  bones, 
in  tumors,  and  in  aneurism.  The  symptoms  are  those  of  a  compression  of 
the  cord.  A  chronic  form  is  much  more  common,  and  is  a  constant  accom- 
paniment of  tuberculous  caries  of  the  spine.  The  internal  surface  of  the 
dura  may  be  smooth,  while  the  external  is  rough  and  covered  with  caseous 
masses.  The  entire  durn  may  be  surrounded  or  the  process  may  be  con- 
jBned  to  the  ventral  surface. 


952  DISEASES  OP  THE  NERVOUS  SYSTEM. 

Pachymeningitis  Interna. — This  occurs  in  three  forms:  (1)  Pseudo- 
membranouS;,  (3)  purulent,  and  (3)  hsemorrhagic.  The  first  two  are  un- 
important. Pseudo-membranous  inflammation  of  the  lining  membrane  of 
the  dura  is  not  usually  recognized,  but  a  most  characteristic  example  of  it 
came  under  my  observation  as  a  secondary  process  in  pneumonia.  Purulent 
pachymeningitis  may  follow  an  injury,  but  is  more  commonly  the  result 
of  extension  from  inflammation  of  the  pia.  It  is  remarkable  how  rarely  pus 
is  found  between  the  dura  and  arachnoid  membranes. 


H^MOEEHAGic  PACHYMENINGITIS  {H cematoma  of  the  Dura  Mater). 

Cerebral  Form. — This  remarkable  condition,  first  described  by  Virchow, 
is  very  rare  in  general  medical  practice.  During  ten  years  no  instance  of  it 
came  under  my  observation  at  the  Montreal  General  Hospital.  On  the  other 
hand,  in  the  post-mortem  room  of  the  Philadelphia  Hospital,  which  received 
material  from  a  large  almshouse  and  asylum,  the  cases  were  not  uncommon, 
and  within  three  months  I  saw  four  characteristic  examples,  three  of  which 
came  from  the  medical  wards.  The  frequency  of  the  condition  in  asylum 
work  may  be  gathered  from  the  fact  that  in  1,185  post  mortems  at  the  Gov- 
ernment Hospital  for  the  Insane,  Washington,  to  June  30,  1897,  there  were 
197  cases  with  "  a  true  neo-membrane  of  internal  pachymeningitis  "  (Black- 
burn). Of  these  cases,  45  were  chronic  dementia,  37  were  general  paresis, 
30  senile  dementia,  28  chronic  mania,  28  chronic  melancholia,  22  chronic 
epileptic  insanity,  6  acute  mania,  and  1  case  imbecility.  Forty-two  of  the 
cases  were  in  persons  over  seventy  years  of  age. 

It  has  also  been  found  in  profound  ansemia  and  other  diseases  of  the 
blood  and  of  the  blood-vessels,  and  is  said  to  have  followed  certain  of  the 
acute  fevers.  Herter  has  called  attention  to  the  not  infrequent  occurrence 
of  the  lesion  in  badly  nourished,  cachectic  children. 

The  morbid  anatomy  is  interesting.  Virchow's  view  that  the  delicate 
vascular  membrane  precedes  the  haemorrhage  is  undoubtedly  correct.  Prac- 
tically we  see  one  of  three  conditions  in  these  cases:  (a)  Subdural  vascular 
membranes,  often  of  extreme  delicacy,  formed  by  the  penetration  of  blood- 
vessels and  granulation  tissue  into  an  inflammatory  exudate  (so-called  "  or- 
ganization "  of  an  inflammatory  exudate);  (b)  simple  subdural  hEemor- 
rhage;  (c)  a  combination  of  the  two,  vascular  membrane  and  blood-clot. 
Certainly  the  vascular  membrane  may  exist  without  a  trace  of  haemorrhage 
— simply  a  fibrous  sheet  of  varying  thickness,  permeated  with  large  vessels, 
which  may  form  beautiful  arborescent  tufts.  On  the  other  hand,  there 
are  instances  in  which  the  subdural  haemorrhage  is  found  alone,  but  it  is 
possible  that  in  some  of  these  at  least  the  hemorrhage  may  have  destroyed 
all  trace  of  the  vascular  membrane.  In  some  cases  a  series  of  laminated 
clots  are  found,  forming  a  layer  from  3  to  5  mm.  in  thickness.  Cysts  may 
occur  within  this  membrane.  The  source  of  the  haemorrhage  is  probably  the 
dural  vessels.  Huguenin  and  others  hold  that  the  bleeding  comes  from  the 
vessels  of  the  pia  mater,  but  certainly  in  the  early  stage  of  the  condition 
there  is  no  evidence  of  this;  on  the  other  hand,  the  highly  vascular  sub- 
dural membrane  may  be  seen  covered  with  the  thinnest  possible  sheeting 


AFFECTIONS  OF  THE   MENINGES.  953 

of  clot,  which  has  evidently  come  from  the  dura.  The  subdural  hemor- 
rhage is  usually  associated  with  atrophy  of  the  convolutions,  and  it  is  held 
that  this  is  one  reason  why  it  is  so  common  in  the  insane,  especially  in  de- 
mentia paralytica  and  dementia  senilis;  but  there  must  be  some  other 
factor  than  atrophy,  or  we  should  meet  with  it  in  phthisis  and  various 
cachectic  conditions  in  which  the  cerebral  wasting  is  as  common  and  almost 
as  marked  as  in  cases  of  insanity. 

The  symptoms  are  indefinite,  or  there  may  be  none  at  all,  especially 
when  the  haemorrhages  are  small  or  have  occurred  very  gradually,  and  the 
diagnosis  cannot  be  made  with  certainty.  Headache  has  been  a  prominent 
symptom  in  some  cases,  and  when  the  condition  exists  on  one  side  there 
may  be  hemiplegia.  The  most  helpful  symptoms  for  diagnosis,  indicating 
that  the  hc"emorrhage  in  an  apoplectic  attack  is  meningeal,  are  (1)  those 
referable  to  increased  intracerebral  pressure  (slowing  and  irregularity  of 
the  pulse,  vomiting,  coma,  contracted  pupils  reacting  to  light  slowly  or  not 
at  all)  and  (2)  paresis  and  paralysis,  gradually  increasing  in  extent,  accom- 
panied by  symptoms  which  point  to  a  cortical  origin.  Extensive  bilateral 
disease  may,  however,  exist  without  any  symptoms  whatever. 

Spinal  Form. — The  spinal  pachymeningitis  interna,  described  by  Char- 
cot and  Joffroy,  involves  chiefly  the  cervical  region  (P.  cervicalis  hyper- 
tropMca).  The  interspace  between  the  cord  and  the  dura  is  occupied  by  a 
firm,  concentrically  arranged,  fibrinous  growth,  which  is  seen  to  have  de- 
veloped within,  not  outside  of,  the  dura  mater.  It  is  a  condition  ana- 
tomically identical  with  the  hsemorrhagic  pachymeningitis  interna  of  the 
brain.  The  cord  is  usually  compressed;  the  central  canal  may  be  dilated — 
hydromyelus — and  there  are  secondary  degenerations.  The  nerve  roots  are 
involved  in  the  growth  and  are  damaged  and  compressed.  The  extent  is 
variable.  It  may  be  limited  to  one  segment,  but  more  commonly  involves 
a  considerable  portion  of  the  cervical  enlargement.  The  disease  is  chronic, 
and  in  some  cases  presents  a  characteristic  group  of  symptoms.  There 
are  intense  neuralgic  pains  in  the  course  of  the  nerves  whose  roots  are 
involved.  They  are  chiefly  in  the  arms  and  in  the  cervical  region,  and 
vary  greatly  in  intensity.  There  may  be  hypergesthesia  with  numbness  and 
tingling;  atrophic  changes  may  develop,  and  there  may  be  areas  of  anaes- 
thesia. Gradually  motor  disturbances  appear;  the  arms  become  weak  and 
the  muscles  atrophied,  particularly  in  certain  groups,  as  the  flexors  of  the 
hand.  The  extensors,  on  the  other  hand,  remain  intact,  so  that  the  con- 
dition of  claw-hand  is  gradually  produced.  The  grade  of  the  atrophy  de- 
pends much  upon  the  extent  of  involvement  of  the  cervical  nerve  roots, 
and  in  many  cases  the  atrophy  of  the  muscles  of  the  shoulders  and  arms 
becomes  extreme.  Tlie  condition  is  one  of  cervical  paraplegia,  with  con- 
tractures, flexion  of  the  wrist,  and  typical  main  en  griffe.  Usually  before 
the  arms  are  greatly  atrophied  there  are  the  symptoms  of  what  the  French 
writers  term  the  second  stage — namely,  involvement  of  the  lower  extremi- 
ties and  the  gradual  production  of  a  spastic  paraplegia,  which  may  develop 
several  months  after  the  onset  of  the  disease,  and  is  due  to  secondary  changes 
in  the  cord. 

The  disease  runs  a  chronic  course,  lasting,  perhaps,  two  or  more  years. 

60 

» 


954  DISEASES  OP   THE  NERVOUS  SYSTEM. 

In  a  few  instances,  in  which  symptoms  pointed  definitely  to  this  condition, 
recovery  has  taken  place.  The  disease  is  to  be  distinguished  from  amyo- 
trophic lateral  sclerosis,  syringomyelia,  and  tumors.  From  the  first  it  is 
separated  by  the  marked  severity  of  the  initial  pains  in  the  neck  and  arms;, 
from  the  second  by  the  absence  of  the  sensory  changes  characteristic  of 
syringomyelia.  From  certain  tumors  it  is  very  difficult  to  distinguish; 
in  fact,  the  fibrinous  layers  form  a  tumor  around  the  cord. 

The  condition  known  as  hcematoma  of  the  dura  mater  may  occur  at  any 
part  of  the  cord,  or,  in  its  slow,  progressive  form — pachymeningitis  hsem- 
orrhagica  interna — may  be  limited  to  the  cervical  region  and  produce  the 
symptoms  just  mentioned.  It  is  sometimes  extensive,  and  may  coexist  with 
a  similar  condition  of  the  cerebral  dura.  Cysts  may  occur  filled  with  haem- 
orrhagic  contents. 

Diseases  of  the  Pia  Matee  {Acute  Cereiro-spinal  Leptomeningitis). 

Etiology. — Under  cerebro-spinal  fever  and  tuberculosis  the  two  most 
important  forms  of  meningitis  have  been  described.  Other  conditions  with 
which  meningitis  is  associated  are:  (1)  llie  acute  fevers,  more  particularly 
pneumonia,  erysipelas,  and  septicemia;  less  frequently  small-pox,  typhoid 
fever,  scarlet  fever,  measles,  etc.  (2)  Injury  or  disease  of  tlie  hones  of  the 
sJcull.  In  this  group  by  far  the  most  frequent  cause  is  necrosis  of  the  petrous 
portion  of  the  temporal  bone  in  chronic  otitis.  (3)  Extension  from  disease 
of  the  nose.  Meningitis  has  followed  perforation  of  the  skull  in  sounding  the 
frontal  sinuses,  suppurative  disease  of  these  sinuses,  and  necroses  of  the 
cribriform  plate.  As  mentioned  under  cerebro-spinal  fever,  the  infection 
is  thought  to  be  possible  through  the  nose.  (4)  As  a  terminal  infection  in 
chronic  nephritis,  arterio-sclerosis,  heart-disease,  gout,  and  the  wasting 
diseases  of  children. 

The  following  etiological  table  of  the  acute  forms  of  meningitis  may 
be  useful  to  the  student: 

r  ^  fl.  Of  cerebro-spinal  }  {a)  Sporadic.    I  oipiococcus  intracellularis. 
fever.  J  (o)  Epidemic.  )      ^ 

2.  Pneumococcic.       [  -^^eninges  alone  involved  or  in  a  general  )  pneumococcus. 
)      pneumococcus  infection.  ) 

1.  Tuberculous Bacillus  tuberculosis. 

f      (a)  Secondary  to  pneumonia,  en- "] 

2.  Pneumo-  I  docarditis,  etc.  I  Pneumococcus. 
coccic.  ]      [b)  Secondary  to  disease  or  injury  [ 

[  of  cranium  or  its  fossae.  J 

r     (a)  Folio  vring  local  disease  of  era-  "I 
o     -p  .     J      nium  or  a  local  infection  elsewhere.  1      Various  forms  of  staph- 

^.    ryogenic.  -j      ^^^  Terminal  infection  in  various  j  ylococci  and  streptococci. 

1^  chronic  maladies.  J 

4.  Miscella-  (  In  tvphoid  fever,  influenza,  diph-  i  Typhoid  bacillus,  influ- 
neous  acute  •]  theria,'  gonorrhoea,  anthrax,  actino-  y  enza  bacillus,  diphtheria 
infections.    (  mycosis,  and  other  acute  diseases.       )  bacillus,  gonococcus,  etc. 

Morbid  Anatomy. — The  basal  or  cortical  meninges  may  be  chiefly 
attacked,  The  degree  of  involvement  of  the  spinal  meninges  varies.  In 
the  form  associated  with  pneumonia  and  ulcerative  endocarditis  the  disease 
is  bilateral  and  usually  limited  to  the  cortex.  In  extension  from  disease  of 
the  ear  it  is  often  unilateral  and  uiay  be  accompanied  with  abscess  or  with 


Ph 


c  i 


AFFECTIONS  OF  THE  MENINGES.  955 

thrombosis  of  the  sinuses.  In  the  non-tuberculous  form  in  children,  in  the 
meningitis  of  chronic  Bright's  disease,  and  in  cachectic  conditions  the  base 
is  usually  involved.  In  the  cases  secondary  to  pneumonia  the  eJEEusion  be- 
neath the  arachnoid  may  be  very  thick  and  purulent,  completely  hiding 
the  convolutions.  The  ventricles  also  may  be  involved,  though  in  these 
simple  forms  they  rarely  present  the  distention  and  softening  which  is  so 
frequent  in  the  tuberculous  meningitis.  For  a  more  detailed  description 
the  student  is  referred  to  the  sections  on  cerebro-spinal  fever  and  tubercu- 
lous meningitis. 

Symptoms. — The  clinical  features  of  meningitis  have  already  been 
described  at  length  in  the  diseases  Just  referred  to,  and  I  shall  here  give  a 
general  summary.  I  have  already,  on  several  occasions,  called  attention  to 
the  fact  that  cortical  meningitis  is  not  to  be  recognized  by  any  symptoms 
or  set  of  symptoms  from  a  condition  which  may  be  produced  by  the  poison 
of  many  of  the  specific  fevers.  In  the  cases  of  so-called  cerebral  pneumonia, 
unless  the  base  is  involved  and  the  nerves  affected,  the  disease  is  unrecog- 
nizable, since  identical  symptoms  may  be  produced  by  intense  engorgement 
of  the  meninges.  In  typhoid  fever,  in  which  meningitis  is  very  rare,  the 
twitchings,  spasms,  and  retractions  of  the  neck  are  almost  invariably  as- 
sociated with  cerebro-spinal  congestion,  not  with  meningitis.  Actual  men- 
ingitis does,  however,  occur  in  typhoid  fever,  and,  as  Ohlmacher's  cases 
show,  the  typhoid  bacilli  may  be  present  in  the  exudate. 

A  knowledge  of  the  etiology  gives  a  very  important  clew.  Thus,  in 
middle-ear  disease  the  development  of  high  fever,  delirium,  vomiting,  con- 
vulsions, and  retraction  of  the  head  and  neck  would  be  extremely  suggestive 
of  meningitis  or  abscess.  Headache,  which  may  be  severe  and  continuous, 
is  the  most  common  symptom.  While  the  patient  remains  conscious  this  is 
usually  the  chief  complaint,  and  even  when  semicomatose  he  may  continue 
to  groan  and  to  place  his  hand  on  his  head.  In  the  fevers,  particularly 
in  pneumonia,  there  may  be  no  complaint  of  headache.  Delirium  is  fre- 
quently early,  and  is  most  marked  when  the  fever  is  high.  Convulsions 
are  less  common  in  simple  than  in  tuberculous  meningitis.  They  were 
not  present  in  a  single  instance  in  the  cases  which  I  have  seen  in  pneu- 
monia, ulcerative  endocarditis,  or  septicaemia.  In  the  simple  meningitis 
of  children  they  may  occur.  Epileptiform  attacks  which  come  and  go  are 
highly  characteristic  of  direct  irritation  of  the  cortex.  Eigidity  and  spasm 
or  twitchings  of  the  muscles  are  more  common.  Stiffness  and  retraction  of 
the  muscles  of  the  neck  are  important  symptoms;  but  they  are  by  no  means 
constant,  and  are  most  frequent  when  the  inflammation  is  extensive  on  the 
meninges  of  the  cervical  cord.  There  may  be  trismus,  gritting  of  the  teeth, 
or  spastic  contraction  of  the  abdominal  muscles.  Vomiting  is  a  common 
symptom  in  the  early  stages,  particularly  in  basilar  meningitis.  Constipa- 
tion is  usually  present.  In  the  late  stages  the  urine  and  fasces  may  be 
passed  involuntarily.  Optic  neuritis  is  rare  in  the  meningitis  of  the  cortex, 
but  is  not  uncommon  when  the  base  is  involved.  Leube  lays  stress  on  the 
hypera}sthesia  of  the  skin  and  muscles,  especially  of  the  muscles  of  the  neck 
and  calves. 

Important  symptoms  are  due  to  lesions  of  the  nerves  at  the  base.     Stra- 


956  DISEASES  OF   THE  NERVOUS  SYSTEM. 

bismus  or  ptosis  may  occur.  The  facial  nerve  may  be  involved^  producing 
slight  paralysis^,  or  there  may  be  damage  to  the  fifth  nerve,  producing  an- 
esthesia and,  if  the  Gasserian  ganglion  is  affected,  trophic  changes  in  the 
cornea.  The  pupils  are  at  first  contracted,  subsequently  dilated,  and  per- 
haps unequal.  The  refiexes  in  the  extremities  are  often  accentuated  at  the 
beginning  of  the  disease;  later  they  are  diminished  or  entirely  abolished. 
Herpes  is  common,  particularly  in  the  epidemic  form. 

Fever  is  present,  moderate  in  grade,  rarely  rising  above  103°.  In  the 
non-tiiberculous  leptomeningitis  of  debilitated  children  and  in  Bright's 
disease  there  may  be  little  or  no  fever.  The  pulse  may  be  increased  in  fre- 
quency at  first,  though  this  is  unusual.  One  of  the  striking  features  of  the 
disease  is  the  slowness  of  the  pulse  in  relation  to  the  temperature,  even  in 
the  early  stages.  Subsequently  it  may  be  irregular  and  still  slower.  The 
very  rapid  emaciation  which  often  occurs  is  doubtless  to  be  referred  to 
a  disturbance  of  the  cerebral  influence  upon  metabolism.  Kernig's  sign 
has  been  described  under  cerebro-spinal  fever.  Lumbar  puncture  is  ex- 
ceedingly valuable  for  diagnosis.  ISTot  only  does  this  frequently  prove 
indisputably  the  existence  of  an  acute  meningitis,  but  the  bacteriological 
examination  may  decide  as  to  the  etiological  factor,  and  thus  yield  a  more 
rational  basis  for  treatment. 

Treatment. — There  are  no  remedies  which  in  any  way_  control  the 
course  of  acute  meningitis.  An  ice-bag  should  be  applied  to  the  head  and, 
if  the  subject  is  young  and  full-blooded,  general  or  local  depletion  may  be 
practised.  Absolute  rest  and  quiet  should  be  enjoined.  When  disease  of 
the  ear  is  present,  a  surgeon  should  be  early  called  in  consultation,  and  if 
there  are  symptoms  of  meningo-encephalitis  which  can  in  any  way  be  local- 
ized trephining  should  be  practised.  An  occasional  saline  purge  will  do 
more  to  relieve  the  congestion  than  blisters  and  local  depletion.  The  warm 
baths,  as  recommended  by  Aufrecht  and  described  under  cerebro-spinal 
fever,  should  be  given  every  three  hours.  It  is  possible  that  recovery  may 
follow  in  the  primary  pneumococcus  form  (Netter).  If  counter-irritation 
is  deemed  essential,  the  thermo-cautery  may  be  lightly  applied  to  the  back 
of  the  neck.  Large  doses  of  the  perchloride  of  iron,  iodide  of  potassium, 
and  mercury  are  recommended  by  some  authors. 

The  application  of  an  ice-cap,  attention  to  the  bowels  and  stomach,  and 
keeping  the  fever  within  moderate  limits  by  sponging,  are  the  necessary 
measures  in  a  disease  recognized  as  almost  invariably  fatal,  and  in  which 
the  cases  of  recovery  are  extremely  doubtful.  Quincke's  lumbar  puncture 
(see  page  107)  may  be  used  as  a  therapeutic  measure.  Flirbringer  in  one 
case  removed  60  cc.  of  cloudy  fluid,  in  which  tubercle  bacilli  were  found. 
The  headache  and  other  cerebral  symptoms  disappeared,  and  the  patient, 
a  man  of  twenty,  recovered.  Wallis  Ord  and  Waterhouse  report  a  case 
of  recovery,  in  a  child  of  five  years,  after  trephining  and  drainage.  In  a 
recent  case  Halsted  made  an  unsuccessful  attempt  to  irrigate  the  cerebro- 
spinal meninges  in  the  manner  suggested  by  Leonard  Hill. 


SCLEROSES  OP  THE   BRAIN.  957 

The  Simple  Meningitis  of  Infants  (Non-tuberculous  Leptomeningitis 

Infantum). 

This  form  has  been  specially  studied  by  Gee  and  Barlow,  and  has  been 
exhaustively  considered  by  Barlow  and  Lees  in  Allbutt's  System.  Of  110 
cases,  84  occurred  during  the  first  year.  There  are  two  classes,  the  verti- 
cal and  the  posterior-basic.  In  all  cases  there  is  distention  of  the  lateral 
and  third  ventricles,  generally  of  the  fourth  also,  with  "  effusion  of  lymph, 
thickening  of  the  pia-arachnoid,  and  matting  of  the  parts  over  the  pos- 
terior and  central  area  of  the  base  of  the  brain  from  the  lower  end  of  the 
medulla  to  the  optic  commissure^'  (J.  W.  Carr).  The  disease  is  most  com- 
mon in  infants  under  one  year.  Head  retraction  appears  early  and  persists 
throughout,  being  rarely  absent.  It  is  usually  much  more  marked  than  in 
tuberculous  meningitis.  Three  forms  of  tonic  spasm  are  seen — retraction 
of  the  head,  opisthotonos,  and  extensor  or  flexor  spasm  of  the  limbs.  At 
a  comparatively  early  stage,  even  weeks  before  death,  the  infants  pass  into 
stupor  or  complete  coma.  This  form  is  sometimes  met  with  in  older  chil- 
dren. As  already  mentioned,  the  evidence  is  accumulating  to  show  thai 
this  disease  is  the  sporadic  variety  of  cerebro-spinal  fever. 

Chronic  Leptomeningitis. — This  is  rarely  seen  apart  from  syphilis  or 
tuberculosis,  in  which  the  meningitis  is  associated  with  the  growth  of  the 
granulomata  in  the  meninges  and  about  the  vessels.  The  symptoms  in  such 
cases  are  extremely  variable,  depending  entirely  upon  the  situation  of  the 
growth.  They  may  closely  resemble  those  of  tumor  and  be  associated  with 
localized  convulsions.  The  epidemic  meningitis  may  run  a  very  chronic 
course.  The  leptomeningitis  infantum  may  be  chronic.  In  the  cases  re- 
ported by  Gee  and  Barlow  the  duration  in  some  instances  extended  even  to 
a  year  and  a  half.  Quincke's  meningitis  serosa  is  considered  with  hydro- 
cephalus. 

11.    SCLEROSES    OF    THE    BRAIN. 

General  Remarks. — The  connective  tissue  of  the  central  nervous 
system  is  of  two  kinds — one,  the  neuroglia,  special  and  peculiar,  derived 
from  the  ectoderm,  with  distinct  morphological  and  chemical  characters; 
the  other,  in  the  meninges  and  accompanying  the  blood-vessels,  derived 
from  the  mesoderm,  identical  with  the  ordinary  collagenous  fibrous  tissue 
of  the  body.  Both  play  important  parts  in  indurative  processes  in  the 
brain  and  cord.  A  convenient  division  of  the  cerebro-spinal  scleroses  is  into 
degenerative,  inflammatory,  and  developmental  forms. 

The  degenerative  scleroses  comprise  the  largest  and  most  important  sub- 
division, in  which  provisionally  the  following  groups  may  be  made:  (a) 
The  common  secondary  degeneration  which  follows  when  nerve-fibres  are 
cut  off  from  their  trophic  centres  (the  severance  of  portions  of  neurones 
from  the  main  portions  containing  the  nuclei);  (b)  toxic  forms,  among  which 
may  be  placed  the  scleroses  from  lead  and  ergot,  and,  most  important  of  all, 
the  sclerosis  of  the  dorsal  columns,  due  in  such  a  large  proportion  of  cases 
to  the  virus  of  syphilis.     Other  unknown  toxic  agents  may  possibly  induce 


958  DISEASES  OF  THE  NERVOUS  SYSTEM. 

degeneration  of  the  nerve-fibres  in  certain  tracts.  The  systemic  paths  in 
the  cord  differ  apparently  in  their  susceptibility  and  the  dorsal  columns 
appear  most  prone  to  undergo  this  change;  (c)  the  sclerosis  associated 
with  change  in  the  smaller  arteries  and  capillaries,  which  is  met  ^\^.th  as  a 
senile  process  in  the  conyolutions.  In  all  probability  some  of  the  forms  of 
insular  sclerosis  are  due  to  primary  alterations  in  the  blood-vessels;  but 
it  is  not  yet  settled  whether  the  lesion  in  these  cases  is  a  primary  degen- 
eration of  the  nerve  cells  and  fibres  to  which  the  sclerosis  is  secondary,  or 
whether  the  essential  factor  is  an  alteration  in  nutrition  caused  by  lesions 
of  the  capillaries  and  smaller  arteries. 

The  inflammatory  scleroses  embrace  a  less  important  and  less  extensive 
group,  comprising  secondary  forms  which  develop  in  consequence  of  irri- 
tative inflammation  about  tumors,  foreign  bodies,  haemorrhages,  and  abscess. 
Histologically  these  are  chiefly  mesodermic  (vascular)  scleroses,  which  arise 
from  the  connective  tissue  about  the  blood-vessels.  Possibly  a  similar 
change  may  follow  the  primary,  acute  encephalitis,  which  Striimpell  holds 
is  the  initial  lesion  in  the  cortical  sclerosis  which  is  so  commonly  found 
"post  mortem  in  infantile  hemiplegia. 

The  developmental  scleroses  are  believed  to  be  of  a  purely  neurogliar 
character,  and  embrace  the  new  growth  about  the  central  canal  in  syringo- 
myelia and,  according  to  recent  French  writers,  the  sclerosis  of  the  dor- 
sal columns  in  Friedreich's  ataxia.  It  is  stated  that  histologically  this 
form  is  different  from  the  ordinary  variety.  It  may  be,  too,  that  the  diffuse 
cortical  sclerosis  met  with  as  a  congenital  condition  without  thickening 
of  the  meninges  belongs  to  this  t^-pe.  It  is  not  improbable  that  many 
forms  of  scleroses  are  of  a  mixed  character,  in  which  both  the  ectodermic 
glia  and  mesodermic  connective  tissue  are  involved. 

Anatomically  we  meet  with  the  following  varieties: 

(1)  Miliary  sclerosis  is  a  term  which  has  been  applied  to  several  differ- 
ent conditions.  Gowers  mentions  a  case  in  which  there  were  grayish-red 
spots  at  the  junction  of  the  white  and  gray  matters,  and  in  which  the  neu- 
roglia was  increased.  There  is  also  a  condition  in  which,  on  the  surface 
of  the  convolutions,  there  are  small  nodular  projections,  varying  from  a 
half  to  five  or  more  millimetres  in  diameter.  Single  nodules  of  this  sort 
are  not  uncommon;  sometimes  they  are  abundant.  So  far  as  is  known  no 
symptoms  are  produced  by  them. 

(2)  Diffuse  sclerosis,  which  may  involve  an  entire  hemisphere,  or  a 
single  lobe,  in  which  case  the  term  sclerose  lohaire  has  been  applied  to  it 
by  the  French.  It  is  not  an  important  condition  in  general  medical  prac- 
tice, but  occurs  most  frequently  in  idiots  and  imbeciles.  In  extensive  cor- 
tical sclerosis  of  one  hemisphere  the  ventricle  is  usually  dilated.*  The 
s}Tnptoms  of  this  condition  depend  upon  the  region  affected.  There  may 
be  a  considerable  extent  of  sclerosis  without  symptoms  or  without  much 
mental  impairment.  In  a  majority  of  cases  there  is  hemiplegia  or  diplegia 
with  imbecility  or  idiocy. 

*  In  my  monograph  on  Cerebral  Palsies  of  Children  I  have  given  a  description  of  the 
distribution  of  the  sclerosis  in  ten  specimens  in  the  museum  at  the  Elwyn  Institution. 


SCLEROSES  OF  THE   BRAIN.  959 

(3)  Tuberous  Sclerosis. — In  this  remarkable  form,  which  is  also  known 
as  hypertrophic  sclerosis,  there  are  on  the  convolutions  areas,  projecting 
beyond  the  surfaces,  of  an  opaque  white  color  and  exceedingly  firm.  The 
sclerosis  may  not  disturb  the  S3^mmetry  of  the  convolution,  but  simply  cause 
a  great  enlargement,  increase  in  the  density,  and  a  change  in  the  color. 

These  three  forms  are  not  of  much  practical  interest  except  in  asylum 
and  institution  work.  The  last  variety  forms  a  well-characterized  disease 
0^  considerable  importance,  namely: 

{4:)  Insular  Sclerosis  {Sclerose  en  plaques). 

Definition. — A  chronic  affection  of  the  brain  and  cord,  characterized 
by  localized  areas  in  which  the  nerve  elements  are  more  or  less  replaced  by 
connective  tissue.  This  may  occur  in  the  brain  or  cord  alone,  more  com- 
monly in  both. 

Etiology. — This  is  obscure.  Kahler,  Marie,  and  others  assign  great 
importance  to  the  infectious  diseases,  particularly  scarlet  fever.  It  is 
found  most  commonly  in  young  persons,  and  cases  are  not  uncommon  in 
children,  in  whom  Pritchard  states  that  more  than  50  cases  have  been  re- 
ported. Sachs  has  recently  reviewed  the  whole  subject  (Jour,  of  Nerv.  and 
Mental  Diseases,  1898). 

Morbid  Anatomy. — The  sclerotic  areas  are  widely  distributed 
through  the  brain  and  cord,  and  cases  limited  to  either  part  alone  are  almost 
unknown.  The  grayish-red  areas  are  scattered  indifferently  through  the 
white  and  gray  matter  (E.  W.  Taylor).  The  patches  are  most  abundant 
in  the  neighborhood  of  the  ventricles,  and  in  the  pons,  cerebellum,  basal 
ganglia,  and  the  medulla.  The  cord  may  be  only  slightly  involved  or 
there  may  be  irregular  areas  in  different  regions.  The  cervical  region  is 
most  often  the  seat  of  nodules.  The  nerve-roots  and  the  branches  of  the 
Cauda  equina  are  often  attacked.  Histologically  in  the  sclerosed  patches 
there  is  very  marked  proliferation  of  the  neuroglia,  the  fibres  of  which  are 
denser  and  firmer.  The  gradual  growth  destroys  the  medulla  of  the  nerves, 
but  the  axis  cylinders  persist  in  a  remarkable  way.  There  is  as  a  conse- 
quence relatively  little  secondary  degeneration  of  nerve  tracts. 

Symptoms.— The  onset  is  slow  and  the  disease  is  chronic.  Feeble- 
ness of  the  legs  with  irregular  pains  and  stiffness  are  among  the  early 
symptoms.  Indeed,  the  clinical  picture  may  be  that  of  spastic  paraplegia 
with  great  increase  in  the  reflexes.  The  following  are  the  most  important 
features : 

(a)  Volitional  Tremor  or  So-called  Intention  Tremor. — There  is  no  paraly- 
sis of  the  arms,  but  on  attempting  to  pick  up  an  object  there  is  trembling 
or  rapid  oscillation.  A  patient  may  be  unable  to  lift  even  a  glass  of  water 
to  the  mouth.  The  tremor  may  be  marked  in  the  legs  and  in  the  head, 
which  shakes  as  he  walks.  When  the  patient  is  recumbent  the  muscles  may 
be  perfectly  quiet.  On  attempting  to  raise  the  head  from  the  pillow, 
trembling  at  once  comes  on.  (&)  Scanning  Speech. — The  words  are  pro- 
nounced slowly  and  separately,  or  the  individual  syllables  may  be  accentu- 
ated.    This  staccato  or  syllabic  utterance  is  a  common  feature,     (c)  Nys- 


960  DISEASES  OF  THE  NERVOUS  SYSTEM. 

tagmus,  a  rapid  oscillatory  movement  of  both  eyes,  constitutes  an  important 
symptom. 

Sensation  is  unaffected  in  a  majority  of  the  eases.  Optic  atrophy  some- 
times occurs,  but  not  so  frequently  as  in  tabes.  The  sphincters,  as  a  rule, 
are  unaffected  until  the  last  stages.  Mental  debility  is  not  uncommon. 
Eemarkable  remissions  occur  in  the  course  of  the  disease,  in  which  for  a 
time  all  the  symptoms  may  improve.  Vertigo  is  common,  and  there  may 
be  sudden  attacks  of  coma,  such  as  occur  in  general  paresis. 

The  symptoms,  on  the  whole,  are  extraordinarily  variable,  corresponding 
to  the  very  irregular  distribution  of  the  nodules. 

The  diagnosis  in  well-marked  cases  is  easy.  Volitional  tremor,  scan- 
ning speech,  and  nystagmus  form  a  characteristic  symptom-group.  With 
this  there  is  usually  more  or  less  spastic  weakness  of  the  legs.  Paralysis 
agitans,  certain  cases  of  general  paresis,  and  occasionally  hysteria  may 
simulate  the  disease  very  closely.  If  the  ease  is  not  seen  until  near  the 
end  the  diagnosis  may  be  impossible.  Buzzard  holds  that  of  all  organic 
diseases  of  the  nervous  system  disseminated  sclerosis  in  its  early  stages  is 
that  which  is  most  commonly  mistaken  for  hysteria.  The  points  to  be 
relied  upon  in  the  differentiation  are,  in  order  of  importance,  the  nystag- 
mus, the  bladder  disturbances,  and  the  volitional  tremor.  The  tremor  in 
hysteria  is  not  volitional.     Unilateral  cases  are  recorded. 

Much  more  puzzling,  however,  are  the  instances  of  pseudo-scUrose  en 
plaques,  which  have  been  described  by  Westphal.  French  writers  regard 
them  as  instances  of  hysterical  tremor.  In  children  the  condition  may 
with  difficulty  be  separated  from  Friedreich's  ataxia. 

The  prognosis  is  unfavorable.  Ultimately,  the  patient,  if  not  carried 
off  by  some  intercurrent  affection,  becomes  bedridden. 

Treatment. — No  known  treatment  has  any  influence  on  the  progress 
of  sclerosis  of  the  brain.  Neither  the  iodides  nor  mercury  have  the  slight- 
est effect,  but  a  prolonged  course  of  nitrate  of  silver  may  be  tried,  and  ar- 
senic is  recommended. 


m.    CHRONIC    DIFFUSE    MENINGO-ENCEPHALITIS 

(Dementia  Paralytica  ;  General  Paresis). 

Definition. — A  chronic,  progressive  meningo-encephalitis  associated 
with  psychical  and  motor  disturbances,  finally  leading  to  dementia  and 
paralysis. 

Etiology. — Males  are  affected  much  more  frequently  than  females. 
It  occurs  chiefly  between  the  ages  of  thirty  and  fifty-five.  Heredity  is  a 
factor  in  only  a  few  instances.  An  overwhelming  majority  of  the  cases  are 
in  married  people.  Statistics  show  that  it  is  more  common  in  the  lower 
classes  of  society,  but  in  this  country  in  general  medical  practice  the  dis- 
ease is  certainly  more  common  in  the  well-to-do  classes.  An  important 
predisposing  cause  is  "a  life  absorbed  in  ambitious  projects  with  all  its 
strongest  mental  efforts,  its  long-sustained  anxieties,  deferred  hopes,  and 
straining  expectation  "  (Mickle).     The  habits  of  life  so  frequently  seen  in 


CHRONIC  DIFFUSE  MENINGO-ENCEPHALITIS.  961 

active  business  men  in  our  large  cities,  and  well  expressed  by  the  phrase 
"  burning  the  candle  at  both  ends/'  strongly  predispose  to  the  disease. 
The  important  individual  factor  is  syphilis,  which  is  an  antecedent  in 
from  70  to  90  per  cent  of  all  cases.  To  this  disease  dementia  paralytica 
and  tabes  dorsalis  are  so  closely  related  that  Fournier  describes  them 
under  the  heading  Les  Affections  Parasyphilitiques.  His  work,  with  this 
title,  is  full  of  interesting  details  gleaned  from  an  enormous  experience. 
He  suggests  that  these  two  disorders  may  be  not  merely  diverse  expressions 
of  one  and  the  same  morbid  entity,  but  that  they  possibly  may  be  one  and 
the  same  disease. 

Morbid  Anatomy. — Both  the  vascular  and  nerve  elements  are  in- 
volved. The  general  lesions  in  the  vascular  system  are  inflammatory,  and 
those  in  the  nerve  structures  degenerative.  The  membranes  show  a  dif- 
fuse chronic  meningitis.  The  dura  is  often  thickened  and  vascular.  There 
is  increase  of  fluid  in  the  subdural  space.  The  pia  in  early  cases  is  hyper- 
trophied,  oedematous,  and  adherent  to  the  cortex.  Later  there  may  be  no 
adhesion.  Its  Ij^mph  spaces  are  full  of  small  cells  which  may  block  the 
channels.  The  vessels  show  changes,  especially  in  the  media.  In  older 
cases  the  inflammatory  condition  is  not  so  marked. 

The  brain  is  usually  small  and  weighs  less  than  normal.  The  convolu- 
tions are  atrophied,  especially  in  the  anterior  and  middle  lobes.  In  acute 
cases  there  may  be  hyperaemia  and  swelling  due  to  congestion  and  oedema. 
In  advanced  cases  the  consistence  is  increased.  Histologically  there  is 
atrophy  of  the  nerve  elements  and  hypertrophy  of  the  connective  tissue. 
The  lesions  of  the  neurone  are  retrogressive.  Simple  atrophy  may  be 
found.  Pigmentary  and  fatty  degeneration  are  common.  In  certain  areas 
cells  disappear  entirely  and  no  nerve  elements  are  found.  Adjoining  areas 
may,  however,  show  little  alteration.  Changes  are  common  in  the  neurog- 
lia. In  advanced  cases  there  may  be  great  diminution  in  the  medullated 
fibres. 

There  are  various  views  as  to  the  nature  of  the  changes.  The  vascular 
theory  is  that  from  an  inflammatory  process  starting  in  the  sheaths  of  the 
arterioles  there  is  a  diffuse  parenchymatous  degeneration  with  atrophic 
changes  in  the  nerve  cells  and  neuroglia.  A  contrary  view  is  that  the  pri- 
mary degeneration  is  in  the  neurone  with  secondary  meningo-encepha- 
litis. 

The  degenerative  changes  are  not  limited  to  the  cortex,  but  also  invade 
subcortical  regions  and  the  spinal  cord.  In  the  spinal  cord  changes  are  al- 
most constantly  found,  usually  sclerosis  of  the  dorsal  fasciculi,  either  alone 
or,  more  commonly,  with  involvement  of  the  lateral. 

Symptoms. — (a)  Prodromal  Stage. — This  is  of  variable  duration,  and 
is  characterized  by  a  general  mental  state  which  finds  expression  in  symp- 
toms trivial  in  themselves  but  important  in  connection  with  others.  Irri- 
tability, inattention  to  business  amounting  sometimes  to  indifference  or 
apathy,  and  sometimes  fi  rJiatige  in  character,  marked  by  acts  which  may  as- 
tonish the  friends  and  relatives,  may  be  the  first  indications.  There  may 
be  unaccountable  fatigue  after  moderate  physical  or  mental  exertion.  In- 
stead of  apathy  or  indifference  there  may  be  an  extraordinary  degree  of 


962  DISEASES  OF  THE  NERVOUS  SYSTEM. 

physical  and  mental  restlessness.  The  patient  is  continually  planning  and 
scheming,  or  may  launch  into  extravagances  and  speculation  of  the  wildest 
character.  A  common  feature  at  this  period  is  the  display  of  an  un- 
bounded egoism.  He  boasts  of  his  personal  attainments,  his  property,  his 
position  in  life,  or  of  his  wife  and  children.  Following  these  features  are 
important  indications  of  moral  perversion,  manifested  in  offences  against 
decency  or  the  law,  many  of  which  acts  have  about  them  a  suspicious 
effrontery.  Forgetfulness  is  common,  and  may  be  shown  in  inattention  to 
business  details  and  in  the  minor  courtesies  of  life.  At  this  period  there 
may  be  no  motor  phenomena.  The  onset  of  the  disease  is  usually  insidi- 
ous, although  cases  are  reported  in  which  epileptiform  or  apoplectiform 
seizures  were  the  first  symptoms.  Among  the  early  motor  features  are 
tremor  of  the  tongue  and  lips  in  speaking,  slowness  of  speech  and  hesi- 
tancy, inequality  of  the  pupils,  and  the  Argyll  Eobertson  pupil. 

(h)  Second  Stage. — This  is  characterized  in  brief  by  .mental  exaltation 
or  excitement  and  a  progress  in  the  motor  symptoms.  "  The  intensity  of 
the  excitement  is  often  extreme,  acute  maniacal  states  are  frequent;  in- 
cessant restlessness,  obstinate  sleeplessness,  noisy,  boisterous  excitement,  and 
blind,  uncalculating  violence  especially  characterize  such  states''  (Lewis). 
It  is  at  this  stage  that  the  delusion  of  grandeur  becomes  marked  and  the 
patient  believes  himself  to  be  possessed  of  countless  millions  or  to  have 
reached  the  most  exalted  sphere  possible  in  profession  or  occupation.  This 
expansive  delirium,  as  it  is  called,  is,  however,  not  characteristic,  as  was 
-formerly  supposed,  of  paralytic  dementia.  Besides,  it  does  not  always  oc- 
cur, but  in  its  stead  there  may  be  marked  melancholia  or  hypochondriasis, 
or,  in  other  instances,  alternate  attacks  of  delirium  and  depression. 

The  facies  has  a  peculiar  stolidity,  and  in  speaking  there  is  marked 
tremulousness  of  the  lips  and  facial  muscles.  The  tongue  is  also  tremu- 
lous, and  may  be  protruded  with  difficulty.  The  speech  is  slow,  inter- 
rupted, and  blurred.  "Writing  becomes  difficult  on  account  of  unsteadi- 
ness of  the  hand.  Letters,  syllables,  and  words  may  be  omitted.  The  sub- 
ject matter  of  the  patient's  letters  gives  valuable  indications  of  the  mental 
condition.  In  many  instances  the  pupils  are  unequal,  irregular,  sluggish, 
sometimes  large.  Important  symptoms  in  this  stage  are  apoplectiform 
seizures  and  paralysis.  There  may  be  slight  syncopal  attacks  in  which  the 
patient  turns  pale  and  may  fall.  Some  of  these  are  fetit  mal.  In  the  true 
apoplectiform  seizure  the  patient  falls  suddenly,  becomes  unconscious,  the 
limbs  are  relaxed,  the  face  is  flushed,  the  breathing  stertorous,  the  tem- 
perature increased,  and  death  may  occur.  The  epileptic  seizures  are  more 
common  than  the  apoplectiform  and  may  occur  in  the  disease.  A  definite 
aura  is  not  uncommon.  The  attack  usually  begins  on  one  side  and  may  not 
spread.  There  may  be  twitchings  either  in  the  facial  or  brachial  muscles. 
Typical  Jacksonian  epilepsy  may  occur.  In  a  case  which  died  recently 
under  my  care,  these  seizures  were  among  the  early  symptoms  and  the  dis- 
ease was  regarded  as  cerebral  syphilis.  Paralysis,  either  monoplegic  or 
hemiplegic,  may  follow  these  epileptic  seizures,  or  may  come  on  Avitk  great 
suddenness  and  be  transient.  In  this  stage  the  gait  becomes  impaired,  the 
patient  trips  readily,  has  difficulty  in  going  up  or  down  stairs,  and  the  walk 


CHRONIC  DIFFUSE   MENINGO-ENCEPITALITIS,  963 

may  be  spastic  or  occasionally  tabetic.  This  paresis  may  be  progressive. 
The  knee-jerk  is  usually  increased.  Bladder  or  rectal  symptoms  gradually 
develop.  The  patient  becomes  helpless,  bedridden,  and  completely  de- 
mented, and  unless  care  is  taken  may  suffer  from  bedsores.  Death  occurs 
from  exhaustion  or  from  some  intercurrent  affection.  The  absence  of  pain 
reaction  on  pressure  upon  the  ulnar  nerve  behind  the  elbow  (Biernacki's 
symptom)  is  apparently  not  of  any  special  value.  The  spinal-cord  features 
of  dementia  paralytica  may  come  on  with  or  precede  the  mental  troubles; 
in  80  per  cent  of  the  cases  they  follow  them.  There  are  cases  in  which  one 
is  in  doubt  for  a  time  whether  the  symptoms  indicate  tabes  or  dementia 
paralytica,  and  it  is  well  to  bear  in  mind  that  every  feature  of  pre-ataxic 
tabes  may  exist  in  the  early  stage  of  general  paresis. 

Diagnosis. — The  recognition  of  the  disease  in  the  earliest  stage  is  ex- 
tremely diiScult,  as  it  is  often  impossible  to  decide  that  the  slight  altera- 
tion in  conduct  is  anything  more  than  one  of  the  moods  or  phases  to  which 
most  men  are  at  times  subject.  The  following  description  by  Folsom  is 
an  admirable  presentation  of  the  diagnostic  characters  of  the  early  stage 
of  the  disease:  "  It  should  arouse  suspicion  if,  for  instance,  a  strong,  healthy 
man,  in  or  near  the  prime  of  life,  distinctly  not  of  the  '  nervous,'  neurotic, 
or  neurasthenic  type,  shows  some  loss  of  interest  in  his  affairs  or  impaired 
faculty  of  attending  to  them;  if  he  becomes  varyingly  absent-minded,  heed- 
less, indifferent,  negligent,  apathetic,  inconsiderate,  and,  although  able  to 
follow  his  routine  duties,  his  ability  to  take  up  new  work  is,  no  matter  how 
little,  diminished;  if  he  can  less  well  command  mental  attention  and  con- 
centration, conception,  perception,  reflection,  judgment;  if  there  is  an  un- 
wonted lack  of  initiative,  and  if  exertion  causes  unwonted  mental  and 
physical  fatigue;  if  the  emotions  are  intensified  and  easily  change,  or  are 
excited  readily  from  trifling  causes;  if  the  sexual  instinct  is  not  reasonably 
controlled;  if  the  finer  feelings  are  even  slightly  blunted;  if  the  person  in 
question  regards  with  a  placid  apathy  his  own  acts  of  indifference  and 
irritability  and  their  consequences,  and  especially  if  at  times  he  sees  himself 
in  his  true  light  and  suddenly  fails  again  to  do  so;  if  any  symptoms  of 
cerebral  vaso-motor  disturbances  are  noticed,  however  vague  or  variable." 

There  are  cases  of  cerebral  syphilis  which  closely  simulate  dementia  para- 
lytica. The  mode  of  onset  is  important,  particularly  since  paralytic  symp- 
toms are  usually  early  in  syphilis.  The  affection  of  the  speech  and  tongue 
is  not  present.  Epileptic  seizures  are  more  common  and  more  liable  to 
be  cortical  or  Jacksonian  in  character.  The  expansive  delirium  is  rare. 
While  symptoms  of  general  paresis  are  not  common  in  connection  with 
the  development  of  gummata  or  definite  gummatous  meningitis,  there  are, 
on  the  other  hand,  instances  of  paresis  which  follow  syphilitic  infection 
so  closely  that  an  etiological  connection  between  the  two  must  be  acknowl- 
edged. Post  mortem  in  such  cases  there  may  be  nothing  more  than  a 
general  arterio-sclerosis  and  diffuse  meningo-encephalitis,  which  may  pre- 
sent nothing  distinctive,  but  the  lesions,  nevertheless,  may  be  caused  by 
the  syphilitic  virus.  There  are  certain  forms  of  lead  encephalopathy  which 
resemble  general  paresis,  and,  considering  the  association  of  plunibism  with 
arterio-sclerosis,  it  is  not  unlikely  that  the  anatomical  substratum  of  the 


964  DISEASES  OF   THE  NERVOUS  SYSTEM. 

disease  may  resiilt  from  this  poison.  Tumor  may  sometimes  simulate  pro- 
gressive paresis,  but  in  the  former  the  signs  of  general  increase  of  the  intra- 
cranial pressure  (pain  in  the  head,  choked  disks,  slowing  of  the  pulse-rate, 
projectile  vomiting)  are  usually  present. 

Prognosis. — -The  disease  rarely  ends  in  recovery.  As  a  rule  the  prog- 
ress is  slowly  downward  and  the  case  terminates  in  a  few  years,  although 
it  is  occasionally  prolonged  ten  or  fifteen  years. 

Treatment. — The  only  hope  of  permanent  relief  is  in  the  cases  follow- 
ing syphilis,  T^'hich  should  be  placed  upon  large  doses  of  iodide  of  potas- 
sium. Careful  nursing  and  the  orderly  life  of  an  asylum  are  the  only 
measures  necessary  in  a  great  majority  of  the  cases.  For  sleeplessness  and 
the  epileptic  seizures  bromides  may  be  used.  Prolonged  remissions,  which 
are  not  uncommon,  are  often  erroneously  attributed  to  the  action  of  reme- 
dies. Active  treatment  in  the  early  stage  by  wet-packs,  cold  to  the  head, 
and  systematic  massage  have  been  followed  by  temporary  improvement. 


lY.   DIFFUSE  AND  FOCAL  DISEASES   OF  THE   SPIjS'AL 

COED. 

I.   TOPICAL    DIAGNOSIS. 

We  have  seen  that  a  lesion  involving  a  definite  part  of  the  gray  matter 
of  the  lower  motor  segment  is  accompanied  by  loss  of  the  power  to  per- 
form certain  definite  movements.  A  disease,  such  as  anterior  polio-mye- 
litis, which  is  confined  to  the  gray  matter,  gives  as  its  only  s}Tnptom  a 
characteristic  lower-segment  paralysis.  The  muscles  paralyzed  reveal  the 
seat  of  the  lesion.  In  many  instances  a  transverse  section  of  the  spinal 
cord  is  involved  to  a  greater  or  less  extent;  if  complete,  there  is  lower-seg- 
ment paralysis  at  the  level  of  the  lesion.  If  the  muscles  so  paralyzed  are 
the  same  on  the  two  sides  of  the  body,  the  lesion  is  strictly  transverse,  for, 
obviously,  if  the  cord  is  involved  higher  on  one  side  than  on  the  other  the 
paralyzed  muscles  will  vary  accordingly.  Besides  the  paralysis  due  to  in- 
volvement of  the  lower  segment,  the  muscles  whose  centres  are  below  the 
lesion  may  also  be  paralyzed  by  the  involvement  of  the  upper  segment  in 
the  pyramidal  tract,  and  present  all  the  characteristics  of  such  a  paralysis. 
The  degree  of  the  paralysis  depends  upon  the  intensity  of  the  lesion  of  the 
pyramidal  tract,  and  varies  from  a  slight  weakness  in  the  flexion  of  the 
ankle  to  an  absolute  paralysis  of  all  the  muscles  below  the  lesion.  The 
sphincter  muscles  of  the  bladder  and  rectum  are  also  often  paralyzed. 

Sensory  s}Tnptoms  are  usually  less  prominent,  but  when  the  spinal  cord 
is  much  diseased  there  is  a  dulling  of  sensation  all  over  the  body  below  the 
lesion.  The  upper  border  of  disturbed  sensation  often  indicates  the  level 
of  the  disease,  especially  when  this  is  in  the  thoracic  region,  where  the  cor- 
responding motor  paralysis  is  not  easy  to  demonstrate.  It  is  to  be  noted 
that  the  anaesthesia  does  not  reach  quite  to  the  level  of  the  lesion;  thus 
if  the  fifth  thoracic  segment  be  involved,  the  anaesthesia  will  include  the 


TOPICAL  DIAGNOSIS. 


965 


area  supplied  by  the  sixth  segment,  but  not  that  supplied  by  the  fifth.  This 
is  due  to  the  overlapping  of  the  areas.  There  is  often  a  narrow  zone  of 
hypersesthesia  above  the  anaesthetic  region. 

When  the  transverse  lesion  is  complete  and  the  lower  part  of  the  cord  is 
cut  off  from  all  influence  from  above,  there  is  complete  sensory  and  motor 
paralysis,  and  the  deep  reflexes  instead  of  being  exaggerated  are  lost. 

The  different  reflexes  are  dependent  upon  different  levels  of  the  cord 
(see  Starr's  table,  p.  905),  and  their  absence  or  presence  may  be  important 
localizing  symptoms. 

Unilateral  Lesions. — The  motor  symptoms  which  follow  lesions  con- 
fined to  one  half  of  the  cross-s6ction  of  the  spinal  cord  follow  the  same 
rules  as  those  given  for  transverse  lesions,  except  that  they  are  confined  to 
one  side  of  the  body — that  is,  they  are  on  the  same  side  as  the  lesion. 

The  sensory  symptoms  are  peculiar.  On  the  side  corresponding  to  the 
disease — the  paralyzed  side — there  is  angesthesia  corresponding  to  the  seg- 
ment of  the  cord  involved;  above  this  there  is  a  narrow  zone  of  hyperses- 
thesia, but  below  this  there  is  no  diminution  in  the  senses  of  touch,  pain, 
or  temperature;  indeed,  there  is  often  hypersesthesia.  The  muscular  sense, 
however,  is  impaired.  On  the  side  opposite  to  the  lesion  there  may  be  com- 
plete loss  of  the  sense  of  touch,  pain,  and  temperature,  or  it  may  only  in- 
volve one  or  two  of  these,  pain  and  temperature  usually  being  associated. 

The  following  table,  slightly  modified  from  Gowers,  illustrates  the  dis- 
tribution of  these  symptoms  in  a  complete  hemi-lesion  of  the  cord: 


Cord. 


Zone  of  cutaneous  hyperaesthesia. 
Zone  of  cutaneous  anesthesia. 
Lower    segment    paralysis     with 
atrophy. 


Upper  segment  paralysis. 
Hyperaesthesia  of  skin. 
Muscular  sense  impaired. 
Reflex   action  first  lessened  and 

then  increased. 
Temperature  raised. 


Lesion. 


Muscular  power  normal. 
Loss  of  sensibility  of  skin. 
Muscular  sense  normal. 
Reflex  action  normal. 
Temperature  same  as  that  above 
lesion. 


It  is  only  in  exceptional  cases  that  all  these  features  are  met  with,  for  they 
vary  with  its  extent  and  intensity. 

This  combination  of  symptoms  was  first  recognized  by  Brown-Sequard, 
after  whom  it  has  been  named.  It  is  common  in  syphilitic  diseases  of  the 
cord,  and  may  follow  tumors,  stab-wounds,  fracture  and  caries  of  the  spine, 
and  it  is  not  infrequently  associated  with  syringomyelia  and  haemorrhages 
into  the  cord. 

The  explanation  of  the  disturbance  in  sensation  is  not  satisfactory,  and 
can  not  be  until  our  knowledge  of  the  paths  of  sensory  conduction  is  more 
accurate.  These  cases  have  convinced  most  clinicians  that  in  man  the 
paths  for  touch,  pain,  and  temperature  cross  in  the  middle  line  soon  after 
entering  the  spinal  cord,  and  proceed  toward  the  brain  in  the  opposite 
side,  while  that  for  muscular  sense  remains  in  the  dorsal  columns  of  the 


966  DISEASES  OF   THE  NERVOUS  SYSTEM. 

same  side.  We  have  seen  that  anatomy  lends  some  support  to  this  view, 
and  this  is  the  explanation  that  is  usually  given.  The  experiments  on 
animals  have  thrown  some  doubt  on  this  view,  especially  those  of  Mott  on 
monkeys,  which  seem  to  indicate  that  the  sensory  paths  for  the  most  part 
remain  on  the  same  side  of  the  cord. 


II.    AFFECTIONS    OF   THE    BLOOD-VESSELS. 

1.  Congestion. 

Apart  from  actual  myelitis,  we  rarely  see  post  mortem  evidences  of  con- 
gestion of  the  spinal  cord,  and  when  we  do,  it  is  usually  limited  either  to  the 
gray  matter  or  to  a  definite  portion  of  the  organ.  There  is  necessarily, 
from  the  posture  of  the  body  post  mortem,  a  greater  degree  of  vascularity 
in  the  dorsal  portion  of  the  cord.  The  white  matter  is  rarely  found  con- 
gested, even  when  inflamed;  in  fact,  it  is  remarkable  how  uniformly  pale 
this  portion  of  the  cord  is.  The  gray  matter  often  has  a  reddish-pink  tint, 
but  rarely  a  deep  reddish  hue,  except  when  myelitis  is  present.  If  we  know 
little  anatomically  of  conditions  of  congestion  of  the  cord,  we  know  less 
clinically,  for  there  are  no  features  in  any  way  characteristic  of  it. 

2.  Anemia. 

So,  too,  with  this  state.  There  may  be  extreme  grades  of  ansemia  of  the 
cord  without  symptoms.  In  chlorosis  and  pernicious  anaemia  there  are 
rarely  symptoms  pointing  to  the  cord,  and  there  is  no  reason  to  suppose  that 
such  sensations  as  heaviness  in  the  limbs  and  tingling  are  especially  asso- 
ciated with  anaemia. 

There  are,  however,  some  very  interesting  facts  with  reference  to  the 
profound  anaemia  of  the  cord  which  follows  ligature  of  the  aorta.  In  ex- 
periments made  in  Welch's  laboratory  by  Herter,  it  was  found  that  within 
a  few  moments  after  the  application  of  the  ligature  to  the  aorta  paraplegia 
came  on.  Paralysis  of  the  sphincters  developed,  but  less  rapidly.  This 
condition  is  of  interest  in  connection  with  the  occasional  rapid  develop- 
ment of  a  paraplegia  after  profuse  haemorrhage,  usually  from  the  stomach 
or  uterus.  It  may  come  on  at  once  or  at  the  end  of  a  week  or  ten  days, 
and  is  probably  due  to  an  anatomical  change  in  the  nerve  elements  similar 
to  that  produced  in  Herter's  experiments.  The  degeneration  of  the  dorsal 
columns  of  the  cord  in  pernicious  anaemia  has  already  been  described. 

3.  Embolism  and  Thkombosis. 

Blocking  of  the  spinal  arteries  by  emboli  rarely  occurs.  It  may  be  pro- 
duced experimentally,  and  Money  found  that  it  was  associated  with  chorei- 
form movements.  Thrombosis  of  the  smaller  vessels  in  connection  with 
endarteritis  plays  an  important  part  in  many  of  the  acute  and  chronic 
changes  in  the  cord. 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  967 

4.  Endarteritis. 

It  is  remarkable  how  frequently  in  persons  over  fifty  the  arteries  of  the 
spinal  cord  are  found  sclerotic.  The  following  forms  may  be  met  with: 
(1)  A  nodular  peri-arteritis  or  endarteritis  associated  with  syphilis  and 
sometimes  with  gummata  of  the  meninges;  (2)  an  arteritis  obliterans,  with 
great  thickening  of  the  intima  and  narrowing  of  the  lumen  of  the  vessels, 
involving  chiefly  the  medium  and  larger-sized  arteries.  Miliary  aneurisms 
or  aneurisms  of  the  larger  vessels  are  rarely  found  in  the  spinal  cord.  In 
the  classical  work  of  Leyden  but  a  single  instance  of  the  latter  is  mentioned. 

5.    HEMORRHAGE  INTO  THE   SpINAL  MeMBRANES;    HeMATORRHACHIS. 

In  meningeal  apoplexy,  as  it  is  called,  the  blood  may  be  between  the 
dura  mater  and  the  spinal  canal — extra-meningeal  haemorrhage — or  within 
the  dura  mater — intra-meningeal  hsemorrhage. 

(a)  Extra-meningeal  hcemorrhage  occurs  usually  as  a  result  of  trauma. 
The  exudation  may  be  extensive  without  compression  of  the  cord.  The 
blood  comes  from  the  large  plexuses  of  veins  which  may  surround  the  dura. 
The  rupture  of  an  aneurism  into  the  spinal  canal  may  produce  extensive 
and  rapidly  fatal  hsemorrhage. 

(h)  Intra-meningeal  hcemorrhage  is  rather  more  common,  but  is  rarely 
extensive  from  causes  acting  directly  on  the  spinal  meninges  themselves. 
Scattered  haemorrhages  are  not  infrequent  in  the  acute  infectious  fevers, 
and  I  have  twice,  in  malignant  small-pox,  seen  much  extravasation.  Bleed- 
ing occurs  also  in  death  from  convulsive  disorders,  such  as  epilepsy,  tetanus, 
and  strychnia  poisoning.  The  most  extensive  hsemorrhages  occur  in  cases 
in  which  the  blood  comes  from  rupture  of  an  aneurism  at  the  base  of  the 
brain,  either  of  the  basilar  or  vertebral  artery.  In  several  cases  of  this  kind 
I  have  found  a  large  amount  of  blood  in  the  spinal  meninges.  In  ventricu- 
lar apoplexy  the  blood  may  pass  from  the  fourth  ventricle  into  the  spinal 
meninges.  There  is  a  specimen  in  the  medical  museum  of  McGill  College 
of  the  most  extensive  intraventricular  haemorrhage,  in  which  the  blood 
passed  into  the  fourth  ventricle,  and  descended  beneath  the  spinal  arach- 
noid for  a  considerable  distance.  On  the  other  hand,  haemorrhage  into 
the  spinal  meninges  may  possibly  ascend  into  the  brain. 

The  symptoms  in  moderate  grades  may  be  slight  and  indefinite.  In 
the  non-traumatic  cases  the  hsemorrhage  may  either  come  on  suddenly  or 
after  a  day  or  two  of  uneasy  sensations  along  the  spine.  As  a  rule,  the 
onset  is  abrupt,  with  sharp  pain  in  the  back  and  symptoms  of  irritation  in 
the  course  of  the  nerves.  There  may  be  muscular  spasms,  or  paralysis  may 
come  on  suddenly,  either  in  the  legs  alone  or  both  in  the  legs  and  arms. 
In  some  instances  the  paralysis  develops  more  slowly  and  is  not  complete. 
There  is  no  loss  of  consciousness,  and  there  are  no  signs  of  cerebral  dis- 
turbance. The  clinical  picture  naturally  varies  with  the  site  of  the  haemor- 
rhage. If  in  the  lumbar  region,  the  legs  alone  are  involved,  the  reflexes  may 
be  abolished,  and  the  action  of  the  bladder  and  rectum  is  impaired.  If  in 
the  thoracic  region,  there  is  more  or  less  complete  paraplegia,  the  reflexes  are 


968  DISEASES  OF  THE  NERVOUS  "SYSTEM. 

usually  retained,  and  there  are  signs  of  disturbance  in  the  thoracic  nerves, 
such  as  girdle  sensations,  pains,  and  sometimes  eruption  of  herpes.  In  the 
cervical  region  the  arms  as  well  as  the  legs  may  be  involved;  there  may 
be  difficulty  in  breathing,  stiffness  of  the  muscles  of  the  neck,  and  occa- 
sionally pupillary  symptoms. 

The  prognosis  depends  much  upon  the  cause  of  the  haemorrhage.  Ee- 
covery  may  take  place  in  the  traumatic  cases,  and  in  those  associated  with 
the  infectious  diseases. 

6.  H^MOEEHAGE  INTO  THE  Spinal  Coed  {HcematomyeUa). 

It  is  more  common  in  males  than  in  females,  and  at  the  middle  period 
of  life.  The  cases  have  followed  either  cold  and  exposure  or  overexertion, 
and,  most  frequently  of  all,  traumatism.  It  is  most  frequent  in  the  lower 
cervical  region,  the  most  common  site  for  dislocation  and  fracture  of  the 
spine.  It  occurs  also  in  tetanus  and  convulsions.  Hsemorrhage  into  the 
cord  may  follow  injuries  of  the  spinal  column,  gun-shot  wounds,  etc.,  even 
when  the  cord  itself  has  not  been  touched  (H.  Gushing).  Hgemorrhage  may 
be  associated  with  tumors,  with  syringo-myelia,  or  with  myelitis;  it  is  often 
difficult  to  determine  whether  the  case  is  one  of  primary  hgemorrhage  with 
myelitis,  or  myelitis  with  a  secondary  haemorrhage. 

The  anatomical  condition  is  very  varied.  The  cord  may  be  enlarged 
at  the  site  of  the  haemorrhage,  and  occasionally  the  white  substance  may 
be  lacerated  and  blood  may  escape  beneath  the  meninges.  The  extravasa- 
tion is  chiefly  in  the  gray  matter,  and  may  be  limited  or  focal,  or  very 
diffuse,  extending  a  considerable  distance  in  the  cord.  In  a  case  which 
occurred  at  the  Montreal  General  Hospital  under  ^ilkins  the  haemorrhage 
occupied  a  position  opposite  the  region  of  the  fifth  and  sixth  cervical  nerves 
and  on  transverse  section  the  cord  was  occupied  by  a  dark-red  clot  measur- 
ing 12  by  5  mm.,  around  which  the  white  substance  formed  a  thin,  ragged 
wall.  The  clot  could  be  traced  upward  as  far  as  the  second  cervical,  and 
downward  as  far  as  the  fourth  thoracic  segment. 

The  sudden  onset  of  the  symptoms  is  the  most  characteristic  feature 
in  haematomyelia.  The  loss  of  power  necessarily  varies  with  the  locality 
affected.  If  in  the  cervical  region,  both  arms  and  legs  may  be  involved; 
but  if  in  the  thoracic  or  lumbar,  there  is  only  paraplegia.  There  is  usually 
loss  of  sensation,  and  at  first  loss  of  reflexes.  Myelitis  frequently  develops 
and  becomes  extensive,  with  fever  and  trophic  changes.  The  condition 
may  rapidly  prove  fatal;  in  other  instances  there  is  gradual  recovery,  often 
with  partial  paralysis. 

The  diagnosis  may  be  made  in  some  instances,  particularly  those  in 
which  the  onset  is  sudden  after  injury,  but  there  is  great  difficulty  in  dif- 
ferentiating haemorrhagic  myelitis  from  certain  cases  of  haemorrhage  into 
the  spinal  meninges. 


AFFECTIONS  OF  THE   BLOOD-VESSELS.  969 

7.  Caisson  Disease  {Diver's  Paralysis;  Compressed  Air  Disease). 

This  remarkable  affection,  found  in  divers  and  in  workers  in  caissons, 
is  characterized  by  a  paraplegia,  more  rarely  a  general  palsy,  which  super- 
venes on  returning  from  the  compressed  atmosphere  to  the  surface. 

The  disease  has  been  carefully  studied  by  the  French  writers,  by  Ley- 
den  and  Schultze  in  Germany,  and  in  this  country  particularly  by  A.  H. 
Smith.  It  has  been  made  the  subject  of  a  special  monograph  by  Snell. 
The  pressure  must  be  more  than  that  of  three  atmospheres.  The  symptoms 
are  especially  apt  to  come  on  if  the  change  from  the  high  to  the  ordinary 
atmospheric  pressure  is  quickly  made.  They  may  supervene  immediately 
on  leaving  the  caisson,  or  they  may  be  delayed  for  several  hours.  Pains 
of  the  most  atrocious  character  about  the  knees,  elbows,  or  other  joints, 
without  swelling,  as  a  rule,  pain  and  swelling  in  the  muscles,  epigastric 
pain,  and  vomiting  are  the  most  common  symptoms.  Headache,  giddiness, 
and  paralysis  are  less  frequent.  Paraplegia  occurred  in  15  per  cent  of  Dr. 
Smith's  cases  and  in  61  per  cent  of  the  St.  Louis  cases.  Monoplegia  and 
hemiplegia  are  rare.  In  the  most  extreme  instances  the  attacks  resemble 
apoplexy;  the  patient  rapidly  becomes  comatose  and  death  occurs  in  a  few 
hours.  In  the  case  of  paraplegia  the  outlook  is  usually  good,  and  the 
paralysis  may  pass  off  in  a  day,  or  may  continue  for  several  weeks  or  even 
for  months. 

The  explanation  of  this  condition  is  by  no  means  satisfactory.  Several 
careful  autopsies  have  been  niade.  In  Leyden's  case  death  occurred  on  the 
fifteenth  day,  and  in  the  thoracic  portion  of  the  cord  there  were  numerous 
foci  of  haemorrhages  and  signs  of  an  acute  myelitis.  In  Schultze's  case 
death  occurred  in  two  and  a  half  months,  and  a  disseminated  myelitis  was 
found  in  the  thoracic  region.  In  both  cases  there  were  fissures,  and  appear- 
ances as  if  tissue  had  been  lacerated.  In  a  case  examined  on  the  third  day 
(Ziegler's  Beitrage,  1892)  this  condition  of  fissuring  and  laceration  was 
found.  It  has  been  suggested  that  the  symptoms  are  due  to  the  liberation 
in  the  spinal  cord  of  bubbles  of  nitrogen  which  have  been  absorbed  by  the 
blood  under  the  high  pressure,  and  the  condition  found  at  the  autopsies 
just  referred  to  is  held  to  favor  this  view. 

Death  is  rare;  it  occurred  in  12  of  76  cases  at  the  St.  Louis  bridge,  in 
3  of  the  110  cases  at  the  Brooklyn  bridge.  In  the  recent  important  work 
of  the  Frith  of  Forth  bridge  and  the  Blackwell  tunnel  there  were  no 
fatalities  from  this  cause. 

The  most  successful  treatment  is  recompression.  A  medical  air  lock 
should  be  provided  at  the  works,  well  heated  and  filled  with  bunks,  etc. 
The  recompression  stops  the  pain  and  relieves  the  symptoms.  Morphia 
may  be  required. 


61 


970  DISEASES  OP  THE  NERVOUS  SYSTEM. 

III.    COMPRESSION    OF   THE   SPINAL   CORD 

{Compression  Uyelifis). 

DefiLuition. — Interruption  of  the  functions  of  the  cord  by  slow  com- 
pression. 

Etiology. — Caries  of  the  spine,  new  growths,  aneurism,  and  parasites 
are  the  important  causes  of  slow  compression.  Caries,  or  Pott's  disease,  as 
it  is  usually  called,  after  the  surgeon  who  first  described  it,  is  in  the  great 
majority  of  instances  a  tuberculous  affection.  In  a  few  cases  it  is  due  to 
syphilis  and  occasionally  to  extension  of  disease  from  the  pharynx.  It  is 
most  common  in  early  life,  but  may  occur  after  middle  age.  It  follows 
trauma  in  a  few  cases.  Compression  occasionally  results  from  aneurism  of 
the  thoracic  aorta  or  the  abdominal  aorta,  in  the  neighborhood  of  the  coeliac 
axis. 

Malignant  growths  frequently  cause  a  compression  paraplegia.  A  retro- 
peritoneal sarcoma  or  the  lymphadenomatous  growths  of  Hodgkin's  disease 
may  invade  the  vertebrge.  More  commonly,  however,  the  involvement  is 
secondary  to  scirrhus  of  the  breast. 

Of  parasites,  the  echinococcus  and  the  cysticercus  occasionally  occur  in 
the  spinal  canal.  For  a  masterly  consideration  of  the  whole  question,  par- 
ticularly from  a  surgical  standpoint,  Kocher's  monograph  is  all-important 
(Mitt.  a.  d.  Grenzgebiet.  der  Chir.  u.  d.  Med.,  1896,  Bd.  i). 

Symptoms. — These  may  be  considered  as  they  affect  the  bones,  the 
nerves,  and  the  cord. 

(1)  Vertebral. — In  malignant  diseases  and  in  aneurism,  erosion  of  the 
bodies  may  take  place  without  producing  any  deformity  of  the  spine.  Fatal 
haemorrhage  may  follow  erosion  of  the  vertebral  artery.  In  caries,  on  the 
other  hand,  it  is  the  rule  to  find  more  or  less  deformity,  amounting  often 
to  angular  curvature.  The  compression  is  largely  due  to  the  thickening 
of  the  dura  and  the  presence  of  caseous  and  inflammatory  products  between 
this  membrane  and  the  bone.  The  compression  is  rarely  produced  directly 
by  the  bone.  Pain  is  a  constant  and,  in  the  case  of  aneurism  and  tumor,  an 
agonizing  feature.  In  caries,  the  spinal  processes  of  the  affected  vertebrae 
are  tender  on  pressure,  and  pain  follows  Jarring  movements  or  twisting  of 
the  spine.  There  may  be  extensive  tuberculous  disease  without  much  de- 
formity, particularly  in  the  cervical  region. 

(2)  Nerve-root  Symptoms. — These  result  from  compression  of  the  nerve 
roots  as  they  pass  out  between  the  vertebrae.  A  cervico-brachial  neuralgia 
may  be  an  early  symptom.  It  is  remarkable  how  frequently,  even  in  ex- 
tensive caries,  they  escape  and  the  patient  does  not  complain  of  radiating 
pains  in  the  distribution  of  the  nerves  from  the  affected  segment.  Pains 
are  more  common  in  cancer  of  the  spine  secondary  to  that  of  the  breast, 
and  in  such  cases  may  be  agonizing.  There  may  be  acutely  painful  areas — 
the  anresthesia  dolorosa,  in  regions  of  the  skin  which  are  anaesthetic  to  tac- 
tile and  painful  impressions.  Trophic  disti]^bances  may  occur,  particularly 
herpes.  In  the  cervical  or  lumbar  regions  pressure  on  the  ventral  roots 
may  give  rise  to  wasting  of  the  muscles  supplied  by  the  affected  nerves. 


COMPRESSION  OF  THE  SPINAL   CORD.  971 

(3)  Cord  Symptoms. — (a)  Cervical  Begion. — Not  infrequently  the  caries 
is  high  up  between  the  axis  and  the  atlas  or  between  the  latter  and  the  oc- 
cipital bone.  In  such  instances  a  retropharyngeal  abscess  may  be  present, 
giving  rise  to  dilSculty  in  swallowing.  There  may  be  spasm  of  the  cervical 
muscles,  the  head  may  be  fixed,  and  movements  may  either  be  impossible 
or  cause  great  pain.  In  a  case  of  this  kind  in  the  Montreal  General  Hos- 
pital movement  was  liable  to  be  followed  by  transient,  instantaneous  paraly- 
sis of  all  four  extremities,  owing  to  compression  of  the  cord.  In  one  of 
these  attacks  the  patient  died. 

In  the  lower  cervical  region  there  may  be  signs  of  interference  with 
the  cilio-spinal  centre  and  dilatation  of  the  pupils.  Occasionally  there  is 
flushing  of  the  face  and  ear  of  one  side  or  unilateral  sweating.  Deformity 
is  not  so  common,  but  healing  may  take  place  with  the  production  of  a 
callus  of  enormous  breadth,  with  complete  rigidity  of  the  neck. 

(&)  Thoracic  Region. — The  deformity  is  here  more  marked  and  pressure 
symptoms  are  more  common.  The  time  of  onset  of  the  paralysis  varies 
very  much.  It  may  be  an  early  symptom,  even  before  the  curvature  is 
manifest.  More  commonly  it  is  late,  occurring  many  months  after  the  curva- 
ture has  developed.  The  paraplegia  is  slow  in  its  development;  the  patient 
at  first  feels  weak  in  the  legs  or  has  disturbance  of  sensation,  numbness, 
tingling,  pins  and  needles.  The  girdle  sensation  may  be  marked,  or  severe 
pains  in  the  course  of  the  intercostal  nerves.  Motion  is,  as  a  rule,  more 
quickly  lost  than  sensation.  Finally,  there  is  complete  interruption  with 
the  production  of  paraplegia,  usually  of  the  spastic  type,  with  exaggeration 
of  the  reflexes.  Bastian's  symptom — abolition  of  the  reflexes — is  rarely 
met  with  in  compression  from  caries.  The  paraplegia  may  persist  for 
months,  or  even  for  more  than  a  year,  and  recovery  still  be  possible. 

(c)  Lumbar  Begion. — In  the  lower  dorsal  and  lumbar  regions  the  symp- 
toms are  practically  the  same,  but  the  sphincter  centres  are  involved  and 
the  reflexes  are  not  .exaggerated. 

Diagnosis. — Caries  is  by  far  the  most  frequent  cause  of  slow  com- 
pression of  the  cord,  and  when  there  are  external  signs  the  recognition  is 
easy.  There  are  cases  in  which  the  exudation  in  the  spinal  canal  between 
the  dura  and  the  bone  leads  to  compression  before  there  are  any  signs  of 
caries,  and  if  the  root  symptoms  are  absent  it  may  be  extremely  difficult 
to  arrive  at  a  diagnosis.  Janeway  has  called  attention  to  persistent  lum- 
bago as  a  symptom  of  importance  in  masked  Pott's  disease,  particularly 
after  injury.  Brown-Sequard's  paralysis  is  more  common  in  tumor  and  in 
injuries  than  in  caries.  Pressure  on  the  nerve  roots,  too,  is  less  frequent 
in  caries  than  in  malignant  divsease.  The^cervical  form  of  pachymeningitis 
also  produces  a  pressure  paralysis,  the  symptoms  of  which  have  already  been 
detailed.  Pressure  from  secondary  carcinoma  is  naturally  suggested  when 
spinal  symptoms  follow  within  a  few  years  after  an  operation  for  cancer  of 
the  breast.  In  paraplegia  following  tumor  of  the  vertebra  secondary  to 
cancer  of  the  breast,  and  in  the  erosion  of  the  spine  by  retroperitoneal 
growtJis,  the  suffering  is  most  intense.  Tlie  condition  hns  been  well  termed 
paraplegia  dolorosa.  I  have  seen  2  cases  in  which  the  breast  tumor  had 
not  been  recognized. 


972  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — In  compression  by  aneurism  or  tumor  the  condition  is 
hopeless.  In  the  former  the  pains  are  often  not  very  severe,  but  in  the 
latter  morphia  is  always  necessary.  On  the  other  hand,  compression  by 
caries  is  often  successfully  relieved  even  after  the  paralysis  has  persisted 
for  a  long  period.  When  caries  is  recognized  early,  rest  and  support  to 
the  spine  by  the  various  methods  now  used  by  surgeons  may  do  much  to 
prevent  the  onset  of  paraplegia.  When  paralysis  has  developed,  rest  with 
extension  gives  the  best  hope  of  recovery.  It  is  to  be  remembered  that 
restoration  may  occur  after  compression  of  the  cord  has  lasted  for  many 
months,  or  even  more  than  a  year.  Cases  have  been  cured  by  rest  alone; 
the  extradural  and  inflammatory  products  are  absorbed  and  the  caries  heals. 
The  most  brilliant  results  in  these  cases  have  been  obtained  by  suspension,  a 
method  introduced  by  J.  K.  Mitchell  in  1826,  and  pursued  with  remarkable 
success  by  his  son.  Weir  Mitchell.  During  my  association  with  the  Infirmary 
for  Nervous  Diseases  I  had  numerous  opportunities  of  witne^ing  the  really 
remarkable  effects  of  persistent  suspension,  even  in  apparently  desperate 
and  protracted  cases.  Mitchell's  conclusions  are  that  suspension  should 
be  employed  early  in  Pott's  disease;  that  used  with  care  it  enables  us  slowly 
to  lessen  the  curve;  that  in  these  cases  there  must  be,  in  some  form,  a  re- 
placement of  the  crumpled  tissues;  that  unless  there  is  great  loss' of  power 
the  use  of  the  spine-car  or  chair  of  J.  K.  Mitchell  enables  suspension,  espe- 
cially in  children,  to  be  combined  with  some  exercise;  that  no  case  of  Pott's 
disease  should  be  considered  desperate  without  its  trial;  that  suspension 
has  succeeded  after  failures  of  other  accepted  methods;  that  the  pull  prob- 
ably acts  more  or  less  directly  on  the  cord  itself,  and  that  the  gain  is  not 
explicable  merely  by  obvious  effects  on  the  angular  bone  curve;  that  the 
methods  of  extension  to  be  used  in  carious  cases  may  be  very  varied,  pro- 
vided only  we  get  active  extension;  that  the  plan  and  the  length  of  time 
of  extension  must  be  made  to  conform  to  the  needs,  endurance,  and  sensa- 
tion of  the  individual  case.  It  may  be  months  before  there  are  any  signs 
of  improvement.  In  protracted  cases,  after  suspension  has  been  tried  for 
months,  laminectomy  may  be  considered,  and  has  in  some  instances  been 
successful. 

The  general  treatment  of  caries  is  that  of  tuberculosis — fresh  air,  good 
food,  cod-liver  oil,  and  arsenic.  Counter-irritation  in  these  instances  is  of 
doubtful  value. 

Lesions  op  the  Cauda  Equina  and  Conus  Medullaris. 

The  spinal  cord  extends  only  to  the  second  lumbar  vertebra.  Injury, 
tumors,  and  caries  at  or  below  this  level  involve  not  the  cord  itself,  but  the 
bundle  of  nerves  known  as  the  cauda  equina  and  the  terminal  portion  of 
the  cord,  the  conus  medullaris.  Much  attention  has  been  given  to  lesions 
of  this  part.  The  whole  subject  is  admirably  discussed  in  Thorburn's  work. 
Fractures  and  dislocations  are  common  in  the  lumbo-sacral  region,  tumors 
not  infrequently  involve  the  filaments  of  the  cauda  equina,  and  some  of 
the  nerves  may  be  entangled  in  the  cicatrix  of  a  spina  bifida. 

In  a  fracture  or  dislocation  of  the  first  lumbar  vertebra  the  conus  me- 


TUMORS  OF  THE  SPINAL  CORD  AND  ITS  MEMBRANES.  973 

dullaris  may  be  compressed  with  the  last  sacral  nerves  given  of!  from  it. 
In  a  case  reported  by  KirchhoH;  there  was  laceration  of  the  conus  with 
complete  paralysis  of  the  bladder  and  rectum,  a  case  which  is  held  to  favor 
the  view  that  the  ano-vesical  centre  in  man  is  situated  in  this  region  of  the 
cord.  There  are  several  instances  on  record  in  which  injury  of  the  cauda 
equina  has  produced  paralysis  of  the  bladder  and  rectum  alone,  sometimes 
with  a  slight  patch  of  ansesthesia  in  the  neighborhood  of  the  coccyx  or  the 
perinseum.  More  commonly  branches  of  the  sacral  or  lumbar  nerve  roots 
are  involved,  producing  an  irregularly  distributed  motor  and  sensory  paraly- 
sis in  the  legs.  When  the  lumbar  nerve  roots  from  the  second  to  the  fifth 
are  compressed,  there  is  paralysis  of  the  muscles  of  the  legs,  with  the  ex- 
ception of  the  flexors  of  the  ankles,  the  peronsei,  the  long  flexors  of  the 
toes,  and  the  intrinsic  muscles  of  the  feet,  and  loss  of  sensation  in  the  front, 
inner  and  outer  part  of  the  thighs,  the  inner  side  of  the  legs,  and  the  inner 
side  of  the  foot.  The  sacral  roots  may  alone  be  involved.  Thus  in  a  case 
which  I  have  reported  the  patient  fell  from  a  bridge  and  had  paralysis  of 
the  legs  and  of  the  bladder  and  rectum.  When  seen  sixteen  years  after  the 
injury,  there  was  slight  weakness,  with  wasting  of  the  left  leg;  there  was 
complete  loss  of  the  function  in  the  ano-vesical  and  genital  centres,  and 
ansesthesia  in  a  strip  at  the  back  part  of  the  thigh  (in  the  distribution  of 
the  small  sciatic),  and  of  the  perinseum,  scrotum,  and  penis.  The  urethra 
was  also  insensitive. 

Starr's  table  and  Head's  figures,  given  in  the  general  introduction,  will 
be  found  useful  in  determining  the  nerve  fibres  and  segments  involved  in 
these  cases  of  injury  of  the  cauda  equina. 


IV.   TUMORS   OF   THE   SPINAL   CORD    AND    ITS 
MEMBRANES. 

New  growths  may  develop  in  the  cord  or  in  its  membranes,  or  may 
extend  into  them  from  the  spine.  The  first  two  alone  will  be  considered. 
Occasionally  lipoma  and  parasites  occur  in  the  extradural  space.  Within 
the  dura  fibromata,  sarcomata,  and  syphilitic  and  tuberculous  growths  are 
most  common.  In  the  cord  itself,  and  attached  to  the  pia  mater,  the  tu- 
berculous, syphilitic,  and  gliomatous  growths  are  most  frequent.  Of  50 
cases  of  tumor  of  the  spinal  cord  and  its  envelopes,  analyzed  by  Mills  and 
Lloyd,  only  3  were  parasitic.  Of  these,  26  were  some  form  of  neoplasm,  of 
which  sarcomata  were  most  common,  5  were  gummatous,  and  4  tubercu- 
lous. Herter  has  recently  reported  3  cases  of  solitary  tubercle  in  the  cord, 
and  has  analyzed  others  from  the  literature.  Of  24  cases  in  which  the  age 
was  given,  15  occurred  between  the  ages  of  fifteen  and  thirty-five,  and  5 
before  the  fifth  year.  The  tumor  is  most  common  in  the  dorsal  and  lumbar 
regions,  and  is  usually  met  with  in  connection  with  tuberculous  lesions  else- 
where. 

The  anatomical  effects  of  tumor  are  very  varied.  Slow  compression 
is  usually  produced  by  growths  external  to  the  cord,  and  it  is  remarkable 
what  a  high  grade  of  compression  the  cord  will  bear  without  serious  inter- 


974  DISEASES  OF  THE  NEKVOUS  SYSTEM. 

ference  with  its  functions.  In  cases  of  prolonged  interruption  ascending 
and  descending  degenerations  occur.  Tumors  developing  within  the  cord 
may  lead  to  syringo-myelia.  And,  lastly,  tumors  not  infrequently  excite 
intense  myelitis. 

Symptoms. — These  will  naturally  vary  a  good  deal  with  the  segment 
involved  and  with  the  degree  of  pressure  and  the  extent  of  implication  of 
the  nerve  roots. 

Within  the  cord  the  symptoms  are  those  of  a  gradually  progressing 
paraplegia,  which  may  at  first  have  the  picture  of  a  Brown-Sequard  paraly- 
sis. Atrophy  follows  the  involvement  of  the  ventral  cornua,  and  vaso- 
motor disturbances  may  be  marked.  The  reflexes  are  lost  at  the  level  of 
the  lesion,  but  if  this  be  in  the  thoracic  cord,  the  reflexes  are  retained  in  the 
legs.  The  symptoms  are  apt  to  be  complicated  with  those  of  acute  or  sub- 
acute myelitis,  which  may  completely  alter  the  clinical  picture.  Tumors 
of  the  spinal  membranes  are  characterized  by  the  early  onset  and  persist- 
ence of  the  root  symptoms,  which  consist  of^radiating  pains,  the  girdle  sen- 
sation, and  hypergesthesia,  or  ansesthesia  in  various  portions  of  the  trunk. 
There  may  even  be  severe  pain  in  the  angesthetic  areas.  Irritation  of  the 
motor  roots  may  cause  spasm  of  the  muscles  supplied,  or  wasting  with 
paralysis.  The  paraplegia  supervenes  some  time  after  the  occurrence  of 
the  root  symptoms.  In  the  thoracic  region  the  level  of  the  growth  is  usu- 
ally accurately  defined  by  the  level  of  the  pain  and  the  condition  of  the 
reflexes. 

The  diagnosis  of  tumor  within  the  cord  is  sometimes  easy,  the  charac- 
teristic features  being  the  constancy  and  severity  of  the  root  symptoms  at 
the  level  of  the  growth  and  the  progressive  paralysis.  Caries  may  cause 
identical  symptoms,  but  the  radiating  pains  are  rarely  so  severe.  Cervical 
meningitis  simulates  tumor  very  closely,  and  in  reality  produces  identical 
effects,  but  the  very  slow  progress  and  the  bilateral  character  from  the 
outset  may  be  sufficient  to  distinguish  it. 

In  chronic  transverse  myelitis  the  symptoms  may,  according  to  Gowers, 
simulate  tumor  very  closely  and  present  radiating  pains,  a  sense  of  con- 
striction, and  progressive  paralysis. 

The  nature  of  the  tumor  can  rarely  be  indicated  with  precision.  With 
a  marked  syphilitic  history  gumma  may  naturally  be  suspected,  and  with 
coexisting  tuberculous  disease  a  solitary  tubercle. 

Treatm.ent. — If  the  possibility  of  syphilitic  infection  is  present  the 
iodide  of  potassium  should  be  given  in  large  and  increasing  doses.  For 
the  severe  pains  counter-irritation  is  sometimes  beneficial,  particularly  the 
thermo-cautery;  morphia  is,  however,  often  necessary. 

In  a  few  instances  tumors  of  the  cord  or  of  the  membranes  are  amena- 
ble to  surgical  treatment.  The  removal  by  Horsley  of  a  growth  from  the 
spinal  membranes  was  one  of  the  most  brilliant  of  recent  operations. 

Abscess  of  the  cord  is  a  rare  lesion,  of  which  only  3  or  4  cases  have*been 
described,  all  metastatic.    It  may  occur  without  meningitis. 


SYRINGOMYELIA.  975 


V.    SYRINGOMYELIA. 


Definition. — A  gliomatous  new  formation  about  the  central  canal  of 
the  sjiinal  cord,  with  cavity  formation. 

Etiology  and  Morbid  Anatomy. — Syringomyelia  must  be  dis- 
tinguished from  dilatation  of  the  central  canal — hydromyelus — slight 
grades  of  which  are  not  very  uncommon  either  as  a  congenital  condition  or 
as  a  result  of  the  pressure  of  tumors.  The  cavity  of  syringomyelia  has  a  vari- 
able extent  in  the  cord,  sometimes  running  the  entire  length,  but  in  many 
cases  involving  only  the  cervical  and  thoracic  regions  or  a  more  limited  area. 
It  is  usually  in  the  dorsal  portion  of  the  cord  and  may  extend  only  into  one 
dorsal  cornu.  The  transverse  section  may  be  oval  or  circular  or  narrow 
and  fissure-like.  It  varies  at  different  levels.  The  condition  is  now  re- 
garded as  a  gliosis,  a  development  of  embryonal  neurogliar  tissue  in  which 
hemorrhage  or  degeneration  takes  place  with  the  formation  of  cavities. 

Of  190  cases,  133  were  in  men,  57  in  women  (Schlesinger).  A  large 
majority  of  the  cases  begin  before  the  thirtieth  year.  The  disease  has  been 
met  with  in  three  members  of  the  same  family. 

Symptoms. — The  clinical  features  are  extremely  complex.  In  the 
classical  form  there  are  irregular  pains,  chiefly  in  the  cervical  region;  mus- 
cular atrophy  develops,  which  may  be  confined  to  the  arms,  or  sometimes 
extends  to  the  legs.  The  reflexes  are  increased  and  a  spastic  condition 
develops  in  the  legs.  Ultimately  the  clinical  picture  may  be  that  of  an  amy- 
otrophic lateral  sclerosis.  The  tactile  sensation  is  usually  intact  and  the 
muscular  sense  is  retained,  but  painful  and  thermic  sensations  are  not  recog- 
nized, or  there  may  be  in  rare  instances  complete  anaesthesia  of  the  skin  and 
of  the  mucous  membranes  (Dejerine).  This  combination  of  loss  of  pain- 
ful and  thermic  sensations  with  paralysis  of  an  amyotrophic  type  is  re- 
garded as  pathognomonic  of  the  disease.  The  special  senses  are  usually 
intact  and  the  sphincters  uninvolved.  Trophic  troubles  are  not  uncom- 
mon. Owing  to  the  loss  of  the  pain  and  heat  sensations,  the  patients  are 
apt  to  injure  themselves.  Scoliosis  also  may  be  present  in  these  cases. 
The  loss  of  painful  and  thermic  impressions  is  due  to  the  fact  that  these 
pass  to  the  brain  in  the  peri-ependymal  gray  matter,  particularly  that  por- 
tion in  the  dorsal  roots,  which  is  almost  constantly  involved  in  syringo- 
myelia. The  tactile  sensation  is  retained  because  the  postero-lateral  column 
is  uninvolved. 

Schlesinger,  in  his  recent  monograph  (1895),  recognizes  the  following 
types:  (1)  With  the  classical  features  above  described,  which  may  begin 
in  the  cervical  or  lumbar  regions:  (2)  a  motor  type,  with  the  picture  of 
an  amyotrophic  or  a  spastic  paralysis — the  sensation  may  be  undisturbed 
for  years;  (3)  with  predominant  sensory  features,  simulating  hysterical 
hemiplegia,  or  with  general  pain  and  temperature  anajsthesia;  (4)  with 
pronounced  trophic  disturbances — to  this  type  belong  the  cases  described 
as  Morvan's  disease,  an  affection  characterized  by  neuralgic  pains,  cuta- 
neous anaesthesia,  and  painless,  destructive  whitlows;  and  (5)  the  tabetic 
type,  either  a  combination  of  the  symptoms  of  tabes  in  the  lower,  and  of 


976  DISEASES  OF   THE  NERVOIJS  SYSTEM. 

syringomyelia  in  the  upper  extremities^  or  a  pure  tabetic  symptom-com- 
plex^ due  to  invasion  by  the  gliosis  of  the  dorsal  columns  (Oppenheim). 
Arthropathies  occur  in  about  10  per  cent  of  the  cases.     ' 

In  typical  cases  the  diagnosis  is  easy.  The  combination  of  an  amyo- 
trophic paralysis,  the  picture  of  progressive  muscular  atrophy  of  the  Aran- 
Duchenne  type,  with  retention  of  tactile  and  loss  of  thermic  and  painful 
sensation,  is  probably  pathognomonic  of  the  disease.  Of  affections  with 
which  it  may  be  confounded,  ansesthetic  leprosy  is  the  most  important, 
since  the  angesthesia  and  the  wasting  may  closely  simulate  it;  but,  as  a 
rule,  in  leprosy  trophic  changes  are  more  or  less  marked.  There  is  often 
loss  of  phalanges  and  there  is  no  characteristic  dissociation  of  sensory  im- 
pressions. 

VI.   ACUTE    MYELITIS. 

Etiology. — Acute  myelitis  results  from  many  causes,  and  may  affect 
the  cord  in  a  limited  or  extended  portion — the  gray  matter  chiefly,  or  the 
gray  and  white  matter  together.  It  is  met  with:  (a)  As  an  independent 
affection  following  exposure  to  cold,  or  exertion,  and  leading  to  rapid  loss 
of  power  with  the  symptoms  of  an  acute  ascending  paralysis.  (&)  As  a 
sequel  of  the  infectious  diseases,  such  as  small-pox,  typhus,  and  measles, 
(c)  As  a  result  of  traumatism,  either  fracture  of  the  spine  or  very  severe 
muscular  effort.  Concussion  without  fracture  may  produce  it,  but  this  is 
rare.  Acute  myelitis,  for  instance,  scarcely  ever  follows  railway  accidents. 
{d)  In  diseases  of  the  bones  of  the  spine,  either  caries  or  cancer.  This  is  a 
more  common  cause  of  localized  acute  transverse  myelitis  than  of  the  diffuse 
affection,  (e)  In  disease  of  the  cord  itself,  such  as  tumors  and  syphilis; 
in  the  latter,  either  in  association  with  gummata,  in  which  case  it  is  usually 
a  late  manifestation;  or  it  may  follow  within  a  year  or  eighteen  months  of 
the  primary  affection. 

Morbid  Anatomy. — In  localized  acute  myelitis  affecting  white  and 
gray  matter,  as  met  with  after  accident  or  an  acute  compression,  the  cord  is 
swollen,  the  pia  injected,  the  consistence  greatly  reduced,  and  on  incising 
the  membrane  an  almost  diffluent  fluid  may  escape.  In  less  intense  grades, 
on  section  at  the  affected  area,  the  distinction  between  the  gray  and  white 
matter  is  lost,  or  is  extremely  indistinct.  The  tissue  may  be  injected,  or, 
as  is  often  the  case,  hsemorrhagic.  It  is  particularly  in  these  forms,  due 
to  extension  of  disease  from  without  or  to  acute  compression,  that  we 
find  definite  involvement  of  the  white  matter.  In  other  instances  the 
gray  matter  is  chiefly  affected.  There  may  be  localized  areas  throughout 
the  cord  in  which  the  gray  matter  is  reduced  in  consistence  and  hasm- 
orrhagic,  the  so-called  red  softening.  There  may  be  definite  cavity  forma- 
tions in  these  foci.  In  some  cases  of  disseminated  or  focal  myelitis  the 
meninges  also  are  involved  and  there  is  a  myelomeningitis.  x\nd,  lastly, 
there  are  instances  in  which,  throughout  a  long  section  of  the  cord,  some- 
times through  the  lumbar  and  the  greater  part  of  the  thoracic,  or  in  the 
thoracic  and  cervical  regions,  there  is  a  diffuse  myelitis  of  the  gray  sub- 
stance. 


ACUTE  MYELITIS.  977 

Histologically  the  nerve  fibres  are  much  swollen  and  irregularly  dis- 
torted, the  axis  cylinders  are  beaded,  the  myelin  droplets  are  abundant, 
and  the  laminated  bodies  known  as  corpora  amylacea  may  be  seen.  The 
granular  fatty  cells  are  also  numerous  and  there  may  be  leucocytes  and 
red  blood-corpuscles.  Changes  in  the  blood-vessels  are  striking;  the  smaller 
veins  are  distended  and  may  show  varicosities.  The  perivascular  lymph 
spaces  contain  numerous  leucocytes,  and  the  smaller  arteries  themselves 
are  frequently  the  seat  of  hyaline  thrombi.  The  ganglion  cells  are  swollen 
and  irregular  in  outline,  the  protoplasm  is  extremely  granular  and  vacuo- 
lated, and  the  nuclei,  though  usually  invisible,  may  show  signs  of  division, 
and  the  processes  of  the  cells  are  not  seen. 

In  cases  which  persist  for  some  time  we  have  an  opportunity  of  seeing 
the  later  stages  of  acute  myelitis.  The  acute,  inflammatory,  hyperamic  or 
red  softening  is  succeeded  by  stages  in  which  the  affected  area  becomes 
more  yellow  from  gradual  alteration  of  the  blood-pigment,  and  finally  white 
in  color  from  the  advancing  fatty  degeneration.  In  cases  of  compression 
myelitis,  a  sclerosis  may  gradually  be  produced  with  the  anatomical  picture 
of  a  chronic  diffuse  myelitis. 

Symptoms. — (a)  Acute  Diffuse  Myelitis. — This  form  may  follow  ex- 
posure to  cold,  or  occurs  in  connection  with  syphilis  or  one  of  the  infec- 
tious diseases,  or  is  seen  in  a  typical  manner  in  the  extension  from  in- 
juries or  from  tumor.  The  onset,  though  scarcely  so  abrupt  as  in  hasmor- 
rhage,  may  be  sudden;  a  person  may  be  attacked  on  the  street  and  have 
difficulty  in  getting  home.  In  some  instances,  the  onset  is  preceded  by 
pains  in  the  legs  or  back,  or  a  girdle  sensation  is  present.  It  may  be 
marked  by  chills,  occasionally  by  convulsions;  fever  is  usually  present  from 
the  beginning — at  first  slight,  but  subsequently  it  may  become  high. 

The  motor  functions  are  rapidly  lost,  sometimes  as  quickly  as  in  Lan- 
dry's ascending  paralysis.  The  paraplegia  may  be  complete,  and,  if  the 
myelitis  extends  to  the  cervical  region,  there  may  be  impairment  of  mo- 
tion, and  ultimately  complete  loss  of  power  of  the  upper  extremities  as 
well.  The  sensation  is  lost,  but  there  may  at  first  be  hyperesthesia.  The 
reflexes  in  the  initial  stage  are  increased,  but  in  acute  central  myelitis,  un- 
less limited  in  extent  to  the  thoracic  and  cervical  regions,  the  reflexes  are 
usually  abolished.  The  rectum  and  bladder  are  paralyzed.  Trophic  dis- 
turbances are  marked;  the  muscles  waste  rapidly;  the  skin  is  often  con- 
gested, and  there  may  be  localized  sweating.  The  temperature  of  the 
affected  limbs  may  be  lowered.  Acute  bed-sores  may  develop  over  the  sacrum 
or  on  the  heels,  and  sometimes  a  multiple  arthritis  is  present.  In  these 
acute  cases  the  general  symptoms  become  greatly  aggravated,  the  pulse 
is  rapid,  the  tongue  becomes  dry;  there  is  delirium,  the  fever  increases,  and 
may  reach  107°  or  108°. 

The  course  of  the  disease  is  variable.  In  very  acute  cases  death  follows 
in  from  five  to  ten  days.  The  cases  following  the  infectious  diseases,  par- 
ticularly the  fevers  and  sometimes  syphilis,  may  run  a  milder  course. 

The  diagnosis  of  this  variety  of  acute  myelitis  is  rarely  difficult.  In 
common  with  the  acute  ascending  paralysis  of  Landry,  and  with  certain 
cases  of  multiple  neuritis,  it  presents  a  rapid  and  progressive  motor  paraly- 


978  DISEASES  OF  THE  NERVOUS  SYSTEM. 

sis.  From  the  former  it  is  distinguished  by  the  more  marked  involvement 
of  sensation,  the  trophic  disturbances,  the  paralysis  of  bladder  and  rectum, 
the  rapid  wasting,  the  electrical  changes,  and  the  fever.  From  acute  cases 
of  multiple  neuritis  it  may  be  more  difficult  to  distinguish,  as  the  sensory 
features  in  these  cases  may  be  marked,  though  there  is  rarely,  if  ever,  in 
multiple  neuritis  complete  auEesthesia;  the  wasting,  moreover,  is  more  rapid 
in  myelitis.  The  bladder  and  rectum  are  rarely  involved — though  in  ex- 
ceptional cases  they  may  be — and,  most  important  of  all,  the  trophic 
changes,  the  development  of  bullse,  bed-sores,  etc.,  are  not  seen  in  multiple 
neuritis. 

(h)  Acute  Transverse  Myelitis. — The  symptoms  naturally  differ  with  the 
situation  of  the  lesion. 

(1)  Acute  transverse  myelitis  in  the  thoracic  region,  the  most  common 
situation,  produces  a  very  characteristic  picture.  The  symptoms  of  onset 
are  variable.  There  may  be  initial  pains  or  numbness  and  tingling  in  the 
legs.  The  paralysis  may  set  in  quickly  and  become  complete  within  a 
few  days;  but  more  commonly  it  is  preceded  for  a  day  or  two  by  sensa- 
tions of  pain,  heaviness,  and  dragging  in  the  legs.  The  paralysis  of  the 
lower  limbs  is  usually  complete,  and  if  at  the  level,  say,  of  the  sixth  thoracic 
vertebra,  the  abdominal  muscles  are  involved.  Sensation  may  be  partially 
or  completely  lost.  At  the  onset  there  may  be  numbness,  tingling,  or  even 
hypergesthesia  in  the  legs.  At  the  level  of  the  lesion  there  is  often  a  zone 
of  hypergesthesia,  which  is  discovered  by  passing  a  test-tube  containing  hot 
water  along  the  spine,  when  the  sensation  of  warmth  changes  to  one  of 
actual  pain.  A  girdle  sensation  may  occur  early,  and  when  the  lesion  is  in 
this  situation  it  is  usually  felt  between  the  ensiform  and  umbilical  regions. 
The  reflex  functions  are  variable.  There  may  at  first  be  abolition  of  the 
reflexes;  subsequently,  the  reflexes,  which  pass  through  the  segments  lower 
than  the  one  affected,  may  be  exaggerated  and  the  limbs  may  take  on  a 
condition  of  spastic  rigidity.  It  does  not  always  happen,  however,  that  the 
reflexes  are  increased  in  a  total  transverse  lesion  of  the  cord.  They  may  be 
entirely  lost,  as  first  pointed  out  by  Bastian.  That  this  is  not  due  to  the 
preliminary  shock  is  shown  by  the  fact  that  the  abolition  of  the  reflexes 
may  continue  for  four  or  more  months.  The  trojjhic  changes  are  not 
marked.  The  muscles  become  extremely  flabby,  but  not  wasted  in  an  ex- 
treme degree;  subsequently  rigidity  develops.  If  the  gray  matter  of  the 
lumbar  cord  is  involved,  the  flaecidity  persists  and  the  wasting  may  be 
considerable.  The  reaction  of  degeneration  is  not  present.  The  tempera- 
ture of  the  paralyzed  limbs  is  variable.  It  may  at  first  rise,  then  fall  and 
become  s^^bnormal.  Lesions  of  the  skin  are  not  uncommon,  and  bed-sores 
are  apt  to  form.  There  is  at  first  retention  of  urine  and  subsequent  incon- 
tinence. If  the  lumbar  centres  are  involved,  there  are  from  the  outset 
vesical  symptoms.  The  urine  is  alkaline  in  reaction  and  may  rapidly  be- 
come ammoniacal.  The  bowels  are  constipated  and  there  is  usually  incon- 
tinence of  the  faeces.  Some  writers  attribute  the  cystitis  associated  with 
transverse  myelitis  to  disturbed  trophic  influence. 

The  course  of  complete  transverse  myelitis  depends  a  good  deal  upon 
its  cause.     Death  may  result  from  extension.     Segments  of  the  cord  may 


TOPICAL  DIAGNOSIS.  979 

be  completely  and  permanently  destroyed;,  in  which  case  there  is  persistent 
paraplegia.  The  pyramidal  fibres  below  the  lesion  undergo  the  secondary 
degeneration^,  and  there  is  an  ascending  degeneration  of  the  dorsal  me- 
dian columns.  If  the  lower  segments  of  the  cord  are  involved  the  legs 
may  remain  haccid.  In  some  instances  a  transverse  myelitis  of  the  thoracic 
region  involves  the  ventral  horns  above  and  below  the  lesion,  producing 
flaccidity  of  the  muscles,  with  wasting,  fibrillar  contractions,  and  the  reac- 
tion of  degeneration.  More  commonly,  however,  in  the  cases  which  last 
many  months  there  is  more  or  less  rigidity  of  the  muscles  with  spasm  or  per- 
sistent contraction  of  the  flexors  of  th_e  knee. 

(3)  Transverse  Myelitis  of  the  Cervical  Region. — If  the  lesion  is  at  the 
level  of  the  sixth  or  seventh  cervical  nerves,  there  is  paralysis  of  the  upper 
extremities,  more  or  less  complete,  sometimes  sparing  the  muscles  of  the 
shoulder.  Gradually  there  is  loss  of  sensation.  The  paralysis  is  usually 
complete  below  the  point  of  lesion,  but  there  are  rare  instances  in  which  the 
arms  only  are  affected,  the  so-called  cervical  paraplegia.  In  addition  to  the 
symptoms  already  mentioned  there  are  several  which  are  more  characteristic 
of  transverse  myelitis  in  the  cervical  region,  such  as  the  occurrence  of 
vomiting,  hiccough,  and  slow  pulse,  which  may  sink  to  20  or  30,  pupillary 
changes — myosis — sometimes  attacks  of  dysphagia,  dyspnoea,  or  syncope. 

Treatment  of  Acute  Myelitis. — In  the  rapidly  developing  form 
due  either  to  a  diffuse  inflammation  in  the  gray  matter  or  to  transverse 
myelitis,  the  important  measures  are:  Scrupulous  cleanliness,  care  and 
watchfulness  in  guarding  against  bed-sores,  the  avoidance  of  cystitis,  either 
by  systematic  catheterization  or,  if  there  is  incontinence,  by  a  carefully 
adjusted  bed  urinal,  or  the  use  of  antiseptic  cotton-wool  repeatedly  changed. 
In  an  acute  onset  in  a  healthy  subject  the  spine  may  be  cupped.  Counter- 
irritation  is  of  doubtful  advantage.  Chapman's  ice-bag  is  sometimes  useful. 
No  drugs  have  the  slightest  influence  upon  an  acute  myelitis,  and  even  in 
subjects  with  well-marked  syphilis  neither  mercury  nor  iodide  of  potassium 
is  curative.  Tonic  remedies,  such  as  quinine,  arsenic,  and  strychnia,  may 
be  used  in  the  later  stages.  When  the  muscles  have  wasted,  massage  is  bene- 
ficial in  maintaining  their  nutrition.  Electricity  should  not  be  used  in  the 
early  stages  of  myelitis.  It  is  of  no  value  in  the  transverse  myelitis  in  the 
thoracic  region  with  retention  of  the  nutrition  in  the  muscles  of  the  leg. 


Y.   DIFFUSE   AND   FOCAL  DISEASES   OF  THE   BRAIN. 
I.    TOPICAL    DIAGNOSIS. 

Only  certain  regions  of  the  brain  give  localizing  symptoms.  These 
are  the  cortical  motor  centres,  the  speech  centres,  the  centres  for  the  spe- 
cial senses,  and  the  tracts  which  connect  these  cortical  areas  with  each 
other  and  with  other  parts  of  the  nervous  system. 

The  following  is  a  brief  summaryaiod;  the  effects  of  lesions  from  the 
cortex  to  the  spinal  cord: 


980  DISEASES  OF  THE  NERVOUS  SYSTEM. 

1.  The  Cerebral  Cortex. — (a)  Destructive  lesions  of  the  motor  cortex 
(central  gyri,  lobiilus  jDaracentralis,  posterior  portions  of  the  three  frontal 
gyri,  especially  of  the  inferior)  cause  paralysis  in  the  muscles  of  the  oppo- 
site side  of  the  body.  The  paralysis  is  at  first  flaccid,  but  the  spastic  condi- 
tion subsequently  develops.  The  extent  of  the  paralysis  depends  upon  that 
of  the  lesion.  It  is  apt  to  be  limited  to  the  muscles  of  the  head  or  of  an  ex- 
tremity, giving  rise  to  the  cerebral  monoplegias  (Fig.  11,  1).  One  group  of 
muscles  may  be  much  more  affected  than  others,  especially  in  lesions  of 
the  highly  differentiated  area  for  the  upper  extremity.  It  is  uncommoji  to 
find  all  the  muscle  groups  of  an  extremity  equally  involved  in  cortical 
monoplegia.  Very  rarely  through  small  bilaterally  symmetrical  lesions 
monoplegia  of  the  tongue  may  result  without  paralysis  of  the  face.  A 
lesion  may  involve  centres  lying  close  together  or  overlapping  one  another, 
thus  producing  associated  monoplegias — e.  g.,  paralysis  of  the  face  and 
arm,  or  of  the  arm  and  leg,  but  not  of  the  face  and  leg  without  involve- 
ment of  the  arm.  Very  rarely  the  whole  motor  cortex  is  involved,  causing 
paralysis  of  the  opposite  side — cortical  hemiplegia.  Usually  in  such  in- 
stances there  is  marked  recovery,  so  that  only  a  monoplegia  persists. 

Adjoining  and  posterior  to  the  motor  area  is  believed  to  be  the  region 
of  the  cortex  in  which  the  impulses  concerned  in  general  bodily  sensation 
(cutaneous  sensibility,  muscle  sense,  visceral  sensations)  first  arrive  (the 
somgesthetic  area).  Combined  with  the  muscular  weakness  there  is  usually 
some  disturbance  of  sensations,  particularly  of  those  of  the  muscular  sense. 
The  stereognostic  sense  is  very  often  affected.  In  brachial  monoplegia,  for 
example,  a  coin  or  a  knife  when  placed  in  the  hand  of  the  paralyzed  limb, 
the  patient's  eyes  being  closed,  is  not  recognized,  owing  to  inappreciation 
of  the  form  and  consistence  of  tlie  object,  and  this  even  though  the  slight- 
est tactile  stimulus  applied  to  the  fingers  or  surface  of  the  hand  is  felt  and 
may  be  correctly  localized.  The  sense  of  touch,  pain,  and  temperature  may 
be  lowered,  but  usually  not  markedly  unless  the  superior  and  inferior 
parietal  lobules  are  involved  in  addition  to  the  central  gyri.  Parsesthesias 
and  vaso-motor  disturbances  are  common  accompaniments  of  paralyses  of 
cortical  origin.     Here,  too,  the  stereognostic  sense  is  frequently  involved. 

(h)  Irritative  lesions  cause  localized  spasms  as  described  above  (page 
917).  The  most  varied  muscle  groups  corresponding  to  particular  move- 
ment forms  may  be  picked  out.  If  the  irritation  be  sudden  and  severe, 
typical  attacks  of  Jacksonian  epilepsy  may  occur.  These  convulsions  are 
usually  preceded  and  accompanied  by  subjective  sensory  impressions.  Ting- 
ling or  pain,  or  a  sense  of  motion  in  the  part,  is  often  the  signal  symptom 
(Seguin),  and  is  of  great  importance  in  determining  the  seat  of  the 
lesion. 

Lesions  are  often  both  destructive  and  irritative,  and  we  then  have 
combinations  of  the  symptoms  produced  by  each.  For  instance,  certain 
muscles  may  be  paralyzed,  and  those  represented  near  them  in  the  cortex 
may  be  the  seat  of  localized  convulsions,  or  the  paralyzed  limb  itself  may 
be  at  times  subject  to  convulsive  spasms,  or  muscles  which  have  been  con- 
vulsed may  become  paralyzed.  Th<9  close  observation  of  the  sequence  of 
the  symptoms  in  such  cases  often  makes  it  possible  to  trace  the  progress 


TOPICAL  DIAGNOSIS.  981 

of  a  lesion  involving  the  motor  cortex.  In  these  cases  the  most  frequent 
cause  is  a  developing  tumor,  though  sometimes  local  thickenings  of  the 
membranes  of  the  brain,  small  abscesses,  minute  haemorrhages,  or  fragments 
of  a  fractured  skull  must  be  held  responsible. 

In  another  section  lesions  involving  the  centres  for  the  special  senses 
are  considered,  and  we  shall  simply  refer  to  them  here.  The  symptoms 
caused  by  lesions  of  the  speech  centres  will  be  described  under  aphasia,  and 
it  is  only  necessary  to  note  here  the  near  situation  of  the  motor  speech  area 
(Broca's  centre)  in  the  left  inferior  frontal  convolution  to  the  centres  for 
the  face  and  arm  on  that  side,  and  to  state  that  motor  aphasia  is  often 
associated  with  monoplegia  of  the  right  side  of  the  face  and  the  right  arm. 
Accompanying  the  paralysis,  following  a  Jacksonian  fit,  of  the  right  face  or 
arm  there  is  often  a  transient  motor  aphasia. 

According  to  Flechsig,  the  sensori-motor  centres  are  limited  to  tolerably 
circumscribed  areas  in  the  cortex,  which  differ  from  other  portions  in  that 
they  are  provided  with  projection  fibres  which  connect  them  with  lower 
centres.  The  remaining  areas  of  the  cortex,  amounting,  he  believes,  to 
about  two  thirds  of  the  whole,  are  devoid  of  projection  fibres  and  are  con- 
cerned entirely  in  associative  aiJtivities.  These  latter  areas,  the  "  association 
centres''  of  Flechsig,  are  three  in  number:  (1)  The  anterior  association 
centre,  including  the  whole  of  the  frontal  lobe  in  front  of  the  soniEesthetic 
area;  (2)  the  middle  association  centre,  corresponding  to  the  cortex  of  the 
island  of  Eeil;  and  (3)  the  large,  posterior  association  centre,  including  the 
precuneus,  the  superior  and  inferior  parietal  lobules,  the  supramarginal 
and  angular  gyri,  and  the  whole  of  the  temporal  and  occipital  lobes  except 
the  auditory  and  visual  sensory  areas. 

Flechsig  attributes  the  higher  psychic  functions,  especially  those  con- 
nected with  the  personality  of  the  individual,  to  the  anterior  association 
centres,  while  the  intellectual  activities  which  have  to  do  with  knowledge 
of  the  external  world  he  believes  correspond  to  the  functions  of  the  large 
posterior  association  centre.  Whether  these  views  be  true,  and,  if  so,  in  how 
far  they  may  be  applied  practically  in  the  localization  of  diseases,  especially 
of  the  mind,  tlie  future  has  to  decide. 

2.  Centrum  Semiovale. — Lesions  in  this  part  may  involve  either  projec- 
tion fibres  (motor  or  sensory)  or  association  fibres.  If  involvement  of  the 
motor  path  cause  paralysis,  this  has  the  distribution  of  a  cortical  palsy  when 
the  lesion  is  near  the  cortex,  and  of  a  paralysis  due  to  a  lesion  of  the  in- 
ternal capsule  when  it  is  near  that  region.  These  lesions  of  the  motor 
fibres  may  be  associated  with  symptoms  due  to  interruption  in  the  other 
systems  of  fibres  running  in  the  centrum  semiovale;  there  may  be  sensory 
disturbances — hemiaua:^sthesia  and  hemianopia — and  if  the  lesion  is  in  the 
left  hemisphere  oue  of  the  fliff'erent  forms  of  aphasia  may  accompany  the 
paralysis. 

3.  Corpus  Callosum. — This  may  be  cougeuitally  absent  without  symp- 
toms. An  acute  lesion  involving  a  large  portion  of  the  corpus  callosum 
may,  however,  yield  symptoms  suggestive  of  its  localization  in  this  region. 
In  the  case  recorded  by  TJcinharrl,  in  which  the  situation  of  the  lesion  was 
suspected  ante-mortem,  there  was  disturbance  of  equilibration   (without 


982  DISEASES  OF  THE  NERVOUS  SYSTEM. 

vertigo)  and  of  the  synergetic  movements  of  both  halves  of  the  body.  The 
autopsy  revealed  a  gliosarcoma  which  had  destroyed  the  posterior  three 
fourths  of  the  corpus  callosum.  In  Bristowe's  4  cases  there  existed,  as 
symptoms  common  to  all^  pain  in  the  head  and  partial  or  complete  hemi- 
plegia, with  gradual  extension  of  the  paralysis  to  the  opposite  side  of  the 
body.  Toward  the  end  of  life  there  was  disturbance  of  speech,  difficulty 
in  deglutition,  incontinence  of  urine  and  faces  and  dementia.  Here  the 
symptoms  have  in  them  nothing  that  can  be  looked  upon  as  pathognomonic; ' 
indeed,  many  of  the  phenomena  were  doubtless  dependent  upon  involvement 
of  the  projection  and  association  fibres  of  the  centrum  semiovale. 

In  animals  in  which  the  corpus  callosum  has  been  cut  experimentally 
progressive  emaciation  has  been  mentioned  as  a  characteristic  phenomenon. 

4.  Internal  Capsule  (Fig.  4). — Through  this  pass  within  a  rather 
narrow  area  all,  or  nearly  all,  of  the  projection  fibres  (both  motor  and 
sensory)  which  are  connected  with  the  cerebral  cortex.  It  is  divided  into 
an  anterior  limb,  a  knee,  and  a  posterior  limb,  the  latter  consisting  of  a 
thalamo-lenticular  portion  (its  anterior  two  thirds)  and  a  retro-lenticular 
portion  (its  posterior  third).  In  considering  the  efllects  of  a  given  focal 
lesion  involving  the  fibres  of  the  internal  c^sule,  it  is  not  to  be  forgotten 
that  the  relations  of  the  two  limbs  of  the  capsule  to  one  another  and  to  the 
knee  vary  considerably  in  different  horizontal  planes.  Much  of  the  con- 
fusion in  the  bibliography  is  dependent  upon  neglect  to  describe  the  hori- 
zontal level  of  the  lesion,  as  well  as  its  situation  in  an  antero-posterior  di- 
rection. The  principal  bundle  passing  through  the  anterior  limb  of  the 
capsule  is  that  which  connects  the  frontal  gyri  and  the  medial  bundle  in 
the  base  of  the  peduncle  (crus)  with  the  nuclei  of  the  pons.  These  fibres 
are  centrifugal,  and  innervate  chiefly  the  lower  motor  nuclei  governing 
bilaterally  innervated  muscles,  especially  those  of  the  eyes,  head,  neck,  and 
probably  those  of  the  mouth,  tongue,  and  larynx.  In  lower  horizontal 
planes  these  fibres  are  situated  near  the  knee  of  the  capsule.  It  is  the  region 
of  the  knee  of  the  capsule  which  transmits  especially  the  fibres  passing 
from  the  cerebral  cortex  to  the  nuclei  of  the  facial,  hypoglossal  and  third 
nerves.  The  path  which  supplies  the  nuclei  governing  the  muscles  used 
in  speech  passes  through  the  knee. 

The  pyramidal  tract  goes  through  the  thalamo-lenticular  portion  of  the 
capsule.  The  motor  fibres  are  arranged  according  to  definite  muscle  group?, 
or  rather  movement  forms,  those  for  the  movements  of  the  arm  being  ante- 
rior to  those  for  the  leg.  The  number  of  fibres  for  a  given  muscle  group 
corresponds  rather  to  the  degree  of  complexity  of  the  movements  than  to 
the  size  of  the  muscles  concerned.  Thus  the  areas  for  the  fingers  and  toes 
are  relatively  large. 

The  fibres  to  the  somaesthetic  area  of  the  cortex — that  is,  those  from  the 
ventro-lateral  group  of  nuclei  of  the  thalamus  and  the  tegmental  radia- 
tions— carrying  impulses  concerned  in  general  bodily  sensation,  pass  up- 
ward through  the  posterior  part  of  the  thalamo-lenticular  portion  of  the 
capsule.  Some  of  these  fibres  pass  through  the  anterior  two  thirds  of  the 
posterior  limb  alongside  of  the  fibres  of  the  pyramidal  tract. 

Through  the  retro-lenticular  portion  of  the  posterior  limb,  opposite  the 


TOPICAL  DIAGNOSIS.  983 

posterior  third  of  the  lateral  surface  of  the  thalamus,  pass  (1)  the  fibres 
carrying  impulses  concerned  in  the  sensations  of  the  opposite  visual  field 
(optic  radiation  from  the  lateral  geniculate  body  to  the  visual  sense  area  in 
the  occipital  cortex);  (2)  the  fibres  carrying  impulses  concerned  in  audi- 
tory sensations  (radiation  from  the  medial  geniculate  body  to  the  auditory 
sense  area  in  the  cortex  of  the  temporal  lobe);  (3)  the  fibres  (probably  cen- 
trifugal) connecting  the  cortex  of  the  temporal  lobe  with  the  nuclei  of 
the  pons. 

With  this  preliminary  knowledge  concerning  the  internal  capsule,  it  is 
not  dif&cult  to  understand  the  symptoms  which  result  when  it  is  diseased. 

Since  here  all  the  fibres  of  the  upper  motor  segment  are  gathered  to- 
gether in  a  compact  bundle,  a  lesion  in  this  region  is  apt  to  cause  complete 
hemi2:)]egia  of  the  opposite  side,  followed  later  by  contractures;  and  if  the 
lesion  involves  the  hinder  portion  of  the  posterior  limb  there  is  also  hemi- 
-  ansesthesia,  including  even  the  special  senses  (Fig.  4).  As  a  rule,  however, 
lesions  of  the  internal  capsule  do  not  involve  the  whole  structure.  The 
disease  usually  affects  mainly  either  the  anterior  or  posterior  portions,  and 
even  in  instances  in  which  at  first  the  symptoms  point  to  total  involvement, 
there  is  a  disappearance  often  of  a  large  part  of  the  phenomena  after  a 
short  time.  Thus  when  the  pyramidal  tract  is  destroyed  (lesion  of  the 
thalamo-lenticular  portion  of  the  capsule)  the  arm  may  be  affected  more 
than  the  leg,  or  vice  versa.  The  facial  paralysis  is  usually  slight,  though 
if  the  lesion  be  well  forward  in  the  capsule  the  paralysis  of  the  face  and 
tongue  may  be  marked. 

Hemianassthesia  alone  without  involvement  of  the  motor  fibres,  due  to 
disease  of  the  capsule,  is  rare.  There  is  usually  also  at  least  partial  paraly- 
sis of  the  leg.  When  the  retro-lenticular  portion  of  the  capsule  is  destroyed 
the  hemiangesthesia  is  accompanied  by  hemianopsia,  disturbance  of  hearing, 
and  sometimes  of  smell  and  taste.  The  occurrence  of  hemichorea,  marked 
tremor,  or  hemiathetosis  after  a  capsular  hemiplegia  points  to  the  involve- 
ment of  the  thalamus  or  of  the  hypothalamic  region  in  the  lesion. 

Charcot  and  others  have  described  cases  in  which  as  a  result  of  disease 
of  the  internal  capsule  there  has  been  paralysis  of  the  face  and  leg  without 
involvement  of  the  arm.  In  such  instances  the  lesion  is  linear,  extending 
from  the  posterior  part  of  the  anterior  limb  of  the  internal  capsule  back- 
ward and  lateralward  to  the  leg  region  in  the  posterior  limb  of  the  capsule, 
the  region  for  the  arm  escaping. 

Capsular  lesions  when  pure  are  not  usually  accompanied  by  aphasic 
symptoms,  alexia,  or  agraphia.  A  "  subcortical  "  motor  aphasia  may  result 
if  the  lesion  is  bilateral,  as  in  pseudo-bulbar  paralysis,  or  if  on  the  left 
side  it  is  so  extensive  as  to  destroy  the  fibres  connecting  Broca's  convolu- 
tion with  the  opposite  hemispheres,  as  well  as  the  pyramidal  fibres  on  the 
same  side. 

5.  Crura  (Cerebral  Peduncles). — From  this  level  through  the  pons,  me- 
dulla, and  cord  the  upper  and  lower  motor  segments  are  represented,  the 
first  by  the  fibres  of  the  pyramidal  tracts  and  by  the  fibres  which  go  from 
the  cerebral  cortex  to  the  nuclei  of  the  cerebral  nerves,  the  latter  by  the 
motor  nuclei  and  the  nerve  fibres  arising  from  them.     Lesions  often  affect 


984:  DISEASES  OP  THE  NERVOUS  SYSTEM. 

both  motor  segments,  and  produce  paralyses  having  the  characteristics  of 
each.  Thus  a  single  lesion  may  involve  the  pyramidal  tract  and  cause  a 
spastic  paralysis  on  the  opposite  side  of  the  body,  and  also  involve  the 
nucleus  or  the  fibres  of  one  of  the  cerebral  nerves,  and  so  produce  a  lower 
segment  paralysis  on  the  same  side  as  the  lesion — crossed  paralysis.  In  the 
crus  the  third  and  fourth  cerebral  nerves  run  near  the  pyramidal  tract,  and 
a  lesion  of  this  region  is  apt  to  involve  them  or  their  nuclei,  causing  partial 
paralysis  of  the  muscles  of  the  eye  on  the  same  side  as  the  lesions,  combined 
with  a  hemiplegia  of  the  opposite  side  (Fig.  10,  3). 

The  optic  tract  also  crosses  the  crus  and  may  be  involved,  giving  hemi- 
anopsia in  the  opposite  halves  of  the  visual  fields. 

If  the  tegmentum  be  the  seat  of  a  lesion  which  does  not  involve  the  base 
of  the  peduncle  (or  pes)  there  may  be  disturbances  of  cutaneous  and  mus- 
cular sensibility,  ataxia,  disturbances  of  hearing,  or  oculo-motor  paralysis. 
An  oculo-motor  paralysis  of  one  side,  accompanied  by  a  hemi-ataxia  of  the 
opposite  side,  appears  to  be  especially  characteristic  of  a  tegmental  lesion. 

6.  Corpora  Quadrigemina. — Anatomical  studies  point  to  the  view  that 
the  superior  colliculus  (anterior  quadrigeminal  body)  represents  the  most 
important  subcortical  central  organ  for  the  control  of  the  eye-muscle  nuclei. 
This  is  supported  to  a  certain  extent  by  clinical  evidence,  though  as  yet 
but  few  cases  have  been  carefully  studied.  Sight  is  only  slightly,  if  at  all, 
disturbed  when  the  superior  colliculus  is  destroyed.  The  pupil  is  usually 
widened,  and  the  pupillary  reaction,  both  to  light  and  on  accommodation, 
interfered  with.  Apparently  actual  paralysis  of  the  eye  muscles  does  not 
occur  unless  the  nucleus  of  the  third  nerve  ventral  to  the  aqueduct  be  also 
injured. 

The  inferior  colliculus  (posterior  quadrigeminal  body),  on  the  other 
hand,  has  been  shown  by  anatomical  study  to  be  an  important  way-station 
in  the  auditory  conduction-path.  A  large  part  of  the  lateral  lemniscus 
ends  in  its  nucleus,  and  from  it  emerge  medullated  fibres  which  pass  through 
the  brachium  quadrigeminum  inferior  to  the  medial  geniculate  body. 
Thence  a  large  bundle  runs  through  the  retro-lenticular  portion  of  the 
internal  capsule  to  the  auditory  sense  area  in  the  cortex  of  the  temporal 
lobe. 

"Weinland  has  collected  19  cases  of  tumors  of  the  corpora  quadrigemina 
from  the  bibliography;  in  9  of  these  auditory  disturbances  were  espe- 
cially noted.  Since  the  central  auditory  path  of  each  side  receives  im- 
pulses from  both  ears,  lesion  of  the  colliculus  on  one  side  may  dull  the 
hearing  on  both  sides,  though  the  opposite  ear  is  usually  the  more  defec- 
tive. Lesion  of  the  inferior  colliculus  may  be  accompanied  by  disturb- 
ance of  mastication,  owing  to  paralysis  of  the  descending  (mesencephalic) 
root  of  the  trigeminus.  The  fourth  nerve  may  also  be  involved.  The 
ataxia  which  sometimes  accompanies  lesions  of  the  corpora  quadrigemina 
is  probably  to  be  referred  to  disturbance  in  conduction  in  the  medial  lem- 
niscus. 

7.  Pons  and  Medulla  Oblongata. — Lesions  involving  the  pyramidal 
tract,  together  with  any  one  of  the  motor  cerebral  nerves  of  this  region, 
cause  crossed  paralysis.     A  lesion  in  the  lower  part  of  the  pons  is  apt  to 


TOPICAL  DIAGNOSIS.  985 

cause  a  lower-segment  paralysis  of  the  face  on  the  same  side  (destruction 
of  the  nucleus  of  the  facial  nerve  or  of  its  root  fibres)  and  a  spastic  paraly- 
sis of  the  arm  and  leg  on  the  opposite  side  (injury  to  pyramidal  tract)  (Fig. 
10,  4).  The  abducens,  the  motor  part  of  the  trigeminus,  and  the  hypo- 
glossus  nerves  may  also  be  paralyzed  in  the  same  manner.  When  the  cen- 
tral fibres  to  the  nucleus  of  the  hypoglossus  are  involved  a  peculiar  form 
of  anarthria  results.  If  the  nucleus  itself  be  diseased,  swallowing  is  inter- 
fered with. 

When  the  sensory  fibres  of  the  fifth  nerve  are  interrupted,  together 
with  the  sensory  tract  (the  medial  lemniscus  or  fillet)  for  the  rest  of  the 
body,  which  has  already  crossed  the  middle  line,  there  is  a  crossed  sensory 
paralysis — i.  e.,  disturbed  sensation  in  the  distribution  of  the  fifth  on  the 
side  of  the  lesion,  and  of  all  the  rest  of  the  body  on  the  opposite  side. 

A  paralysis  of  the  external  rectus  muscle  of  one  eye  and  of  the  internal 
rectus  of  the  other  eye  (conjugate  paralysis  of  the  muscles  which  turn  the 
eyes  to  one  side),  in  the  absence  of  a  "  forced  position  "  of  the  eyeballs,  is 
highly  characteristic  of  certain  lesions  of  the  pons.  In  such  cases  the  in- 
ternal rectus  may  still  be  capable  of  functioning  on  convergence,  or  when 
the  eye  to  which  it  belongs  is  tested  independently  of  that  in  which  the 
external  rectus  is  paralyzed.  This  form  of  paralysis  is  found,  as  a  rule, 
only  when  the  lesion  lies  just  in  front  of  the  abducens  or  involves  the 
nucleus  itself,  or  includes,  besides  the  root  fibres  of  the  abducens,  that  por- 
tion of  the  formatio  reticularis  that  lies  between  them  and  the  fasciculus 
longitudinalis  medialis  (von  Monakow).  The  cases  of  conjugate  paralysis 
just  referred  to  may  be  complicated  by  other  disturbances  of  the  eye-muscle 
movements,  in  which  case  the  interpretation  of  the  symptoms  may  be  ren- 
dered difficult.     The  facial  nerve  is  often  involved  in  these  paralyses. 

In  lesions  of  the  pons  the  patient  often  has  a  tendency  to  fall  toward 
the  side  on  which  the  lesion  is,  probably  on  account  of  implication  of  the 
middle  peduncle  of  the  cerebellum  (brachium  pontis).  Still  more  frequent 
is  the  simple  motor  hemi-ataxia  consequent  upon  lesion  of  the  medial  lem- 
niscus, and  perhaps  of  longitudinal  bundles  in  the  formatio  reticularis. 
This  is  often  accompanied  by  disturbance  of  muscular  and  cutaneous 
sensations.  Only  when  the  lesion  is  very  extensive  are  there  disturb- 
ances of  hearing  (involvement  of  the  lateral  lemniscus  or  corpus  trape- 
zoideum). 

The  symptoms  produced  by  involvement  of  the  different  cerebral  nerves 
will  be  considered  in  detail  in  another  section. 

8.  Cerebellmn. — The  functions  of  this  part  of  the  brain  are  still  under 
consideration.  Luciani,  whose  monograph  is  exhaustive,  regards  it  as  "  an 
end  organ,  directly  or  indirectly  related  to  certain  peripheral  sensory  organs 
and  in  direct  efferent  relationship  with  certain  ganglia  of  the  cerebro-spinal 
axis,  and  indirectly  with  the  motor  apparatus  in  general.  It  is  functionally 
homogeneous,  each  part  exercising  the  functions  of  the  whole,  but  liaving 
special  relations  to  the  muscles  of  the  corresponding  side  of  the  body  " 
(Krauss). 

Lesions  of  the  lateral  lobes  affect  the  corresponding  side  of  the  body, 
while  lesions  of  the  middle  lobe  (vermis)  affect  both  sides.  Partial  removal 
62 


986  DISEASES  OF  THE  NERVOUS  SYSTEM. 

is  followed  by  transient  muscular  weakness;  complete  removal  by  extreme 
incoordination.  Its  one  important  function  would  appear  to  be  the  co- 
ordination of  the  muscular  movements. 

In  monkeys  the  symptoms  differ  much  at  different  periods  after  the 
operation.  During  the  first  five  or  six  days  irritation  phenomena  predom- 
inate. There  is,  according  to  Luciani,  asthenia,  atony  of  the  muscles,  and 
astasia  on  the  side  of  the  body  operated  upon.  The  animal  can  not  stand 
or  walk.  All  these  symptoms  may  gradually  disappear  in  the  course  of  a 
few  months. 

The  experiments  of  J.  S.  Eisien  Eussell  do  not  entirely  confirm  the  ob- 
servations of  Luciani.  In  the  first  place,  the  occurrence  of  asthenia  is  not 
constant,  and  as  to  atony,  while  the  patellar  tendon  reflexes  are  sometimes 
absent,  they  are  as  a  rule  intact  in  pure  cerebellar  lesions.  There  may  be 
even  muscular  rigidity  instead  of  atony.  EusselFs  experiments  make  it 
seem  likely  that  the  cerebellar  hemisphere  of  one  side  exercises  constantly 
an  inhibitory  effect  upon  the  activities  of  the  cerebral  hemisphere  of  the 
opposite  side  (probably  by  way  of  the  brachium  conjunctivum).  Thus  after 
removal  of  one  cerebellar  hemisphere  he  found  that  much  milder  faradic 
stimulation  of  the  contra-lateral  motor  area  would  call  forth  movements 
©f  the  arm  and  leg  than  that  necessary  to  stimulate  the  homo-lateral  motor 
area.  The  epileptic  seizures  following  the  administration  of  absinthe  were 
far  greater  on  the  side  of  ablation.  It  is  not  impossible  that  the  explana- 
tion of  the  epileptiform  attacks  by  no  means  rare  in  cerebellar  disease  is 
here  to  be  sought. 

"W.  C.  Krauss  has  analyzed  the  lesions  and  symptoms  in  100  cases  of 
disease  of  this  part.  The  morbid  conditions  were  as  follows:  Sarcoma  in 
22  cases;  tubercle  in  22;  glioma  in  18;  abscess  in  10;  tumor  of  unspecified 
origia  in  13;  cyst  in  7;  and  1  case  each  of  softening,  endothelioma,  cyst 
and  sarcoma,  cancer,  gumma,  fibroma,  and  hemorrhage.  The  left  lobe  was 
affected  32  times,  the  right  lobe  32  times,  and  the  middle  lobe  17  times. 
Thus  tumor  constituted  by  far  the  most  important  affection.  There  may  be 
no  symptoms  whatever  if  it  is  in  one  hemisphere  only  and  does  not  involve 
the  middle  lobe.  There  are  not  only  instances  of  complete  absence  of  one 
whole  hemisphere,  but  also  of  extensive  bilateral  disease  which  throughout 
life  have  yielded  no  noticeable  symptoms.  Other  portions  of  the  brain 
appear  to  be  able  to  take  on  the  functions  normally  performed  by  the  cere- 
bellum. The  most  common  symptoms  in  tumor  of  the  cerebellurfi  are  as 
foUows: 

Vertigo,  which  is  more  constant  in  this  than  in  affections  of  any  other 
region  of  the  brain.  Some  believe  this  to  be  due  to  involvement  of  the 
aervus  vestibularis  or  its  nuclei  of  termination,  by  means  of  which  the 
semicircular  canals  are  connected  with  the  cerebellum.  The  symptom  was 
present  in  48  of  the  cases  of  Krauss's  collection,  not  reported  in  43.  The 
vertigo  appears  to  be  entirely  independent  of  the  ataxia.  Though  most 
frequently  associated,  either  symptom  may  be  present  without  the  other. 
The  vertigo  of  cerebellar  disease  is  often  associated  with  the  feeling  that 
objects  are  revolving  about  the  body,  or  that  the  body  itself  is  moving. 
Headache  was  present  in  83  cases.     Vomiting  occurred  in  69  cases,  not  re- 


TOPICAL  DIAGNOSIS.  987 

ported  in  23.  Optic  neuritis  was  found  in  66  cases,  not  reported  in  23. 
Very  serious  disturbances  of  vision  ma}^  result  from  pressure  on  the  aque- 
ductus  cerebri,  leading  to  increased  pressure  in  the  third  ventricle;  this, 
through  bulging  of  the  floor,  can  directly  injure  the  chiasm  or  optic  nerve. 

Of  symptoms  which  are  designated  as  more  particularly  cerebellar, 
ataxia  is  the  most  important.  In  cerebellar  ataxia  the  gait  is  irregular  and 
staggering,  often  zigzag,  and  in  attempting  to  walk  the  patient  sways  to 
and  fro  like  a  drunken  man  {demarche  d'ivresse  of  the  French  writers).  As 
a  rule,  the  patient  walks  and  tends  to  fall  toward  the  affected  side,  but  the 
rule  is  not  certain.  The  ataxia  of  cerebellar  disease  is  to  be  sharply  differ- 
entiated from  the  ataxia  of  tabes  dorsalis,  from  cortical  ataxia,  and  prob- 
ably from  the  ataxia  accompanying  diseases  of  the  tegmental  portion  of  the 
pons  and  cerebral  peduncle.  Cerebellar  ataxia  is  both  static  and  dynamic. 
The  opening  or  closing  of  the  eyes  is  of  less  influence  than  in  spinal  ataxia. 
Very  important  for  differential  diagnosis  is  the  fact  that  when  the  patient 
lies  in  bed  movements  tolerably  well  coordinated  can  be  carried  out.  The 
coarse  nature  of  the  incoordination  distinguishes  cerebellar  ataxia  from 
that  due  to  lesion  of  the  cerebral  cortex.  In  the  latter  the  finer  movements 
(buttoning,  etc.)  are  especially  apt  to  be  involved,  and  there  is  usually 
hemi-paresis  or  mono-paresis,  and  often  disturbance  of  muscular  sense  and 
of  the  stereognostic  sense  (von  Monakow).  Cerebellar  ataxia  may  depend 
upon  the  withdrawal  of  the  influence  of  the  cerebellum  upon  the  cerebrum. 

Paresis  of  the  trunk  muscles,  manifest  in  an  inability  to  perform  the 
movements  of  bending,  erection,  and  lateral  flexion  of  the  trunk,  may  be 
present  (Hughlings  Jackson).  Eisien  Eussell  holds  that  the  paralysis  is 
"  probably  directly  due  to  the  withdrawal  of  the  cerebellar  influence  from 
the  muscles." 

Other  less  constant  but  suggestive  symptoms  are  neuralgic  pains  in  the 
region  of  the  neck  and  occiput;  blocking  of  the  vense  Galeni  and  dilatation 
of  the  lateral  ventricles,  causing  in  children  hydrocephalus;  pressure  on 
the  mid-brain,  pons,  or  medulla  oblongata,  producing  paralysis  of  the  cere- 
bral nerves,  rhythmical  contractions  of  the  head  or  extremities,  nystagmus, 
tremor,  anarthria,  auditory  or  visual  disturbances.  There  may  be  glyco- 
suria and  bilateral  rigidity  from  pressure  on  the  motor  paths.  Sudden 
death  may  occur.  Forced  movements,  especially  rotation  of  the  trunk, 
forced  positions  (of  the  head  or  trunk),  and  a  peculiar  forced  position  of  the 
eyes  (one  turned  downward  and  to  the  side,  the  other  upward  and  inward) 
are  almost  pathognomonic  of  disease  of  one  brachium  pontis  (middle  cere- 
bellar peduncle). 

The  reflexes  are  very  variable;  they  were  absent  in  12  cases.  In  pure 
cerebellar  lesion  they  are  probably  intact  or  exaggerated,  but  when  the 
cerebellar  disease  involves  other  structures,  directly  or  indirectly,  through 
action  at  a  distance,  or  when  there  is  associated  disease  of  the  spinal  tracts, 
the  reflexes  may  be  abolished. 

Symptoms  of  general  mental  disturbance  may  accompany  cerebellar  dis- 
ease, but  they  are  not  characteristic.  There  is  often  irritability,  enfeebled 
memory,  and  toward  the  end  sopor  and  coma. 


988  DISEASES  OF  THE  NERVOUS  SYSTEM. 

II.  APHASIA. 

Speecli  disorders  give  important  information  as  to  tlie  position  of 
lesions  of  the  nervous  system,  and  it  is  for  this  reason  that  they  are  con- 
sidered here. 

The  studies  of  Dax,  Broca,  Bastian,  Kussmaul,  Lichtheim,  and  others 
have  done  much  to  widen  our  knowledge  of  this  very  difficult  subject.  The 
student  is  referred  to  the  works  of  these  authors,  and  especially  to  the 
recent  monographs. 

The  speech  movements,  just  as  all  other  voluntary  movements,  require 
not  only  the  motor  mechanism,  but  also  the  sensory,  and  we  have,  as  com- 
posing the  speech  mechanism,  a  sensory  or  receptive  part  as  well  as  a  motor 
or  emissive  part.  These  two  parts  reach  to,  and  are  controlled  by,  the 
mechanism  that  underlies  the  intellectual  process. 

The  muscles  which  are  used  in  the  production  of  articulate  speech  are 
many  and  widely  distributed;  thus  the  respiratory  muscles,  the  muscles  of 
the  larynx,  the  pharynx,  the  tongue,  the  lips,  and  those  which  move  the 
jaws,  are  all  brought  into  play  during  speech.  These  muscles  are  all  active 
in  other  less  complicated  movements;  for  instance,  respiration,  crying, 
sucking,  etc.,  and  these  comparatively  simple  movements  are  represented 
in  the  gray  matter  of  the  lower  motor  segment,  in  the  pons,  medulla,  and 
spinal  cord.  The  association  of  neurones  upon  which  these  movements 
depend  is  made  during  fcetal  life,  and  is  in  good  working  order  at  the  time 
of  birth. 

As  the  child's  brain  grows  and  takes  control  of  the  spinal  centres 
through  the  medium  of  the  pyramidal  tracts,  other  more  complex  move- 
ments are  developed  and  special  neurones  are  set  apart  for  this  purpose. 
There  is,  then,  a  re-representation  (Hughlings  Jackson)  of  the  finer  move- 
ments of  these  muscles  in  the  upper  motor  segment.  They  are  localized  in 
the  central  convolutions  about  the  lower  part  of  the  Eolandic  fissure.  All 
these  muscles  except  those  of  the  tongue  and  lips  are  used  bilaterally,  and  so 
their  movements  on  each  side  of  the  body  are  represented  on  both  sides  of 
the  brain. 

This  group  of  movements,  which  are  in  part  congenital  and  in  part 
acquired  during  the  early  months  of  life,  is  that  from  which  the  delicate 
movements  of  articulate  speech  are  developed.  The  structures  upon  which 
these  movements  depend  make  the  primary  or  elemenitiry  speecli  mech- 
anism. 

The  cortical  centres  are  in  the  lower  third  of  the  central  convolution 
on  both  sides  of  the  brain.  They  are  bilaterally  acting  centres,  and  a 
lesion  limited  to  either  one  should  not  produce  marked  or  permanent  de- 
fects in  speech.  This  is  true  for  the  right  side,  but  on  the  left  Broca's 
convolution  is  so  closely  situated  that  it  is  usually  injured  at  the  same  time, 
and  so  motor  aphasia  results. 

The  Path  from  Cortex  to  Loiver  Motor  Centres. — This  is  made  up  of  the 
pyramidal  fibres  which  go  to  the  nuclei  of  the  pons  and  medulla,  and  in 
the  internal  capsule  is  situated  near  the  knee.  As  in  the  cortex,  a  uni- 
lateral lesion  here  causes  only  slight  disturbances  of  speech  due  to  difficult 


APHASIA.  -  989 

articulation,  following  weakness  of  the  opposite  side  of  the  face  and  tongue. 
On  the  left  side,  if  the  lesion  is  so  near  the  cortex  as  to  involve  the  fibres 
which  connect  Broea's  convolution  with  the  primary  speech  mechanism, 
subcortical  motor  aphasia  is  produced.  Bilateral  lesions  (usually  in  the 
internal  capsule,  hut  at  times  in  the  cortex)  cause  speechlessness,  with 
paralysis  of  the  muscles  of  articulation — pseudo-bulbar  paralysis.  To  these 
speech  defects  Bastian  gives  the  name  Aphemia. 

The  lower  segment  of  the  primary  speech  mechanism  is  made  up  of  the 
motor  nuclei  in  the  medulla,  etc.,  and  the  peripheral  nerves  arising  from 
them.  Lesions  here,  if  extensive  enough — as,  for  instance,  in  progressive 
bulbar  paralysis — may  cause  speechlessness — anarthria  (Bastian);  but  usu- 
ally they  are  more  limited,  giving  various  disturbances  of  articulation. 

As  the  child  learns  to  speak  there  is  developed  in  the  cortex  of  the  brain 
an  association  of  centres  which  takes  control  of  the  primary  speech  mechan- 
ism. The  child  is  constantly  hearing  objects  called  by  names,  and  he  learns 
to  associate  certain  sounds  with  the  look  and  feel  and  taste,  etc.,  of  certain 
things.  When  he  hears  that  sound  he  gets  a  more  or  less  clear  mental 
picture  of  the  object,  or,  in  other  words,  he  has  developed  certain  auditory 
memories.  These  memories  of  the  sounds  of  words  are  stored  in  what  is 
called  the  auditory  speech  centre.  This  centre,  which  in  the  majority  of 
people  is  the  controlling  speech  centre,  is  situated  in  the  first  temporal 
convolution  on  the  left  side  in  right-handed  people,  and  on  the  right  side 
in  those  who  are  left-handed.  The  afferent  impressions  arising  in  the  ears 
reach  the  temporal  lobes,  those  from  each  ear  going  to  both  sides  of  the 
brain.  From  each  of  these  primary,  auditory  centres  impulses  are  sent  to 
the  auditory  speech  centre  in  the  left  hemisphere.  The  child  endeavors, 
and  by  repeated  efforts  learns,  to  make  the  sounds  that  he  hears,  and  he 
first  becomes  able  to  repeat  words,  then  to  speak  voluntarily.  To  do  this, 
he  has  had  to  learn  certain  very  delicate  movements,  and  so  there  has  been 
developed  a  special  centre  in  which  these  movements  are  localized,  which  is 
called — 

The  Motor  Speech  Centre. — This  is  in  Broca's  convolution,  the  posterior 
part  of  the  left  third  frontal  convolution.  The  activity  of  this  centre  was 
excited  under  the  influence  of  impressions  received  from  the  auditory  speech 
centre.  Without  this  influence  it  would  not  have  become  active  (those  who 
are  born  deaf  remain  dumb)  unless  some  other  sensory  impressions  are  made 
to  take  the  place  of  the  auditory  influences,  as  when  deaf-mutes  are  taught 
to  speak  by  the  means  of  sight  and  touch.  Throughout  life  there  is  a  very 
close  interdependence  between  the  motor  and  the  auditory  and  speech  cen- 
tres, and  for  the  perfect  functioning  of  either  we  must  liavc  tlic  normal 
action  of  both.  This  is  so  much  so  that  certain  French  authors  make  no 
sharp  distinction, but  consider  that  these  centres,  with  the  visual  speech  cen- 
tre, make  together  a  general  speech  centre,  which  is  called  the  sphere  of  lan- 
guage; a  lesion  anywhere  in  this  disturbs  to  a  greater  or  less  degree  all  of 
the  psychical  components  which  underlie  speech.  This  is  only  another  way 
of  expressing  the  close  interrelation  of  the  different  speech  centres,  but  it 
is  important  in  freeing  the  mind  of  the  student  from  the  conception  of  the 
different  speech  processes  as  being  carried  on  in  sharply  circumscribed 


990  -DISEASES  OF  THE  NERVOUS  SYSTEM. 

independent  centres,  which  is  apt  to  result  from  a  study  of  the  various  dia- 
grams that  have  been  devised.  The  connection  between  the  auditory  speech 
centre  and  the  motor  speech  centre  is  by  fibre  tracts,  which  run  in  the  white 
matter  of  the  island  of  Eeil. 

In  Broca's  convolution  the  movements  of  the  muscles  which  are  repre- 
sented in  the  primary  speech  mechanism  are  rearranged  in  most  delicate 
combinations  so  as  to  produce  articulate  speech — i.  e.,  motor  speech  memo- 
ries are  stored  here,  or,  as  Bastian,  who  considers  all  cortical  centres  as 
sensory,  would  say,  "  glosso-kinsesthetic  memories."  It  is  from  this  centre 
that  the  intellectual  speech  processes  which  are  carried  on  in  the  cortical 
speech  areas  are  transformed  into  motor  activities.  We  do  not  as  yet  know 
the  exact  anatomical  relation  between  Broca's  convolution  and  the  primary 
speech  mechanism  by  which  this  transformation  is  brought  about.  It  seems 
certain  that  Broca's  convolution  is  connected  by  commissural  fibres  through 
the  corpus  callosum  with  the  corresponding  area  of  the  right  frontal  lobe, 
and  it  can  control  the  speech  movements  when  the  more  direct  path  in  the 
left  pyramidal  tract  has  been  interrupted. 

Broca's  convolution  and  the  corresponding  area  in  the  right  brain  are 
connected  either  directly  by  special  pyramidal  fibres  with  the  bulbar  nu- 
cleus, or,  as  is  more  probable,  indirectly,  through  the  medium  of  the  cortical 
centres  of  the  primary  speech  mechanism  in  the  lower  part  of  the  Rolandic 
region  on  both  sides. 

The  speech  centres  are  in  close  connection  with  the  rest  of  the  brain 
cortex,  and  in  this  way  they  take  part  in  the  general  mental  activities,  of 
which,  indeed,  the  speech  processes  form  a  large  part.  Some  authors  have 
assumed  that  the  several  sensory  elements  which  go  to  make  a  concept  are 
brought  together  in  a  special  region  of  the  brain,  and  here,  as  it  were,  united 
by  a  name.  This  is  called  "  the  centre  for  concepts,"  or  "  naming  centre  " 
(Broadbent),  but  most  writers  have  followed  Bastian  in  considering  that  the 
supposition  of  such  a  centre  is  unnecessary. 

The  mechanism  which  has  been  described  is  that  which  is  developed  in 
uneducated  people  and  in  children  before  they  have  learned  to  read  and 
write,  and  is  of  primary  importance  in  all  speech  processes.  As  the  child 
learns  to  read  he  associates  certain  visual  impressions  with  the  speech 
memories  he  has  already  acquired,  and  he  then  adds  to  his  concepts  the 
visual  memories  of  written  or  printed  symbols.  Thus  memories  are  stored 
in  the  speech  centre. 

This  centre  is  placed  by  nearly  all  authors  in  the  angular  and  supra- 
marginal  convolutions  on  the  left  side,  where  visual  impressions  from  both 
occipital  lobes  are  combined  in  speech  memories.  Von  Monakow  believes 
that  there  is  no  such  special  centre,  but  that  visual  speech  memories  are 
dependent  upon  the  direct  connection  of  the  general  visual  centres  in  both 
occipital  lobes  with  the  speech  sphere.  That  speech  defects  result  from 
injury  to  the  angular  and  supramarginal  convolutions,  he  admits;  but  he 
thinks  these  are  due  to  an  interruption  of  fibre  tracts  which  lie  beneath 
and  not  to  a  destruction  of  a  cortical  centre.  The  distinction  is,  therefore, 
of  more  theoretical  than  practical  importance. 

In  learning  to  write,  the  child  develops  certain  delicate  movements  of 


APHASIA.  991 

the  arm  and  hand,  and  thus  acquires  another  method  of  externalizing  his 
speech  activities.  Whether  or  not  tliis  requires  the  development  of  a  sepa- 
rate writing  centre,  apart  from  the  general  Eolandic  arm  centre,  or  is 
hrought  about  by  an  evolution  of  the  latter  through  the  medium  of  Broca's 
convolution,  is  a  vexed  question.  However  this  may  be,  these  movements 
are  learned  under  the  influence  of  visual  impressions  in  association  with  the 
other  speech  memories,  although  there  is  a  more  direct  path,  which  is  used 
in  copying  unknown  characters.  Just  as  the  movements  of  articulate  speech 
are  constantly  under  the  control  of  auditory  memories,  so  are  the  move- 
ments of  writing  regulated  by  visual  memories;  but  in  this  case  the  other 
speech  memories  are  of  great  importance. 

With  the  development  of  the  associations  which  underlie  reading  and 
writing,  the  speech  mechanism  may  be  said  to  be  complete,  although  its 
activities  are  capable  of  practically  endless  extension,  as  when  music  or 
foreign  languages  are  learned. 

It  will  be  seen  that  the  cortical  speech  centres  occupy  the  part  of  the 
brain  near  the  Sylvian  fissure,  and  that  they  all  receive  their  blood  from 
the  Sylvian  artery.  The  posterior  part  of  this  region  is  sensory  and  the 
anterior  is  motor.  The  sensory  areas  are  near  the  optic  radiation  and  the 
motor  are  near  the  general  motor  tracts,  and  so  with  lesions  of  the  pos- 
terior part,  hemianopia  is  apt  to  be  associated  with  the  speech  disturbance 
while  hemiplegia  occurs  with  disease  of  the  anterior  areas.  These  asso- 
ciations often  help  to  distinguish  a  sensory  from  a  motor  aphasia,  but  each 
type  has  special  characteristics  which  must  be  studied. 

Sensoey  Aphasia,  due  to  Lesions  of  the  Posteeioe  Paet  op  the 
Speech  Aeea,  oe  to  Fibees  going  to  this  Eegion. 

Auditory  Aphasia. — Most  people  in  mentally  recalling  words  do  so  by 
means  of  their  auditory  speech  memories — i.  e.,  they  think  of  the  sound 
of  the  words,  and  it  is  probable,  in  voluntary  speech,  that  the  will  acts 
on  the  motor  centre  indirectly  through  the  auditory  centre.  This  centre 
is  also  necessary  for  reading  in  such  persons.  There  are  certain  persons, 
however,  in  whom  the  mental  processes  are  carried  on  by  visual  memories, 
and  in  these  rare  "  visuals  "  the  visual  speech  centres  take  the  predominant 
place  in  speech  usually  occupied  by  the  auditory  centres. 

Complete  abolition  of  all  the  auditory  speech  memories  by  destruction 
of  the  first  temporal  convolution  causes  the  most  extensive  disturbances  of 
speech.  Such  a  person  is  unable  to  comprehend  speech,  either  spoken  or 
printed.  Voluntary  speech  is  much  disturbed,  and  although  at  first  he 
may  talk  with  his  words  all  transposed  (paraphasia),  he  soon  becomes 
speechless.  Writing  is  also  lost,  and  he  can  neither  repeat  words  nor  write 
at  dictation.    He  may  be  able  to  copy. 

Lesions  are  often  only  partial,  and  the  resultant  disturbance  of  speech 
may  be  simply  a  difficulty  in  speech  due  to  tlic  loss  of  nouns  and  to  para- 
phasia, the  writing  showing  the  same  defect.  He  usually  understands  what 
he  hears  and  reads,  and  can  repeat  words  and  write  at  dictation.  This  is 
the  condition  Bastian  calls  "amnesia  verbalis."  The  condition  may  be  so 
pronounced  that  voluntary  speech  and  writing  are  nearly  lost,  even  when 
the  auditory  memories  can  still  be  aroused  by  new  afferent  impressions  and 


992  DISEASES  OF  THE  NERVOUS  SYSTEM. 

he  is  able  to  understand  what  is  said  to  him  and  what  he  reads.  He  can 
usually  repeat  and  read  aloud. 

The  afferent  paths,  which  reach  the  auditory  speech  centre  from  the 
two  primary  auditory  centres,  may  be  destroyed.  A  lesion  to  do  this  must 
be  in  the  white  matter  beneath  the  first  temporal  convolution  on  the  left 
side.  Such  a  lesion  would  block  all  auditory  impressions  coming  to  the 
centre,  and  the  patient  would  not  be  able  to  understand  anything  that  was 
said  to  him,  could  not  repeat  words  nor  write  from  dictation.  As  the  cor- 
tical centres  are  not  disturbed,  and  the  auditory  speech  memories  are  still 
present,  there  is  no  disturbance  of  voluntary  speech  or  writing,  and  the 
patient  can  read  perfectly.  This  is  pure  word-deafness  or  subcortical 
sensory  aphasia. 

Visual  Aphasia. — Destruction  of  the  visual  centre  in  the  angular  and 
supramarginal  convolutions  causes  a  loss  of  the  visual  speech  memories, 
and  the  patient  is  unable  to  read  printed  or  written  characters.  He  is 
unable  to  write — i.  e.,  there  is  agraphia — :and  he  can  not  copy.  His  under- 
standing of  spoken  words  is  good,  and  vohmtary  speech  is  normal  or  only 
slightly  paraphasic. 

A  subcortical  lesion  involving  the  afferent  fibres  going  to  the  visual 
speech  centre  causes  pure  word-blindness  (subcortical  alexia) — i.  e.,  there 
is  inability  to  understand  written  or  printed  words.  Voluntary  speech  and 
writing  are  good.  The  patient  can  not  read  his  own  writing  except  by  aid 
of  muscle-sense  impression,  in  retracing  the  letters,  either  voluntarily  or 
passively.    Associated  with  this  is  always  hemianopia. 

Word-deafness  and  word-blindness  are  often  combined,  and  at  times  it 
is  not  only  the  tracts  that  connect  the  primary  auditory  and  visual  cen- 
tres with  the  speech  spheres,  but  also  those  which  associate  them  with  the 
other  sensory  centres  in  the  formation  of  concepts,  that  are  diseased.  In 
this  case  he  has  not  only  lost  his  auditory  and  visual  speech  memories,  but 
also  all  of  his  memories  which  have  to  do  with  hearing  and  sight,  and  he 
has  mind-deafness  and  mind-blindness — i.  e.,  he  is  unable  to  recognize 
objects  when  he  hears  or  when  he  sees  them.  Further  than  this,  there  may 
be  a  disassociation  of  all  the  sensory  centres  from  each  other  or  from  the 
higher  psychical  centre,  which  is  practically  the  same  thing,  in  which  case 
the  patient  is  entirely  unable  to  recognize  objects  and  to  use  them  properly 
— ^i.  e.,  he  has  apraxia.  Apraxia  may  occur  alone,  but  is  usually  associated 
with  forms  of  aphasia. 

Motor  Aphasia. — Lesions  of  Broca's  convolution — the  posterior  part  of 
the  left  third  frontal  convolution.  A  complete  lesion  here  causes  paralysis 
of  the  speech  movements.  The  patient  may  be  absolutely  dumb  or  he  may 
have  retained  one  or  two  words  or  phrases  which  are  believed  to  be  due  to 
the  activity  of  the  corresponding  region  of  the  right  brain.  He  will  make 
no  effort  to  repeat  words.  His  mind  is  comparatively  clear,  and  he  under- 
stands what  is  said  to  him  and  is  able  to  read,  although  there  is  usually 
some  difficulty  in  this  due  to  the  lack  of  motor  speech  memories.  He  will 
not  be  able  to  indicate  that  he  has  a  mental  picture  of  words.  This  is 
tested  by  asking  him  to  squeeze  the  observer's  hand  or  to  make  expiratory 
efforts  the  number  of  times  there  are  syllables  in  a  well-known  name. 


APHASIA.  993 

Voluntary  writing  is  usually  lost  in  cortical  motor  aphasia,  and  many 
authors  believe  that  writing  movements  are  controlled  from  this  centre. 
Others,  who  believe  that  there  is  a  special  writing  centre,  contend  that  a 
lesion  strictly  limited  to  Broca's  convolution  would  not  cause  agraphia,  and 
cite  cases  which  seem  to  support  their  view.  If  there  is  much  disturbance 
of  internal  speech,  writing  will  be  impaired. 

Subcortical  motor  aphasia  has  already  been  spoken  of.  It  is  due  to  the 
destruction  of  the  fibres  which  join  Broca's  convolution  to  the  primary 
speech  mechanism.  Lesions  which  have  produced  this  type  of  aphasia  have 
been  in  the  white  matter  of  the  left  hemisphere  near  Broca's  convolution. 
There  is  complete  loss  of  the  power  of  speech  without  any  disturbance  of 
internal  speech.  The  patient  can  write  perfectly  if  the  hand  is  not  para- 
lyzed and  his  mental  processes  are  not  disturbed. 

Cases  of  aphasia  are  rarely  simple,  and  it  is  often  impossible  to  classify 
them  accurately.  The  problems  involved  are,  in  reality,  exceedingly  com- 
plicated, and  the  student  must  not  for  a  moment  suppose  that  cases  are  as 
straightforward  as  the  various  diagrams  at  first  sight  would  appear  to 
indicate.  A  majority  of  them  are  very  complex,  but  with  patience  the  diag- 
nosis of  the  different  varieties  can  often  be  worked  out.  The  following 
tests  should  be  applied  in  each  case  of  aphasia,  after  the  presence  or  absence 
of  paralysis  has  been  determined  and  whether  the  patient  is  right-handed 
or  left-handed:  (1)  The  power  of  recognizing  the  nature,  uses,  and  relations 
of  objects — i.  e.,  whether  apraxia  is  present  or  not;  (2)  the  power  to  recall 
the  name  of  familiar  objects  seen,  smelled,  or  tasted,  or  of  a  sound  when 
heard,  or  of  an  object  touched;  (3)  the  power  to  understand  spoken  words; 
(4)  the  capability  of  understanding  printed  or  written  language;  (5)  the 
power  of  appreciating  and  understanding  musical  tunes;  (6)  the  power  of 
voluntary  speech — in  this  it  is  to  be  noted  particularly  whether  he  misplaces 
words  or  not;  (7)  the  power  of  reading  aloud  and  of  understanding  what  he 
reads;  (8)  the  power  to  write  voluntarily  and  of  reading  what  he  has  written; 
(9)  the  power  to  copy;  (10)  the  power  to  write  at  dictation;  and  (11)  the 
power  of  repeating  words. 

The  medico-legal  aspects  of  aphasia  are  of  great  importance.  No  general 
principle  can  be  laid  down,  but  each  case  must  be  considered  on  its  merits. 
Langdon,  in  reviewing  the  whole  question,  concludes :  "  Sanity  established, 
any  legal  document  should  be  recognized  when  it  can  be  proved  that  the 
person  making  it  can  understand  fully  its  nature  by  any  receptive  channel 
(viz.,  hearing,  vision,  or  muscular  sense),  and  can,  in  addition,  express  assent 
or  dissent  with  certainty  to  proper  witnesses,  whether  this  expression  be  by 
spoken  speech,  written  speech,  or  pantomime." 

Prognosis  and  Treatment. — In  young  persons  the  outlook  is  good, 
and  the  power  of  speech  is  gradually  restored  apparently  by  the  education 
of  the  centres  on  the  opposite  side  of  the  brain.  In  adults  the  condition  is 
less  hopeful,  particularly  in  the  cases  of  complete  motor  aphasia  with  right 
hemiplegia.  The  patient  may  remain  speechless,  tliough  capable  of  under- 
standing everything,  and  attempts  at  re-education  may  be  futile.  Partial 
recovery  may  occur,  and  the  patient  may  be  able  to  talk,  but  misplaces 
words.     In  sensory  aphasia  the  condition  may  be  only  transient,  and  the 


994  DISEASES  OF  THE  NERVOUS  SYSTEM. 

different  forms  rarely  persist  alone  without  impairment  of  the  powers  of 
expression. 

The  education  of  an  aphasic  person  requires  the  greatest  care  and  pa- 
tience, particularly  if,  as  so  often  happens,  he  is  emotional  and  irritable. 
It  is  best  to  begin  by  the  use  of  detached  letters,  and  advance,  not  too 
rapidly,  to  words  of  only  one  syllable.  Children  often  make  rapid  progress, 
but  in  adults  failure  is  only  too  frequent,  even  after  the  most  painstaking 
efforts.  In  the  cases  of  right  hemiplegia  with  aphasia  the  patient  may  be 
taught  to  write  with  the  left  hand. 


111.    AFFECTIONS    OF   THE    BLOOD-VESSELS. 

1.  HypEE^iriA. 

Congestion  of  the  brain  has  in  the  past  played  an  important  part  in 
cerebral  pathology.  Undoubtedly  there  are  great  variations  in  the  amount 
of  blood  in  the  cerebral  vessels;  this  is  universally  conceded,  but  how  far 
these  changes  are  associated  with  a  definite  group  of  symptoms  is  not  quite 
so  clear.  The  whole  subject  has  recently  been  revised  by  E.  Geigel,  who 
rightly  insists  that  the  nutrition  of  the  nerve-cells  and  the  possibility  of 
interchange  of  gases  between  the  blood  and  the  cerebral  tissues  is  dependent 
not  only  upon  the  amount  of  blood  in  the  cerebral  vessels,  but  also  upon 
its  chemical  constitution,  and  especially,  it  would  appear,  upon  the  velocity 
of  the  current  in  the  cerebral  capillaries.  The  speed  of  the  blood  flow 
in  the  cerebral  capillaries  depends,  according  to  this  writer,  much  more 
on  the  tension  of  the  walls  of  the  vessels  than  upon  the  height  of  the  ar- 
terial pressure.  In  many  of  the  conditions  designated  as  "  cerebral  h}^er- 
semia"  there  is  really  a  condition  of  lowered  pressure,  for  with  flaccidity 
and  widening  of  the  cerebral  arteries,  due  say  to  paralysis  of  the  s}Tnpa- 
thetic,  the  arterial  pressure  remaining  constant,  there  must  follow  as  the 
result  of  the  diminution  of  the  tension  of  the  vessel  walls  a  decrease  in  the 
velocity  of  the  blood-flow.  On  the  other  hand,  spasm  of  the  cerebral 
arteries,  due  say  to  irritation  of  the  s}Tnpathetic,  gives  rise  not  to  "  anae- 
mia "  as  generally  is  supposed,  but  through  increase  of  vascular  tension 
to  a  higher  velocity  of  flow  through  the  cerebral  capillaries.  It  has 
been  customary  to  describe  cerebral  hyperemia  as  being  either  active  or 
passive  (see  also  Leonard  Hill's  article  in  Allbutt's  System). 

Thus  active  JiijpercBmia  has  been  supposed  to  be  associated  with  febrile 
conditions,  with  increased  action  of  the  heart,  chiUing  of  the  surface,  con- 
traction of  the  superficial  vessels,  and  with  the  suppression  of  certain  cus- 
tomary discharges.  Among  other  recognized  causes  are  plethora,  func- 
tional irritation,  such  as  is  associated  with  excessive  brain  work,  and  the 
action  of  certain  substances,  such  as  alcohol  and  nitrite  of  amyl. 

Passive  hypercemia  was  said  to  result  from  obstruction  in  the  cerebral 
sinuses  and  veins,  engorgement  in  the  lesser  circulation,  as  in  mitral  ste- 
nosis, emphysema,  from  pressure  on  the  superior  cava  by  aneurisms  and 
tumors,  and  in  the  venous  engorgement  which  takes  place  in  prolonged 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  995 

straining  efforts.  In  its  most  intense  form  it  is  seen  in  the  compression  of 
the  superior  cava  by  tumors  and  in  death  from  strangulation. 

The  anatomical  changes  in  congestion  of  the  brain  are  by  no  means 
striking.  Such  an  active  hyperaemia  is  never  visible  post  mortem.  The 
veins  of  the  cortex  are  distended,  the  gray  matter  has  a  deeper  color,  and 
its  vessels  are  full.  The  arteries  at  the  base  and  in  the  Sylvian  fissures 
contain  blood.  Nothing,  however,  can  be  more  uncertain  or  indefinite  than 
the  post-mortem  appearances  of  so-called  hyperaemia  of  the  brain.  The 
most  intense  distention  of  the  vessels  is  seen  in  early  death  during  the 
specific  fevers,  or  in  the  secondary  passive  congestion  due  to  obstruction  in 
the  superior  cava  or  in  the  lesser  circulation.  In  a  majority  of  these  cases 
of  so-called  hypersemia,  while  the  total  mass  of  blood  in  the  brain  may  ex- 
ceed the  normal  by  a  considerable  amount,  yet  the  velocity  of  the  current 
is  so  much  less  than  normal,  that  as  a  result  the  brain  really  has  a  smaller 
supply  of  blood  than  is  normal — that  is,  the  patient  actually  suffers  from 
cerebral  "  anaemia  "  rather  than  from  "  hyper^mia.^' 

Symptoms. — There  are  no  characteristic  or  constant  features  of  dila- 
tation of  the  cerebral  blood-vessels.  It  may  exist  in  the  most  extreme  grade 
without  the  slightest  disturbance  of  the  cerebral  functions,  as  is  witnessed 
frequently  in  the  pressure  by  tumors  on  the  superior  vena  cava.  How  far 
the  headache  and  delirium  of  the  early  stage  of  the  infectious  fevers  is  to 
be  assigned  to  dilatation  of  the  blood-vessels  of  the  brain  it  is  not  easy  to 
determine.  The  headache,  dizziness,  and  unpleasant  sensations  in  aortic 
insufficiency  and  in  some  instances  of  hypertrophy  of  the  heart  have  been 
attributed  to  the  cerebral  congestion. 

As  a  separate  clinical  entity,  congestion  of  the  brain  rarely  comes 
under  observation.  I  have  no  knowledge  of  instances  associated  with  de- 
lirium, fever,  insomnia,  and  convulsions,  or  of  the  so-called  apoplectiform 
variety  described  by  some  writers.  Very  plethoric  persons  are  subject  to 
attacks  of  headache  with  flushing  of  the  fac^e  and  irritability  of  temper, 
attacks  which  may  recur  frequently  and  are  sometimes  relieved  by  bleed- 
ing at  the  nose.  These  have  usually  been  attributed  to  congestion  of  the 
brain.  When  the  so-called  passive  hypereemia  reaches  a  high  grade,  there 
may  be  torpor,  dulness  of  the  intellect,  and  ultimately  deep  coma. 

Leube  suggests  that  the  symptoms  usually  referred  to  active  hyperaemia 
in  the  acute  infectious  diseases,  like  diphtheria  and  erysipelas,  or  in  the 
instances  in  which  hypertrophy  of  the  heart  accompanies  disease  of  the 
kidneys,  may  after  all  be  toxic  in  origin,  rather  than  due  to  alteration  in 
the  circulatory  relations.  At  any  rate,  he  believes  that  it  is  not  possible 
to  make  a  diagnosis  of  such  a  hypersemia.  Flushing  of  the  face  is  by  no 
means  a  safe  guide.  Possibly  an  examination  of  the  eye-grounds  may  be 
helpful. 

2.  Anemia. 

This  may  be  induced  by  loss  of  blood,  either  quickly,  as  in  haemor- 
rhage, or  gradually,  as  in  the  severe  primary  and  secondary  anaemias. 
The  anaemia  may  be  local  and  due  to  causes  which  interfere  with  the  blood 
supply  to  the  brain,  as  narrowing  of  the  vessels  by  endarteritis,  pressure. 


996  DISEASES  OF  THE  NERVOUS  SYSTEM. 

narrowing  of  the  aortic  orifice,  or  it  may  follow  an  unequal  distribution 
of  the  blood  in  consequence  of  dilatation  of  certain  vascular  territories. 
Thus,  rapid  distention  of  the  intestinal  vessels,  such  as  occurs  after  the 
removal  of  ascitic  fluid,  may  cause  sudden  death  from  cerebral  ansemia. 
The  commonest  illustration  of  this  is  the  fainting  fit  from  emotion,  in 
which  the  blood  supply  to  the  brain  is  insufficient  on  account  of  the  dimin- 
ished arterial  pressure.  Angemia  of  the  cerebral  vessels  may  be  caused 
by  pressure  of  fluid  in  the  ventricles.  The  partial  anasmia  results  from 
obliteration  of  branches  of  the  circle  of  Willis  by  embolism  or  thrombosis. 
Ligature  of  one  carotid  sometimes  causes  a  transient  marked  anaemia  and 
disturbance  of  function  on  one  side  of  the  brain. 

The  anatomical  condition  of  the  brain  in  ansemia  is  very  striking. 
The  membranes  are  pale,  only  the  large  veins  are  full,  the  small  vessels 
over  the  g}Ti  are  empty,  and  an  unusual  amount  of  cerebro-spinal  fluid  is 
present.  On  section  both  the  gray  and  white  matter  look  extremely  pale 
and  the  cut  surface  is  moist.     Yery  few  puncta  vasculosa  are  seen. 

Symptoms. — The  eflects  of  angemia  of  the  brain  are  well  illustrated 
by  a  fainting  fit  in  which  loss  of  consciousness  follows  the  heart  weakness. 
When  the  result  of  hemorrhage,  there  are  drowsiness,  giddiness,  inability 
to  stand,  flashes  of  light,  dark  spots  before  the  eyes,  and  noises  in  the  ears; 
the  respiration  becomes  hurried;  the  skin  is  cool  and  covered  with  sweat; 
the  pupils  are  dilated,  there  may  be  vomiting,  headache,  or  delirium,  and 
gradually,  if  the  bleeding  continues,  consciousness  is  lost  and  death  may 
occur  with  convulsions.  In  ordinary  syncope  the  loss  of  consciousness  is 
usually  transient  and  the  recumbent  posture  alone  may  suffice  to  restore 
the  patient  to  consciousness.  In  the  more  chronic  forms  of  brain  ansemia, 
such  as  result  from  the  gradual  impoverishment  of  the  blood,  as  in  pro- 
tracted illness  or  in  starvation,  the  condition  known  as  irritable  weakness 
results.  Mental  effort  is  difficult,  the  slightest  irritation  is  followed  by 
undue  excitement,  the  patient  complains  of  giddiness  and  noises  in  the 
ears,  or  there  may  be  hallucinations  or  delirium.  These  symptoms  are  met 
with  in  an  extreme  grade  as  a  result  of  prolonged  starvation. 

These  symptoms  are  indistinguishable  from  those  due  to  the  so-called 
cerebral  hyperaemia.  The  quality  of  the  blood  is  deteriorated  and  the 
velocity  of  the  blood-flow  is  diminished,  so  that  the  cerebral  nutrition  is 
interfered  with.  It  is  interesting  to  note  that  lack  of  suitable  nutrition 
gives  rise  to  phenomena  of  increased  irritability  in  certain  of  the  cerebral 
centres,  at  least  for  a  time. 

An  interesting  set  of  symptoms,  to  which  the  term  hjdrenceplialoid 
was  applied  by  Marshall  Hall,  occurs  in  the  debility  produced  by  prolonged 
diarrhoea  in  children.  The  child  is  in  a  semi-comatose  condition  with  the 
eyes  open,  the  pupils  contracted,  and  the  fontanelle  depressed.  In  the 
earlier  period  there  may  be  convulsions.  The  coma  may  gradually  deepen, 
the  pupils  become  dilated,  and  there  may  be  strabismus  and  even  retraction 
of  the  head,  symptoms  which  closely  simulate  those  of  basilar  meningitis. 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  997 

3.  (Edema  of  the  Beain. 

In  the  pathology  of  brain  lesions  oedema  formerly  played  a  role  almost 
equal  in  importance  to  congestion.  It  occurs  under  the  following  condi- 
tions: In  general  atrophy  of  the  convolutions,  in  which  case  the  oedema 
is  represented  by  an  increase  in  the  cerebro-spinal  fluid  and  in  that  of  the 
meshes  of  the  pia.  In  extreme  venous  dilatation  from  obstruction,  as  in 
mitral  stenosis  or  in  tumors,  there  may  be  a  condition  of  congestive  oedema, 
in  which,  in  addition  to  great  filling  of  the  blood-vessels,  the  substance  of 
the  brain  itself  is  unusually  moist.  The  most  acute  oedema  is  a  local  pro- 
cess found  around  tumors  and  abscesses.  An  intense  infiltration,  local  or 
general,  may  occur  in  Bright's  disease,  and  to  it,  as  Traube  suggested,  cer- 
tain of  the  ursemic  symptoms  may  be  due. 

The  anatomical  changes  are  not  unlike  those  of  anaemia.  When  the 
oedema  follows  progressive  atrophy,  the  fluid  is  chiefly  within  and  beneath 
the  membranes.  The  brain  substance  is  anasmic  and  moist,  and  has  a  wet, 
glistening  appearance,  which  is  very  characteristic.  In  some  instances  the 
cedema  is  more  intense  and  local  and  the  brain  substance  may  look  infil- 
trated with  fluid.  The  amount  of  fluid  in  the  ventricles  is  usually  in- 
creased. 

The  symptoms  are  in  great  part  those  of  lessened  blood-flow,  and  are 
not  well  defined.  As  just  stated,  some  of  the  cerebral  features  of  urasmia 
may  depend  upon  it.  Of  late  years  cases  have  been  reported  by  Eaymond, 
Tenneson,  and  Dercum,  in  which  unilateral  convulsions  or  paralysis  have 
occurred  in  connection  with  chronic  Bright's  disease,  and  in  which  the 
condition  appeared  to  be  associated  with  cedema  of  the  brain.  The  older 
writers  laid  great  stress  upon  an  apoplexia  serosa,  which  may  really  have 
been  a  general  cedema  of  the  brain.  Inasmuch  as  the  instances  in  which 
cedema  of  the  brain  occurs  are  often  those  in  which  there  is  also  intoxication, 
or  angemia,  or  both,  it  is  probably  impossible  to  say  at  the  bedside  definitely 
which  of  these  possible  factors  is  responsible  for  the  symptoms  in  a  given 
case. 

4.  Cerebkal  H^moerhage. 

The  bleeding  may  come  from  branches  of  either  of  the  two  great 
groups  of  cerebral  vessels — the  hasal,  comprising  the  circle  of  Willis  and 
the  central  arteries  passing  from  it  and  from  the  first  portion  of  the  cere- 
bral arteries,  or  the  cortical  group,  the  anterior,  middle,  and  the  posterior 
cerebral  vessels.  In  a  majority  of  the  cases  the  haimorrhage  is  from  the 
central  branches,  more  particularly  from  those  given  off  by  the  middle 
cerebral  arteries  in  the  anterior  perforated  spaces,  and  which  supply  the 
corpora  striata  and  internal  capsules.  One  of  the  largest  of  these  branches 
which  passes  to  the  third  division  of  the  lenticular  nucleus  and  to  the  an- 
terior part  of  the  internal  capsule,  the  lenticulo-striate  artery  of  Buret,  is  so 
frequently  involved  in  hemorrhage  that  it  has  been  called  by  Charcot  the 
artery  of  cerebral  hccinorrhage.  Haemorrhages  from  this  and  from  the  len- 
ticulo-thalamic  artery  include  more  than  GO  per  cent  of  all  cerebral  hemor- 
rhages.    The  bleeding  may  be  into  the  substance  of  the  brain,  to  which 


998  DISEASES  OP  THE  NERVOUS  SYSTEM. 

alone  the  term  cerebral  apoplexy  is  applied,  or  into  the  membranes,  in  which 
case  it  is  termed  meningeal  hgemorrhage;  both,  however,  are  usually  in- 
cluded under  the  terms  intracranial  or  cerebral  hgemorrhage. 

Etiology. — The  conditions  which  produce  lesions  of  the  blood-ves- 
sels play  a  very  important  part;  thus  the  natural  tendency  to  degeneration 
of  the  vessels  in  advanced  life  makes  apoplexy  much  more  common  after 
the  fiftieth  year.  It  may,  however,  occur  in  children  under  ten.  On  ac- 
count of  the  greater  liability  to  arterial  disease  (associated  probably  with 
muscular  exertion  and  the  abuse  of  alcohol);  men  are  more  subject  to  cere- 
bral hgemorrhage  than  women.  Heredity  was  formerly  thought  to  be  an 
important  factor  in  this  affection,  and  the  apoplectic  habitus  or  build  is 
still  referred  to.  By  this  is  meant  a  stout  plethoric  body  of  medium  size, 
with  a  short  neck.  Heredity  influences  cerebral  haemorrhage  entirely 
through  the  arteries,  and  there  are  families  in  which  these  degenerate  early, 
usually  in  association  with  renal  changes.  The  secondary  hypertrophy  of 
the  heart  brings  with  it  serious  dangers,  which  have  already  been  discussed 
in  the  section  upon  arteries.  The  special  factors  in  inducing  arterio- 
sclerosis— the  abuse  of  alcohol,  immoderate  eating,  syphilis,  and  prolonged 
muscular  exertion — are  found  to  be  important  antecedents  in  a  large  num- 
ber of  cases  of  cerebral  haemorrhage.  Chronic  lead  poisoning  and  gout 
also  may  here  be  mentioned. 

The  endocarditis  of  rheumatism  and  other  fevers  may  indirectly  lead 
to  apoplexy  by  causing  embolism  and  aneurism  of  the  vessels  of  the  brain. 
Cerebral  haemorrhage  occurs  occasionally  in  the  specific  fevers  and  in  pro- 
found alterations  of  the  blood,  as  in  leuksemia  and  pernicious  anaemia. 
The  actual  exciting  cause  of  the  haemorrhage  is  not  evident  in  the  majority 
of  cases.  The  attack  may  be  sudden  and  without  any  preliminary  sj^mp- 
toms.  In  other  instances  violent  exertion,  particularly  straining  efforts,  or 
the  excited  action  of  the  heart  in  emotion  may  cause  a  rupture. 

Morbid  Anatomy. — The  lesions  causing  apoplexy  are  almost  in- 
variably in  the  cerebral  arteries,  in  which  the  following  changes  may  lead 
directly  to  it: 

(a)  The  production  of  miliary  aneurisms,  rupture  of  which  is  the  most 
common  cause  of  cerebral  haemorrhage.  The  origin  of  the  miliary  aneu- 
risms is  disputed.  Charcot  thought  they  resulted  from  changes  in  the 
adventitia  (periarteritis).  Others,  with  Eichler,  Ziegler,  and  Birch-Hirsch- 
feld,  find  the  primary  change  in  the  intima.  The  weight  of  opinion  at 
present,  however,  is  on  the  side  of  the  view  that  the  media  is  first  degen- 
erated (Roth,  Loewenthal).  They  occur  most  frequently  on  the  central 
arteries,  but  also  on  the  smaller  branches  of  the  cortical  vessels.  On  sec- 
tion of  the  brain  substance  they  may  be  seen  as  localized,  small  dark  bodies, 
about  the  size  of  a  pin's  head.  Sometimes  they  are  seen  in  numbers  upon 
the  arteries  when  carefully  withdrawn  from  the  anterior  perforated  spaces. 
According  to  Charcot  and  Bouchard,  who  have  described  them,  they  are 
most  frequent  in  the  central  ganglia.  In  apoplexy  after  the  fortieth  year  if 
sought  for  they  are  rarely  missed.  The  actual  miliary  aneurism,  which 
by  its  rupture  has  occasioned  the  hemorrhage,  may  be  difficult  to  find, 
but  if  one  pours  water  carefully  on  the  area  of  haemorrhage,  or,  better 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  999 

still,  submerges  the  apoplectic  mass  for  a  time,  it  will  usuall}'  be  found 
possible  to  do  so,  and  even  to  find  the  hole  in  its  wall. 

{]))  Aneurism  of  the  branches  of  the  circle  of  Willis.  These  are  by 
no  means  uncommon,  and  will  be  considered  subsequently. 

(c)  Endarteritis  and  periarteritis  in  the  cerebral  vessels  most  commonly 
lead  to  apoplexy  by  the  production  of  aneurisms,  either  miliary  or  coarse. 
There  are  instances  in  which  the  most  careful  search  fails  to  reveal  any- 
thing but  diffuse  degeneration  of  the  cerebral  vessels,  particularly  of  the 
smaller  branches;  so*  that  we  must  conclude  that  spontaneous  rupture  may 
occur  without  the  previous  formation  of  aneurism. 

(d)  Increased  permeability  of  the  v/alls  of  the  vessels  may  account  for 
haemorrhages  by  diapedesis  without  actual  rupture.  Such  haemorrhages 
are  not  uncommon  in  cases  of  contracted  kidney,  grave  anemia,  and  various 
infections  and  intoxications. 

The  hemorrhage  may  be  meningeal,  cerebral,  or  intraventricular. 

Meningeal  hcemorrJiage  may  be  outside  the  dura,  between  this  membrane 
and  the  bone,  or  between  the  dura  and  arachnoid,  or  between  the  arach- 
noid and  the  pia  mater.  The  following  are  the  chief  causes  of  this  form 
of  haemorrhage:  Fracture  of  the  skull,  in  which  case  the  blood  usually 
comes  from  the  lacerated  meningeal  vessels,  sometimes  from  the  torn  si- 
nuses. In  these  cases  the  blood  is  usually  outside  the  dura  or  between  it 
and  the  arachnoid.  The  next  most  frequent  cause  is  rupture  of  aneurisms 
on  the  larger  cerebral  vessels.  The  blood  is  usually  subarachnoid.  An 
intracerebral  haemorrhage  may  burst  into  the  meninges.  A  special  form 
of  meningeal  haemorrhage  is  found  in  the  new-born,  associated  with  injury 
during  birth.  And  lastly,  meningeal  hemorrhage  may  occur  in  the  con- 
stitutional diseases  and  fevers.  The  blood  may  be  in  a  large  quantity  at 
the  base;  in  cases  of  ruptured  aneurism,  particularly,  it  may  extend  into 
the  cord  or  upon  the  cortex.  Owing  to  the  greater  frequency  of  the  aneu- 
risms in  the  middle  cerebral  vessels,  the  Sylvian  fissures  are  often  distended 
with  blood. 

Intracerehral  Jicemorrhage  is  most  frequent  in  the  neighborhood  of  the 
corpus  striatum,  particularly  toward  the  outer  section  of  the  lenticular 
nucleus.  The  haemorrhage  may  be  small  and  limited  to  the  lenticular 
body,  the  thalamus,  and  the  internal  capsule,  or  it  may  extend  into  the 
centrum  semi-ovale,  or  burst  into  the  lateral  ventricle,  or  extend  to  the 
insula.  Haemorrhages  confined  to  the  white  matter — the  centrum  semi- 
ovale — are  rare.  Localized  bleeding  may  occur  in  the  crura  or  in  the  pons. 
Haemorrhage  into  the  cerebellum  is  not  uncommon,  and  usually  comes 
from  the  superior  cerebellar  ..artery .  The  extravasation  may  be  limited  to 
the  substance  or  rupture  int(^  the  fourth  ventricle.  Twice  I  have  known 
sudden  death  in  girls  under  twenty-five  to  be  due  to  cerebellar  haemorrhage. 

Ventricular  Tlcemorrkage. — This  occasionally  but  rarely  is  primary,  com- 
ing from  the  vessels  of  the  plexuses  or  of  the  walls.  More  often  it  is  sec- 
ondary, following  Haemorrhage  into  the  cerebral  substance.  It  is  not  in- 
frequent in  early  life  and  may  occur  during  birth.  Of  94  cases  collected 
by  Edward  Sanders,  7  occurred  during  the  first  year,  and  14  under  the 
twentieth  year.     In  the  cases  which  I  have  seen  in  adults  it  has  almost 


1000  DISEASES  OF  THE  NERVOUS  SYSTEM. 

always  been  caused  by  rupture  of  a  vessel  in  the  neighborhood  of  the  cau- 
date nucleus.  The  blood  may  be  found  in  one  ventricle  only,  but  more 
commonly  it  is  in  both  lateral  ventricles,  and  may  pass  into  the  third  ven- 
tricle and  through  the  aqueduct  of  Sylvius  into  the  fourth  ventricle,  form- 
ing a  complete  mould  in  blood  of  the  ventricular  system.  In  these  cases 
the  clinical  picture  may  be  that  of  "  apoplexie  foudroyante." 

Subsequent  Changes. — The  blood  gradually  changes  in  color,  and  ulti- 
mately the  hemoglobin  is  converted  into  the  reddish-brown  hgematoidin. 
Inflammation  occurs  about  the  apoplectic  area,  limiting  and  confining  it, 
and  ultimately  a  definite  wall  may  be  produced,  inclosing  a  cyst  with  fluid 
contents.  In  other  instances  a  cyst  is  not  formed,  but  the  connective  tissue 
proliferates  and  leaves  a  pigmented  scar.  In  meningeal  hemorrhage  the 
eflused  blood  may  be  gradually  absorbed  and  leave  only  a  staining  of  the 
membranes.  In  other  eases,  particularly  in  infants,  when  the  effusion  is 
cortical  and  abundant,  there  may  be  localized  wasting  of  the  convolutions 
and  the  production  of  a  cyst  in  the  meninges.  Possibly  certain  of  the 
cases  of  porencephaly  are  caused  in  this  way. 

Secondary  degeneration  follows,  varying  in  character  according  to  the 
location  of  the  haemorrhage  and  the  actual  damage  done  by  it  to  nerve  cells 
or  their  medullated  axones.  Thus,  in  persons  dying  some  years  after  a 
cerebral  apoplexy  which  has  produced  hemiplegia  (lesion  of  the  motor  area 
in  the  cortex  or  of  the  p}Tamidal  tract  leading  from  it),  the  degeneration 
may  be  traced  through  the  cerebral  peduncle,  the  ventral  part  of  the  pons, 
the  p}Tamids  of  the  medulla,  the  fibres  of  the  direct  pyramidal  tract  of 
the  cord  of  the  same  side,  and  the  fibres  of  the  crossed  pyramidal  tract  on 
the  opposite  side.  After  hsemorrhages  in  the  middle  and  inferior  frontal 
gyri  there  follows  degeneration  of  the  frontal  cerebro-cortico-pontal  path, 
going  through  the  anterior  limb  of  the  internal  capsule  and  the  medial 
portion  of  the  basis  pedunculi  to  the  nuclei  pontis;  also  degeneration  of  the 
fibres  connecting  the  nucleus  medialis  thalami,  and  the  anterior  part  of  the 
nucleus  lateralis  thalami  with  the  cortex  (Flechsig,  v.  Monakow). 

When  the  temporal  gjTi  or  their  white  matter  are  destroyed  by  a  hsem- 
orrhage  the  lateral  segment  of  the  basis  pedunculi  degenerates  (Dejerine). 
Cerebellar  hasmorrhage,  especially  if  it  injure  the  nucleus  dentatus,  may 
lead  to  degeneration  of  the  brachium  conjunctivum. 

There  may  be  slow  degeneration  in  tbe  lemniscus  medialis,  extending  as 
far  as  the  nuclei  on  the  opposite  side  of  the  medulla  oblongata,  after  hemor- 
rhages in  the  central  gyri,  hypothalamic  region,  or  dorsal  part  of  the  pons. 
Haemorrhages  destroying  the  occipital  cortex,  or  subcortical  hemorrhages 
injuring  the  optic  radiations,  occasion  slow  degeneration  (cellulipetal)  of  the 
radiations  from  the  lateral  geniculate  body,  and  after  a  time  cause  marked 
atrophy  or  even  disappearance  of  its  ganglion  cells. 

S3n2iptonis. — These  may  be  divided  into  primary,  or  those  corLaected 
with  the  onset,  and  secondary,  or  those  which  develop  later  after  the  early 
manifestations  have  passed  away. 

Primary  Symptoms. — Premonitory  indications  are  rare.  As  a  rule,  the 
patient  is  seized  while  in  full  health  or  about  the  performance  of  some 
every-day  action,  occasionally  an  action  requiring  strain  or  extra  exertion. 


AFFECTIONS  OF  THE   BLOOD-VESSELS.  lOOl 

IsTow  and  then  instances  are  found  in  wliich  there  are  sensations  of  numb- 
ness or  tingling  or  pains  in  the  limbs,  or  even  choreiform  movements  in  the 
muscles  of  the  opposite  side,  the  so-called  prehemiplegic  chorea.  In  other 
cases  temporary  disturbances  of  vision  and  of  associated  movements  of  the 
eye-muscles  have  been  noted,  but  none  of  the  prodromata  of  apoplexy  (the 
so-called  "  warnings  ")  are  characteristic.  The  onset  of  the  apoplexy,  as  the 
symptoms  of  cerebral  haemorrhage  are  usually  called,  varies  greatly.  There 
may  be  sudden  loss  of  consciousness  and  complete  relaxation  of  the  extremi- 
ties. In  such  instances  the  name  apoplectic  stroke  is  particularly  appropriate. 
In  other  cases  the  onset  is  more  gradual  and  the  loss  of  consciousness  may 
not  occur  for  a  few  minutes  after  the  patient  has  fallen,  or  after  the  paraly- 
sis of  the  limbs  is  manifest.  In  the  typical  apoplectic  attack  the  condition 
is  as  follows:  There  is  deep  unconsciousness;  the  patient  can  not  be  roused. 
The  face  is  injected,  sometimes  cyanotic,  or  of  an  ashen-gray  hue.  The  pu- 
pils vary;  usually  they  are  dilated,  sometimes  unequal,  and  always,  in  deep 
coma,  inactive.  If  the  haemorrhage  be  so  located  that  it  can  irritate  the 
nucleus  of  the  third  nerve  the  pupils  are  contracted  (haemorrhages  into  the 
pons  or  ventricles).  The  respirations  are  slow,  noisy,  and  accompanied 
with  stertor.  Sometimes  the  Cheyne-Stokes  rhythm  may  be  present.  The 
chest  movements  on  the  paralyzed  side  may  be  restricted,  in  rare  instances 
on  the  opposite  side.  The  cheeks  are  often  blown  out  during  expiration, 
with  spluttering  of  the  lips.  The  pulse  is  usually  full,  slow,  and  of  in- 
creased tension.  The  temperature  may  be  normal,  but  is  often  found  sub- 
normal, and,  as  in  a  case  reported  by  Bastian,  may  sink  below  95°.  In 
cases  of  basal  hasmorrhage  the  temperature,  on  the  other  hand,  may  be  high. 
The  urine  and  faeces  are  usually  passed  involuntarily.  Convulsions  are  not 
common.  It  may  be  difficult  to  decide  whether  the  condition  is  apoplexy 
associated  with  hemiplegia  or  sudden  coma  from  other  causes.  An  indica- 
tion of  hemiplegia  may  be  discovered  in  the  difference  in  the  tonus  of  the 
muscles  on  the  two  sides.  If  the  arm  or  the  leg  is  lifted,  it  drops  "  dead  " 
on  the  affected  side,  while  on  the  other  it  falls  more  slowly.  Eigidity  also 
may  be  present.  In  watching  the  movements  of  the  facial  muscles  in  the 
stertorous  respiration  it  will  be  seen  that  on  the  paralyzed  side  the  relaxa- 
tion permits  the  cheek  to  be  blown  out  in  a  more  marked  manner.  The 
head  and  eyes  may  be  turned  strongly  to  one  side — conjugate  deviation.  In 
such  an  event  the  turning  is  toward  the  side  of  the  hemorrhage. 

In  other  cases,  in  which  the  onset  is  not  so  abrupt,  the  patient  may  not 
lose  consciousness,  but  in  the  course  of  a  few  hours  there  is  loss  of  power, 
unconsciousness  gradually  develops,  and  deepens  into  profound  coma.  This 
is  sometimes  termed  ingravescent  apoplexy.  The  attack  may  occur  during 
sleep.  The  patient  may  be  found  unconscious,  or  wakes  to  find  that  the 
power  is  lost  on  one  side.  Small  haemorrhages  in  the  territory  of  the  cen- 
tral arteries  may  cause  hemiplegia  without  loss  of  consciousness. 

Usually  within  forty-eight  hours  after  the  onset  of  an  attack,  some- 
times within  from  two  to  six  hours,  there  is  febrile  reaction,  and  more  or 
less  constitutional  disturbance  associated  with  infiammatory  changes  about 
the  hfemorrhage  and  absorption  of  the  blood.  The  period  of  inflammatory 
reaction  may  continue  for  from  one  week  to  two  months.  The  patient  may 
63 


1Q02  DISEASES  OP  THE  NERVOUS  SYSTEM. 

die  in  this  reaction,  or,  if  consciousness  has  been  regained,  there  may  be 
delirinm  or  recurrence  of  the  coma.  At  this  period  the  so-called  early 
rigidity  may  develop  in  the  paralyzed  limbs.  The  so-called  trophic  changes 
may  occur,  such  as  sloughing  or  the  formation  of  vesicles.  The  most 
serious  of  these  is  the  sloughing  eschar  of  the  lower  part  of  the  back,  or  on 
the  paralyzed  side,  which  may  appear  within  forty-eight  hours  of  the  onset 
and  is  usually  of  grave  significance.  The  congestion  at  the  bases  of  the 
lungs  so  common  in  apoplexy  is  regarded  by  some  as  a  trophic  change. 

Conjugate  Deviation. — In  a  right  hemiplegia  the  eyes  and  head  may 
be  turned  to  the  left  side;  that  is  to  say,  the  eyes  look  toward  the  cerebral 
lesion.  This  is  almost  the  rule  in  the  conjugate  deviation  of  the  head  and 
eyes  which  occurs  early  in  hemiplegia.  When,  however,  convulsions  or 
spasm  develop  or  the  state  of  so-called  early  rigidity  in  hemiplegia,  the 
conjugate  deviation  of  the  head  and  eyes  may  be  in  the  opposite  direction; 
that  is  to  say,  the  eyes  look  away  from  the  lesion  and  the  head  is  rotated 
toward  the  convulsed  side.  This  symptom  may  be  associated  with  cortical 
lesions,  particularly,  according  to  some  authors,  when  in  the  neighbor- 
hood of  the  supramarginal  and  angular  gyri.  It  may  also  occur  in  a  lesion 
of  the  internal  capsule  or  in  the  pons,  but  in  the  latter  situation  the  con- 
jugate deviation  is  the  reverse  of  that  which  occurs  in  other  cases,  as  the 
patient  looks  away  from  the  lesion,  and  in  spasm  or  convulsion  looks  toward 
the  lesion. 

Hemiplegia. — In  cases  in  which  consciousness  is  restored  and  the  pa- 
tient improves,  a  unilateral  paralysis  may  persist  due  to  the  destruc- 
tion of  the  motor  area  or  the  pyramidal  tract  in  any  part  of  its  course. 
Hemiplegia  is  complete  when  it  involves  face,  arm,  and  leg,  or  partial 
when  it  involves  only  one  or  other  of  these  parts.  This  may  be  the 
result  of  a  lesion  (a)  of  the  motor  cortex;  (b)  of  the  pyramidal  fibres 
in  the  corona  radiata  and  in  the  internal  capsule;  (c)  of  a  lesion  in  the 
cerebral  peduncle;  or  (d)  in  the  pons  Varolii.  The  situation  of  the  lesions 
and  their  effects  are  given  in  Fig.  10.  Hasmorrhage  is  perhaps  the  most 
common  cause,  but  tumors  and  spots  of  softening  may  also  induce  it.  The 
special  details  of  the  hemiplegia  may  here  be  considered.  The  face  (except 
in  lesions  in  the  lower  part  of  the  pons)  is  involved  on  the  same  side  as  the 
arm  and  leg.  This  results  from  the  fact  that  the  facial  muscles  stand  in 
precisely  the  same  relation  to  the  cortical  centres  as  those  of  the  arm  and 
leg,  the  fibres  of  the  upper  motor  segment  of  the  facial  nerve  from  the 
cortex  decussating  just  as  do  those  of  the  nerves  of  the  limbs.  The  facial 
paralysis  is  partial,  involving  only  the  lower  portion  of  the  nerve,  so  that 
the  orbicularis  oculi  and  the  frontalis  muscles  are  uninvolved.  The  signs 
of  the  facial  paralysis  are  usually  well  marked.  There  may  be  a  slight  diffi- 
culty in  elevating  the  eyebrows  or  in  closing  the  eye  on  the  paralyzed  side, 
or  in  rare  cases  the  facial  paralysis  is  complete,  but  the  movements  may  be 
present  with  emotion,  as  laughing  or  crying.  The  hypoglossal  nerve  also 
is  involved.  In  consequence,  the  patient  cannot  put  out  the  tongue 
straight,  but  it  deviates  toward  the  paralyzed  side,  inasmuch  as  the  genio- 
hyo-glossus  of  the  sound  side  is  unopposed.  With  right  hemiplegia  there 
may  be  aphasia.  Even  without  marked  aphasia  difficulty  in  speaking 
and  slowness  are  common. 


AFFECTIONS  OF  THE  BLOOD-VESSELS. 


1003 


Pig.  10.— Diagram  of  motor  path  from  right  brain.  The  upper  segment  is  black,  the 
lower  red.  The  nuclei  of  the  motor  cerebral  nerves  are  shown  on  the  left  side ;  on 
the  right  side  the  cerebral  nerves  of  that  side  are  indicated.  A  lesion  at  1  would 
cause  upper  segment  paralysis  in  the  arm  of  the  'opposite  side — cerebral  mono- 
plegia; at  2,  upper  segment  paralysis  of  the  whole  opposite  side  of  the  body — 
hemiplegia ;  at  3  (in  the  crus),  upper  segment  paralysis  of  the  opposite  face,  arm  and 
leg,  and  lower  segment  paralysis  of  the  eye  muscles  on  the  same  side — crossed  paraly- 
sis ;  at  4  (in  the  lower  part  of  the  pons),  upper  segment  paralysis  of  the  opposite  arm 
and  leg,  and  lower  segment  paralysis  of  the  face  and  the  external  rectus  oji  the  same 
side— crossed  paralysis ;  at  5,  upper  segment  paralysis  of  all  muscles  represented  be- 
low lesion,  and  lower  segment  paralysis  of  muscles  represented  at  level  of  lesion — 
spinal  paraplegia  ;  at  6,  lower  segment  paralysis  of  muscles  localized  at  seat  of  lesion 
— anterior  poliomyelitis.     (Van  Gehuchten,  modified.) 


1004  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  arm  is^  as  a  rule,  more  completely  paralyzed  than  the  leg.  The 
loss  of  230wer  may  be  absolute  or  partial.  In  severe  cases  it  is  at  first  com- 
plete. In  others,  when  the  paralysis  in  the  face  and  arm  is  complete 
that  of  the  leg  is  only  partial.  The  face  and  arm  may  alone  be  paralyzed, 
while  the  leg  escapes.  Less  commonly  the  leg  is  more  affected  than  the 
arm,  and  the  face  may  be  only  slightly  involved. 

Certain  muscles  escape  in  hemiplegia,  particularly  those  associated  in 
symmetrical  movements,  as  those  of  the  thorax  and  abdomen,  a  fact  which 
Broadbent  explains  by  supposing  that  as  the  spinal  nuclei  controlling  these 
movements  on  both  sides  constantly  act  together,  they  ma}',  by  means  of 
this  intimate  connection,  be  stimulated  by  impulses  coming  from  only  one 
side  of  the  brain.  The  degree  of  permanent  paralysis  after  a  hemiplegic 
attack  varies  much  in  different  cases.  When  the  restitution  is  partial,  it  is 
always,  as  Wernicke  has  pointed  out,  certain  groups  of  muscles  which  re- 
cover rather  than  others.  Thus  in  the  leg  the  residual  paralysis  concerns 
the  flexors  of  the  leg  and  the  dorsal  flexors  of  the  foot — i.  e.,  the  muscles 
which,  according  to  Ludwig  Mann,  are  active  in  the  second  period  of  walk- 
ing, shortening  the  leg,  and  bringing  it  forward  while  it  swings.  The  mus- 
cles which  lift  the  body  when  the  foot  rests  upon  the  ground,  those  used  in 
the  first  period  of  walking,  include  the  extensors  of  the  leg  and  the  plantar 
flexors  of  the  foot.  These  "  lengtheners  "  of  the  leg  often  recover  almost 
completely  in  cases  in  which  the  paralysis  is  due  to  lesions  of  the  pyramidal 
tract.  In  the  arms  the  residual  paralysis  usually  affects  the  muscle  groups 
which  oppose  the  thumb,  those  which  rotate  the  arm  outward,  and  the  open- 
ers of  the  hand. 

As  a  rule,  there  is  at  first  no  wasting  of  the  paralyzed  limbs. 

Crossed  Hemiplegia. — A  paralysis  in  which  there  is  loss  of  function  in 
a  cerebral  nerve  on  one  side  with  loss  of  power  (or  of  sensation)  on  the  oppo- 
site side  of  the  body  is  called  a  crossed  or  alternate  hemiplegia.  It  is  met 
with  in  lesions,  commonly  hgemorrhage,  in  the  crus,  the  pons,  and  the  me- 
dulla (rig.  10,  3  and  4). 

(a)  Crus. — The  bleeding  may  extend  from  vessels  supplying  the  corpus 
striatum,  internal  capsule,  and  optic  thalamus,  or  the  hemorrhage  may  be 
primarily  in  the  crus.  In  the  classical  case  of  Weber,  on  section  of  the 
lower  part  of  the  left  crus  an  oblong  clot  15  mm.  in  length  lay  Just  below 
the  medial  and  inferior  surface.  The  characteristic  features  of  a  lesion 
in  this  locality  are  paralysis  of  arm,  face,  and  leg  of  the  opposite  side,  and 
oculo-motor  paralysis  of  the  same  side — the  syndrome  of  Weber.  Sensory 
changes  have  also  been  present.  Haemorrhage  into  the  tegmentum  is 
not  necessarily  associated  with  hemiplegia,  but  there  may  be  incomplete 
paralysis  of  the  oculo-motor  nerve,  with  disturbance  of  sensation  and  ataxia 
on  the  opposite  side  of  the  body.  The  optic  tract  or  the  lateral  geniculate 
body  lying  on  the  lateral  side  of  the  crus  may  be  compressed,  in  which 
event  there  will  be  hemianopsia. 

(&)  Pons  and  Medulla. — Lesions  may  involve  the  pyramidal  tract  and 
one  or  more  of  the  cerebral  nerves.  If  at  the  lower  aspect  of  the  pons,  the 
facial  nerve  may  be  involved,  causing  paralysis  of  the  face  on  the  same 
side  and  hemiplegia  on  the  opposite  side.     The  fifth  nerve  may  be  involved. 


AFFECTIONS  OF   THE   BLOOD-VESSELS.  1005 

with  the  fillet  (the  sensory  tract),  causing  loss  of  sensation  in  the  area  of 
distribution  of  the  fifth  on  the  same  side  as  the  lesion  and  loss  of  sensation 
on  the  opposite  side  of  the  body. 

Sensory  Disturbances  resulting  from  Cerebral  Hcemorrhage. — These  are 
variable.  Hemianajsthesia  may  coexist  with  hemiplegia,  but  in  many  in- 
stances there  is  only  slight  numbing  of  sensation.  When  the  hemianses- 
thesia  is  marked,  it  is  usually  the  result  of  a  lesion  in  the  internal  capsule 
involving  the  retrolenticular  portion  of  the  posterior  limb.  In  C.  L. 
Dana's  study  of  sensory  localization  he  found  that  anaesthesia  of  organic 
cortical  origin  was  always  limited  or  more  pronounced  in  certain  parts,  as 
the  face,  arm,  or  leg,  and  was  generally  incomplete.  Total  anassthesia  was 
either  of  functional  or  subcortical  origin.  Marked  anaesthesia  was  much 
more  common  in  softening  than  in  hsemorrhage.  Complete  hemianses- 
thesia  is  certainly  rare  in  hgemorrhage.  Disturbance  of  the  special  senses 
is  not  common.  Hemianopia  may  exist  on  the  same  side  as  the  paralysis, 
and  there  may  be  diminution  in  the  acuteness  of  the  senses  of  hearing, 
taste,  and  smell.  Gowers  thinks  that  homonymous  hemianopia  of  the 
halves  of  the  visual  fields  apposite  to  the  lesion  is  very  frequent  shortly 
after  the  onset,  though  often  overlooked. 

Psychic  disturbances,  variable  in  nature  and  degree,  may  result  from 
cerebral  hsemorrhage. 

The  Reflexes  in  Apoplectic  Cases. — During  the  apoplectic  coma  all  the 
reflexes  are  abolished,  but  immediately  on  recovery  of  consciousness  they 
return,  first  on  the  non-hemiplegic  side,  later,  sometimes  only  after  weeks, 
on  the  paralyzed  side.  As  to  the  time  of  return,  especiall}^  of  the  patellar 
reflexes,  marked  differences  are  observable  in  individual  cases.  The  deep 
reflexes  later  are  increased  on  the  paralyzed  side,  and  ankle  clonus  may  be 
present.  The  plantar  and  other  superficial  reflexes  are  usually  diminished. 
The  sphincters  are  not  affected. 

The  course  of  the  disease  depends  upon  the  situation  and  extent  of  the 
lesion.  If  slight,  the  hemiplegia  may  disappear  completely  within  a  few 
days  or  a  few  weeks.  In  severe  cases  the  rule  is  that  the  leg  gradually  re- 
covers before  the  arm,  and  the  muscles  of  the  shoulder  girdle  and  upper 
arm  before  those  of  the  forearm  and  hand,    The  face  may  recover  quickly. 

Except  in  the  very  slight  lesions,  in  which  the  hemiplegia  is  transient, 
changes  take  place  which  may  be  grouped  as 

Secondary  Symptoms. — These  correspond  to  the  chronic  stage.  In  a 
case  in  which  little  or  no  improvement  takes  place  within  eight  or  ten 
weeks,  it  will  be  found  that  the  paralyzed  limbs  undergo  certain  changes. 
The  leg,  as  a  rule,  recovers  enough  power  to  enable  the  patient  to  get 
about,  although  the  foot  is  dragged.  Occasionally  a  recurrence  of  severe 
symptoms  is  seen,  even  without  a  new  haemorrhage  having  taken  place.  In 
both  .arm  and  leg  the  condition  of  secondary  contraction  or  late  rigidity  comes 
on  and  is  always  most  marked  in  the  upper  extremity.  The  arm  becomes 
permanently  flexed  at  the  elbow  and  resists  all  attempts  at  extension.  The 
wrist  is  flexed  upon  the  forearm  and  the  fingers  upon  the  hand.  The  posi- 
tion of  the  arm  and  hand  is  very  characteristic.  There  is  frequently,  as 
the  contractures  develop,  a  great  deal  of  pain.    In  the  leg  the  contracture  is 


1006  DISEASES  OF  THE  NERVOUS  SYSTEM. 

rarely  so  extreme.  The  loss  of  power  is  most  marked  in  the  muscles  of 
the  foot,  and  to  prevent  the  toes  from  dragging,  the  knee  in  walking 
is  much  flexed,  or  more  commonly  the  foot  is  swung  round  in  a  half- 
circle. 

The  reflexes  are  at  this  stage  greatly  increased.  These  contractures  are 
permanent  and  incurable,  and  are  associated  with  a  secondary  descending 
sclerosis  of  the  motor  path.  There  are  instances,  however,  in  which  rigid- 
ity and  contracture  do  not  occur,  but  the  arm  remains  flaccid,  the  leg  hav- 
ing regained  its  power.  This  Mmiplegie  flasque  of  Bouchard  is  found  most 
commonly  in  children.  Among  other  secondary  changes  in  late  hemiplegia 
may  be  mentioned  the  following:  Tremor  of  the  affected  limbs,  post-para- 
lytic chorea,  the  mobile  spasm  known  as  athetosis,  arthropathies  in  the 
joints  of  the  affected  side,  and  muscular  atrophy.  Athetosis  and  post- 
hemiplegic chorea  will  be  considered  in  the  hemiplegia  of  children.  The 
cool  surface  and  thin  glossy  skin  of  a  hemiplegic  limb  are  familiar  to  all. 
A  word  may  here  be  said  upon  the  subject  of  muscular  atrophy  of  cerebral 
origin. 

As  a  rule,  atrophy  is  not  a  marked  feature  in  hemiplegia,  but  in  some 
instances  it  does  develop.  It  has  been  thought  to  be  due  in  some  cases  to 
secondary  alterations  in  the  gray  matter  of  the  ventral  horns,  as  in  a  case 
reported  by  Charcot.  Eecently,  however,  attention  has  been  called  by 
Senator,  Quincke,  and  others  to  the  fact  that  atrophy  may  follow  as  a  direct 
result  of  the  cerebral  lesion,  the  ventral  horns  remaining  intact.  In 
Quincke's  case,  atrophy  of  the  arm  followed  the  development  of  a  glioma 
in  the  anterior  central  convolution.  The  gray  matter  of  the  ventral  horns 
was  normal.  These  atrophies  are  most  common  in  cortical  lesions  involv- 
ing the  domain  of  the  third  main  branch  of  the  Sylvian  artery,  and  in  cen- 
tral lesions  involving  the  lenticulo-thalamic  region.  Their  explanation  is 
not  clear.  The  wasting  of  cerebral  origin,  which  occurs  most  frequently  in 
children,  and  leads  to  hemiatrophy  of  the  muscles  along  with  stunted  growth 
of  the  bones  and  Joints,  is  to  be  sharply  separated  from  the  hemiatrophy  of 
the  muscles  of  the  adult  following  within  a  relatively  short  time  upon  the 
hemiplegia. 

Diagnosis. — There  are  three  groups  of  cases  which  offer  increasing 
difficulty  in  recognition. 

(1)  Cases  in  which  the  onset  is  gradual,  a  day  or  two  elapsing  before 
the  paralysis  is  fully  developed  and  consciousness  completely  lost,  are  readily 
recognized,  though  it  may  be  difficult  to  determine  whether  the  lesion  is 
due  to  thrombosis  or  to  haemorrhage. 

(2)  In  the  sudden  apoplectic  stroke  in  which  the  patient  rapidly  loses 
consciousness,  the  difficulty  in  diagnosis  may  be  still  greater,  particularly 
if  the  patient  is  in  deep  coma  when  first  seen. 

The  first  point  to  be  decided  is  the  existence  of  hemiplegia.  This  may 
be  difficult,  although,  as  a  rule,  even  in  deep  coma  the  limbs  on  the  para- 
lyzed side  are  more  flaccid  and  drop  instantly  when  lifted;  whereas,  on  the 
non-paralyzed  side  the  muscles  retain  some  degree  of  tonus.  The  reflexes 
may  be  decreased  or  lost  on  the  affected  side  and  there  may  be  conjugate  de- 
viation of  the  head  and  eyes.  Eigidityin  the  limbs  of  one  side  is  in  favor  of  a 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  1007 

hemiplegic  lesion.  It  is  practically  impossible  in  a  majority  of  these  cases 
to  say  whether  the  lesion  is  due  to  haemorrhage,  embolism,  or  thrombosis. 

(3)  Large  haemorrhage  into  the  ventricles  or  into  the  pons  may  pro- 
duce sudden  loss  of  consciousness  with  complete  relaxation,  so  that  the 
condition  may  simulate  coma  from  urnsmia,  diabetes,  alcoholism,  opium 
poisoning,  or  epilepsy. 

The  previous  history  and  the  mode  of  onset  may  give  valuable  informa- 
tion. In  epilepsy,  convulsions  have  preceded  the  coma;  in  alcoholism,  there 
is  a  history  of  constant  drinking,  while  in  opium  poisoning  the  coma  de- 
velops more  gradually;  but  in  many  instances  the  difficulty  is  practically 
very  great,  and  on  more  than  one  occasion  I  have  seen  mortifying  post- 
mortem disclosures  under  these  circumstances.  With  diabetic  coma  the 
breath  often  smells  of  acetone.  In  ventricular  hsemorrhage  the  coma  is 
sudden  and  develops  rapidly.  The  hemiplegic  symptoms  may  be  transient, 
quickly  giving  place  to  complete  relaxation.  Convulsions  occur  in  many 
cases,  and  may  be  the  very  symptom  to  lead  astray — as  in  a  case  of  ven- 
tricular haemorrhage  which  occurred  in  a  puerperal  patient,  in  whom,  natu- 
rally enough,  the  condition  was  thought  to  be  ursemic.  Rigidity  is  often 
present.  In  haemorrhage  into  the  pons  convulsions  are  frequent.  The 
pupils  may  be  strongly  contracted,  conjugate  deviation  may  occur,  and  the 
temperature  is  apt  to  rise  rapidly.  The  contraction  of  the  pupils  in  pontine 
haemorrhage  naturally  suggests  opium  poisoning.  The  difference  in  tem- 
perature in  the  two  conditions  is  a  valuable  diagnostic  point.  The  apoplecti- 
form seizures  of  general  paresis  have  usually  been  preceded  by  abnormal 
mental  symptoms,  and  the  associated  hemiplegia  is  seldom  permanent. 

It  may  be  impossible  at  first  to  give  a  definite  diagnosis.  In  admissions 
to  hospitals  or  in  emergency  cases  the  physician  should  be  particularly  care- 
ful about  the  following  points:  The  examination  of  the  head  for  injury 
or  fracture;  the  urine  should  be  tested  for  albumin,  examined  for  sugar, 
and  studied  microscopically;  a  careful  examination  should  be  made  of  the 
limbs  with  reference  to  their  degree  of  relaxation  or  the  presence  of  rigidity, 
and  the  condition  of  the  reflexes;  the  state  of  the  pupils  should  be  poted 
and  the  temperature  taken.  The  odor  of  the  breath  (alcohol,  acetone, 
chloroform,  etc.)  should  be  remarked.  The  most  serious  mistakes  are  made 
in  the  case  of  patients  who  are  drunk  at  the  time  of  the  attack,  a  combina- 
tion by  no  means  uncommon  in  the  class  of  patients  admitted  to  hospital. 
Under  these  circumstances  the  case  may  erroneously  be  looked  upon  as  one 
of  alcoholic  coma.  It  is  best  to  regard  each  case  as  serious  and  to  bear  in 
mind  that  this  is  a  condition  in  which,  above  all  others,  mistakes  are 
common. 

Prognosis. — From  cortical  haemorrhage,  unless  very  extensive,  the 
recovery  may  be  complete  without  a  trace  of  contracture.  Tliis  is  more 
common  when  the  haemorrhage  follows  injury  than  when  it  results  from 
disease  of  the  arteries.  Infantile  meningeal  haemorrhage,  on  the  other 
hand,  is  a  condition  which  may  produce  idiocy  or  spastic  dijilegia. 

Large  haemorrhages  into  tlie  corona  radiata,  and  especially  those  which 
rupture  into  the  ventricles,  rapidly  prove  fatal. 

The  hemiplegia  wliieh  follows  lesions  of  the  internal  capsule,  the  result 


1008  DISEASES  OP  THE  NERVOUS  SYSTEM. 

of  rupture  of  the  lenticulo-striate  artery,  is  usually  persistent  and  followed 
by  contracture.  When  the  retro-lenticular  fibres  of  the  internal  capsule 
are  involved  there  may  be  hemianaesthesia,  and  later,  especially  if  the  thala- 
mus be  implicated,  hemichorea  or  athetosis.  In  any  case  of  cerebral  apo- 
plexy the  following  symptoms  are  of  grave  omen:  persistence  or  deepening 
of  the  coma  during  the  second  and  third  day;  rapid  rise  in  temperature 
within  the  first  forty-eight  hours  after  the  initial  fall.  In  the  reaction 
which  takes  place  on  the  second  or  third  day,  the  temperature  usually  rises, 
and  its  gradual  fall  on  the  third  or  fourth  day  with  return  of  consciousness 
is  a  favorable  indication.  The  rapid  formation  of  bed-sores,  particularly 
the  malignant  decubitus  of  Charcot,  is  a  fatal  indication.  The  occurrence 
of  albumin  and  sugar,  if  abundant,  in  the  urine  is  an  unfavorable  symptom. 
When  consciousness  returns  and  the  patient  is  improving,  the  question 
is  anxiously  asked  as  to  the  paralysis.  The  extent  of  this  cannot  be  deter- 
mined for  some  weeks.  With  slight  lesions  it  may  pass  off  entirely.  If 
persistent  at  the  end  of  a  month  some  grade  of  permanent  palsy  is  certain 
to  remain,  and  gradually  the  late  rigidity  supervenes. 

5.  Embolism  and  Thkombosis  {Cerebral  Softening). 

(a)  Embolism. — The  embolus  usually  enters  the  carotid,  rarely  the  verte- 
bral artery.  In  the  great  majority  of  cases  it  comes  from  the  left  heart  and 
is  either  a  vegetation  of  a  fresh  endocarditis  or,  more  commonly,  of  a  recur- 
ring endocarditis,  or  from  the  segments  involved  in  an  ulcerative  process. 
Less  often  the  embolus  is  a  portion  of  a  clot  which  has  formed  in  the  au- 
ricular appendix.  Portions  of  clot  from  an  aneurism,  thrombi  from  athe- 
roma of  the  aorta,  or  from  the  territory  of  the  pulmonary  veins,  may  also 
cause  blocking  of  the  branches  of  the  circle  of  Willis.  In  the  puerperal 
condition  cerebral  embolism  is  not  infrequent.  It  may  occur  in  women 
with  heart-disease,  but  in  other  instances  the  heart  is  uninvolved,  and  the 
condition  has  been  thought  to  be  associated  with  the  development  of  heart- 
clots,^  owing  to  increased  coagulability  of  the  blood.  A  majority  of  cases 
of  embolism  occur  in  heart-disease,  89  per  cent  (Saveliew).  Cases  are  rare 
in  the  acute  endocarditis  of  rheumatism,  chorea,  and  febrile  conditfons.  It 
is  much  more  common  in  the  secondary  recurring  endocarditis  which  at- 
tacks old  sclerotic  valves.  The  embolus  most  frequently  passes  to  the  left 
middle  cerebral  artery,  as  it  enters  the  left  carotid  oftener  than  the  right 
because  of  the  more  direct  course  of  the  blood  in  the  former.  The  poste- 
rior cerebral  and  the  vertebral  are  less  often  affected.  A  large  plug  may 
lodge  at  the  bifurcation  of  the  basilar.  Embolism  of  the  cerebral  vessels  is 
rare. 

Embolism  occurs  more  frequently  in  women,  owing,  no  doubt,  to  the 
greater  frequency  of  mitral  stenosis.  Contrary  to  this  general  statement, 
Newton  Pitt's  statistics  of  79  cases  at  Guy's  Hospital  indicate,  however, 
that  males  are  more  frequently  affected;  for  in  this  series  there  were  44 
males  and  35  females.    Saveliew  gives  54  per  cent  in  women. 

{b)  Thrombosis. — Clotting  of  blood  in  the  cerebral  vessels  occurs  (1) 
about  an  embolus,  (2)  as  the  result  of  a  lesion  of  the  arterial  wall  (either 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  1009 

endarteritis  with  or  without  atheroma  or,  particularly,  the  syphilitic  arteri- 
tis), (3)  in  aneurisms  both  coarse  and  miliary,  and  (4)  very  rarely  as  a  direct 
result  of  abnormal  conditions  of  the  blood.  Thrombosis  occasionally  fol- 
lows ligation  of  the  carotid  artery.  The  thrombosis  is  most  common  in  the 
middle  cerebral  and  in  the  basilar  arteries.  According  to  Kolisko,  soften- 
ing of  limited  areas,  suflBcient  to  induce  hemiplegia,  may  be  caused  by  sud- 
den collapse  of  certain  cerebral  arteries  from  cardiac  weakness. 

Anatomical  Changes. — Degeneration  and  softening  of  the  territory  sup- 
plied by  the  vessels  is  the  ultimate  result  in  both  embolism  and  thrombosis. 
Blocking  in  a  terminal  artery  may  be  followed  by  infarction,  in  which  the 
territory  may  either  be  deeply  infiltrated  with  blood  (hgemorrhagic  infarc- 
tion) or  be  simply  pale,  swollen,  and  necrotic  (anaemic  infarction).  Grad- 
ually the  process  of  softening  proceeds,  the  tissue  is  infiltrated  with  serum 
and  is  moist,  the  nerve  fibres  degenerate  and  become  fatty.  The  neuroglia 
is  swollen  and  oedematous.  The  color  of  the  softened  area  depends  upon 
the  amount  of  blood.  The  haemoglobin  undergoes  gradual  transformation, 
and  the  early  red  color  may  give  place  to  yellow.  Formerly  much  stress 
was  laid  upon  the  difference  between  red,  yellow,  and  white  softening.  The 
red  and  yellow  are  seen  chiefly  on  the  cortex.  Sometimes  the  red  softening 
is  particularly  marked  in  cases  of  embolism  and  in  the  neighborhood  of 
tumors.  The  gray  matter  shows  many  punctiform  haemorrhages — capillary 
apoplexy.  There  is  a  variety  of  yellow  softening — the  plaques  jaunes — 
common  in  elderly  persons,  which  occurs  in  the  gray  matter  of  the  convolu- 
tions. The  spots  are  from  1  to  2  cm.  in  diameter,  sometimes  are  angular  in 
shape,  the  edges  cleanly  cut,  and  the  softened  area  is  represented  by  either 
a  turbid,  yellow  material,  or  in  some  instances  there  is  a  space  crossed  by 
fine  trabeculae,  in  the  meshes  of  which  there  is  fluid.  White  softening 
occurs  most  frequently  in  the  white  matter,  and  is  seen  best  about  tumors 
and  abscesses.  Inflammatory  changes  are  common  in  and  about  the  soft- 
ened areas.  When  the  embolus  is  derived  from  an  infected  focus,  as  in 
ulcerative  endocarditis,  suppuration  may  follow.  The  final  changes  vary 
very  much.  The  degenerated  and  dead  tissue  elements  are  gradually  but 
slowly  removed,  and  if  the  region  is  small  may  be  replaced  by  a  growth  of 
connective  tissue  and  the  formation  of  a  scar.  If  large,  the  resorption 
results  in  the  formation  of  a  cyst.  It  is  surprising  for  how  long  an  area 
of  softening  may  persist  without  much  change. 

The  position  and  extent  of  the  softening  depend  upon  the  obstructed 
artery.  An  embolus  which  blocks  the  middle  cerebral  at  its  origin  involves 
not  only  the  arteries  to  the  anterior  perforated  space,  but  also  the  cortical 
branches,  and  in  such  a  case  there  is  softening  in  the  neighborhood  of  the 
corpus  striatum,  as  well  as  in  part  of  the  region  supplied  by  the  cortical 
vessels.  The  freedom  of  anastomosis  between  these  branches  varies  a  good 
deal.  Thus,  there  are  instances  of  embolism  of  the  middle  cerebral  artery 
in  which  the  soitening  has  only  involved  the  territory  of  the  central 
branches,  in  which  case  blood  has  reached  the  cortex  through  the  anterior 
and  posterior  cerebrals.  Wlien  the  middle  cerebral  is  blocked  (as  is  perhaps 
oftenest  the  case)  beyond  the  point  of  origin  of  the  central  arteries,  one  or 
other  of  its  branches  is  usually  most  involved.     The  embolus  may  lodge 


IQIQ  DISEASES  OF  THE  NERVOUS  SYSTEM. 

in  the  vessel  passing  to  the  third  frontal  convolution^  or  in  the  artery  of 
the  ascending  frontal  or  ascending  parietal;  or  it  may  lodge  in  the  branch 
passing  to  the  supramarginal  and  angular  gyri,  or  it  may  enter  the  lowest 
branch  which  is  clistributed  to  the  upper  convolutions  of  the  temporal  lobe. 
These  are  practically  terminal  arteries,  and  instances  frequently  occur  of 
softening  limited  to  a  part,  at  any  rate,  of  the  territory  supplied  by  them. 
Some  of  the  most  accurate  focalizing  lesions  are  produced  in  this  way. 

Symptoms. — Extensive  thrombotic  softening  may  exist  without  any 
symptoms.  It  is  not  uncommon  in  the  post-mortem  examination  of  the 
bodies  of  elderly  persons  to  find  the  plaques  jaunes  scattered  over  the  con- 
volutions. So,  too,  softening  may  take  place  in  the  "  silent "  regions,  as 
they  are  termed,  without  exciting  any  symptoms.  When  the  central  or 
cortical  branches  of  the  middle  cerebral  arteries  are  involved  the  symp- 
toms are  similar  to  those  of  hgemorrhage  from  the  same  arteries.  Permanent 
or  transient  hemiplegia  results.  When  the  central  arteries  are  involved 
the  softening  in  the  internal  capsule  is  commonly  followed  by  permanent 
hemiplegia.  There  are  certain  peculiarities  associated  with  embolism  and 
with  thrombosis  respectively. 

In  embolism  the  patient  is  usually  the  subject  of  heart-trouble,  or  there 
exist  some  of  the  conditions  already  mentioned.  The  onset  is  sudden, 
without  premonitory  symptoms.  When  the  embolism  blocks  the  left  middle 
cerebral  artery  the  hemiplegia  is  usually  associated  with  aphasia.  In  throm- 
bosis, on  the  other  hand,  the  onset  is  more  gradual;  the  patient  has  pre- 
viously complained  of  headache,  vertigo,  tingling  in  the  fingers;  the  speech 
may  have  been  embarrassed  for  some  days;  the  patient  has  had  loss  of 
memory  or  is  incoherent,  or  paralysis  begins  at  one  part,  as  the  hand,  and 
extends  slowly,  and  the  hemiplegia  may  be  incomplete  or  variable.  Abrupt 
loss  of  consciousness  is  much  less  common,  and  when  the  lesion  is  small 
consciousness  is  retained.  Thus,  in  thrombosis  due  to  syphilitic  disease, 
the  hemiplegia  may  come  on  gradually  without  the  slightest  disturbance 
of  consciousness. 

The  hemiplegia  following  thrombosis  or  embolism  has  practically  the 
characteristics,  both  primary  and  secondary,  described  under  hgemorrhage. 

The  following  may  be  the  effects  of  blocking  the  different  vessels: 
(a)  Vertebral. — The  left  branch  is  more  frequently  plugged.  The  effects 
are  involvement  of  the  nuclei  in  the  medulla  and  symptoms  of  acute  bulbar 
paralysis.    It  rarely  occurs  alone;  more  commonly  with 

(b)  Blocking  of  the  basilar  arterij.  When  this  is  entirely  occluded,  there 
may  be  bilateral  paralysis  from  involvement  of  both  motor  paths.  Bulbar 
symptoms  may  be  present;  rigidity  or  spasm  may  occur.  The  temperature 
may  rise  rapidly.    The  symptoms,  in  fact,  are  those  of  apoplexy  of  the  pons. 

(c)  The  posterior  cerebral  supplies  the  occipital  lobe  on  its  medial  sur- 
face and  the  greater  part  of  the  temporo-sphenoidal  lobe.  If  the  main  stem 
be  thrombosed  there  is  hemianopia  with  sensory  aphasia.  Localized  areas  of 
softening  may  exist  without  symptoms.  Blocking  of  the  main  occipital 
branch  (arteria  occipitalis  of  Buret),  or  of  the  arteria  calcarina,  passing 
to  the  cuneus  may  be  followed  by  hemianopia.  Hemianesthesia  may  re- 
sult from  involvement  of  the  posterior  part  of  the  internal  capsule.     Not 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  1011 

infrequently  symmetrical  thrombosis  of  the  occipital  arteries  of  the  two 
sides  occurs^,  as  in  Forster's  well-known  case.  Still  more  frequent  is  the 
occurrence  of  thrombosis  of  a  branch  of  the  posterior  cerebral  of  one  hemi- 
sphere and  a  branch  of  the  middle  cerebral  of  the  other  (von  Monakow). 
It  is  in  such  cases  that  the  most  pronounced  instances  of  apraxia  are  met 
with. 

(d)  Internal  Carotid. — The  symptoms  are  variable.  As  is  well  known, 
the  vessel  is  in  a  majority  of  cases  ligated  without  risk.  In  other  instances 
transient  hemiplegia  follows;  in  others  again  the  hemiplegia  is  permanent. 
These  variations  depend  on  the  anastomoses  in  the  circle  of  Willis.  If 
these  are  large  and  free,  no  paralysis  follows,  but  in  cases  in  which  the  pos- 
terior communicating  and  the  anterior  communicating  vessels  are  small  or 
absent,  the  paralysis  may  persist.  In  No.  7  of  my  Elwyn  series  of  cases  of 
infantile  hemiplegia,  the  woman,  aged  twenty-four,  when  six  years  old,  had 
the  right  carotid  ligated  for  abscess  folloAving  scarlet  fever,  with  the  result 
of  permanent  hemiplegia.  Blocking  of  the  internal  carotid  within  the 
skull  by  thrombosis  or  embolism  is  followed  by  hemiplegia,  coma,  and  usu- 
ally death.  The  clot  is  rarely  confined  to  the  carotid  itself,  but  spreads 
into  its  branches  and  may  involve  the  ophthalmic  artery. 

(e)  Middle  Cerebral. — This  is  the  vessel  most  commonly  involved,  and, 
as  already  mentioned,  if  plugged  before  the  central  arteries  are  given  off, 
permanent  hemiplegia  usually  follows  from  softening  of  the  internal  cap- 
sule. Blocking  of  the  branches  beyond  this  point  may  be  followed  by 
hemiplegia,  which  is  more  likely  to  be  transient,  involves  chiefly  the  arm 
and  face,  and  if  on  the  left  side  is  associated  with  aphasia.  The  individual 
branches  passing  to  the  inferior  frontal  (producing  typical  motor  aphasia 
if  the  disease  be  on  the  left  side),  anterior  and  posterior  central  gyri  (usually 
causing  total  hemiplegia),  to  the  supramarginal  and  angular  gyri  (giving 
rise,  if  the  thrombosis  be  on  the  left  side,  probably  without  exception  to 
the  so-called  visual  aphasia  (alexia),  usually  also  to  right-sided  hemi- 
anopsia), or  to  the  temporal  gyri  (in  which  event  with  left-sided  thrombosis 
word-deafness  results)  may  be  plugged. 

(f)  Anterior  Cerebral. — No  symptoms  may  follow,  and  even  when  the 
branches  which  supply  the  paracental  lobule  and  the  top  of  the  ascending 
convolutions  are  plugged  the  branches  from  the  middle  cerebral  are  usually 
able  to  effect  a  collateral  circulation  in  these  parts.  Monoplegia  of  the  leg 
may,  however,  result.  Hebetude  and  dulness  of  intellect  may  occur  with 
obstruction  of  the  vessel. 

There  is  unquestionably  grea1»er  freedom  of  communication  in  the  cor- 
tical branches  of  the  different  arteries  than  is  usually  admitted,  although 
it  is  not  possible,  for  example,  to  inject  the  posterior  cerebral  througli  the 
middle  cerebral,  or  the  middle  cerebral  from  the  anterior;  but  the  absence 
of  softening  in  some  instances  in  which  smaller  branches  are  blocked  shows 
how  complete  may  be  the  compensation,  probably  by  way  of  the  capillaries. 
The  dilatation  of  the  collateral  branches  may  take  place  very  rapidly;  thus 
a  patient  with  chronic  nephritis  died  about  twenty-four  hours  after  the 
hemiplegic  attack.  There  were  recent  vegetations  on  the  mitral  valve  and 
an  embolus  in  the  right  middle  cerebral  artery  just  beyond  the  first  two 


1012  DISEASES  OF  THE  NERVOUS  SYSTEM. 

branches.  The  central  portion  of  the  hemisphere  was  swollen  and  oedema- 
tons.  The  right  anterior  cerebral  was  greatly  dilated^  and  by  measurement 
its  diameter  was  found  to  be  nearly  three  times  that  of  the  left. 

Treatment   of  Cerebral   Haemorrhage   and  of  Softening. 

— The  patient  should  be  placed  on  his  back,  with  the  head  high,  the  neck 
free,  kept  absolutely  quiet,  and  measures  immediately  taken  to  reduce  the 
arterial  pressure.  Of  these  the  most  rapid  and  satisfactory  is  venesection, 
which  should  be  practised  whenever  the  arterial  tension  is  much  increased. 
With  a  small  pulse  of  low  tension  and  signs  of  cardiac  weakness  it  is  contra- 
indicated.  The  chief  difficulty  is  in  determining  whether  the  apoplexy  is 
really  due  to  hemorrhage,  or  to  thrombosis  or  embolism,  since  in  the  latter 
group  of  cases  bleeding  probably  does  harm.  As  a  rule,  however,  in  middle- 
aged  men  with  arterio-sclerosis,  an  accentuated  aortic  second  sound,  and 
hypertrophy  of  the  left  ventricle,  bleeding  is  indicated.  Horsley  and  Spen- 
cer have  recently,  on  experimental  grounds,  recommended  the  practice, 
formerly  employed  empirically,  of  compression  of  the  carotid,  particularly 
in  the  ingravescent  form;  or  even,  in  suitable  cases,  passing  a  ligature  round 
the  vessel.  An  ice-bag  may  be  placed  on  the  head  and  hot  bottles  to  the 
feet.  The  bowels  should  be  freely  opened,  either  by  calomel,  or  croton 
oil  placed  on  the  tongue.  Counter-irritation  to  the  neck  or  to  the  feet  is 
not  necessary.  Catheterization  of  the  bladder  may  be  necessary,  especially 
if  the  patient  remain  long  unconscious.  When  dyspnoea,  stertor,  and  signs 
of  mechanical  obstruction  are  present,  the  patient  should  be  turned  on  the 
side,  as  recommended  by  Bowles.  This  procedure  also  lessens  the  liability 
to  congestion  of  the  lungs. 

Special  care  should  be  taken  to  avoid  bed-sores;  and  if  bottles  are  used 
to  the  feet,  they  should  not  be  too  hot,  since  blisters  may  be  readily  caused 
by  much  lower  temperature  than  in  health.  In  the  fever  of  reaction,  aconite 
may  be  indicated,  but  should  be  cautiously  used.  Stimulants  are  not  neces- 
sary, unless  the  pulse  becomes  feeble  and  signs  of  collapse  supervene.  No 
digitalis  is  to  be  given.  During  recovery  the  patient  should  be  still  kept 
entirely  at  rest,  even  in  the  mildest  cases  remaining  in  bed  for  at  least  four- 
teen days.  The  ice-bag  should  still  be  kept  at  the  head.  The  diet  should 
be  light  and  no  medicine  other  than  some  placebo  should  be  administered, 
at  least  during  the  first  month  after  the  hsemorrhage.  Attention  should 
be  paid  to  the  position  occupied  by  the  paralyzed  limb  or  limbs,  which  if 
swollen  may  be  wrapped  in  cotton  batting  or  flannel. 

The  treatment  of  softening  from  thrombosis  or  embolism  is  very  un- 
satisfactory. Venesection  is  not  indicated,  as  it  lowers  the  tension  and 
rather  promotes  clotting.  If,  as  is  often  the  case,  the  heart's  action  is  feeble 
and  irregular,  stimulants  and  small  doses  of  digitalis  may  be  given  with, 
if  necessar}^  ether  or  ammonia.  The  bowels  should  be  kept  open,  but  it  is 
not  well  to  purge  actively,  as  in  haemorrhage. 

In  the  thrombosis  which  follows  syphilitic  disease  of  the  arteries,  and 
which  is  met  with  most  frequently  in  men  between  twenty  and  forty  (in 
whom  the  hemiplegia  often  sets  in  without  loss  of  consciousness),  the  iodide 
of  potassium  should  be  freely  used,  giving  from  20  to  30  grains  three  times 
a  day,  or,  if  necessary,  larger  doses.    If  the  syphilis  has  been  recent,  mer- 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  1013 

curials  by  inunction  are  also  indicated.  Practically  these  are  the  only  cases 
of  hemiplegia  in  which  we  see  satisfactory  results  from  treatment. 

Operative  treatment  has  been  suggested,  and  when  the  diagnosis  of  sub- 
dural haemorrhage  can  be  made  it  is  justifiable.  An  attempt  to  reach  a 
central  haemorrhage  in  the  neighborhood  of  the  internal  capsule  would  only 
increase  the  damage  to  the  brain  substance.  Very  little  can  be  done  for 
the  hemiplegia  which  remains.  The  damage  is  too  often  irreparable  and 
permanent,  and  it  is  very  improbable  that  iodide  of  potassium,  or  any 
other  remedy,  hastens  in  the  slightest  degree  Nature's  dealing  with  the 
blood-clot. 

The  paralyzed  limbs  may  be  gently  rubbed  once  or  twic^  a  day,  and 
this  should  be  systematically  carried  out,  in  order  to  maintain  the  nutri- 
tion of  the  muscles  and  to  prevent,  if  possible,  contractures.  The  massage 
should  not,  however,  be  begun  until  at  least  ten  days  after  the  attack.  The 
rubbing  should  be  toward  the  body,  and  should  not  be  continued  for  more 
than  fifteen  minutes  at  a  time.  After  the  lapse  of  a  fortnight,  or  in  severe 
cases  a  month,  the  muscles  may  be  stimulated  by  the  faradic  current;  faradic 
stimulation  alternating  with  massage,  especially  if  applied  to  the  antagonists 
of  the  muscles  which  ordinarily  undergo  contracture,  is  of  very  great  service, 
even  in  cases  where  there  can  be  but  little  hope  of  any  return  of  voluntary 
movement.  When  contractures  develop,  electricity  properly  applied  at 
intervals  may  still  be  of  some  benefit  along  with  the  passive  movements  and 
frictions. 

In  a  case  of  complete  hemiplegia,  the  friends  should  at  the  outset  be 
frankly  told  that  the  chances  of  full  recovery  are  slight.  Power  is  usually 
restored  in  the  leg  sufficient  to  enable  the  patient  to  get  about,  but  in  the 
majority  of  instances  the  finer  movements  of  the  hand  are  permanently  lost. 
The  general  health  should  be  looked  after,  the  bowels  regulated,  and  the 
secretions  of  the  skin  and  kidneys  kept  active.  In  permanent  hemiplegia 
in  persons  above  the  middle  period  of  life,  more  or  less  mental  weakness  is 
apt  to  follow  the  attack,  and  the  patient  may  become  irritable  and  emo- 
tional. 

And,  lastly,  when  hemiplegia  has  persisted  for  more  than  three  months 
and  contractures  have  developed,  it  is  the  duty  of  the  physician  to  explain 
to  the  patient,  or  to  his  friends,  that  the  condition  is  past  relief,  that  medi- 
cines and  electricity  will  do  no  good,  and  that  there  is  no  possible  hope  of 
cure. 

6.  Aneueism  of  the  Cerebral  Arteries. 

Miliary  aneurisms  are  not  included,  but  reference  is  made  only  to  aneu- 
rism of  the  larger  branches.  The  condition  is  not  uncommon.  There  were 
12  instances  in  my  first  800  autopsies  in  Montreal.*  This  is  a  considerably 
larger  proportion  than  in  Newton  Pitt's  collection  from  Guy's  Hospital, 
19  times  in  9,000  inspections. 

Etiology. — Males  are  more  frequently  affected  than  females.  Of  my 
12  cases  7  were  males.    The  disease  is  most  common  at  the  middle  period 

*  Canada  Medical  and  Surgical  Journal,  vol.  xiv. 


1014  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  life.  One  of  my  cases  was  a  lad  of  six.  Pitt  describes  one  at  the  same 
age.  The  chief  causes  are  (a)  endarteritis,  either  simple  or  syphilitic,  which 
leads  to  weakness  of  the  wall  and  dilatation;  and  (h)  embolism.  As  pointed 
out  by  Church,  these  aneurisms  are  often  found  with  endocarditis.  Pitt, 
in  his  recent  study  of  the  subject,  concludes  that  it  is  exceptional  to  find 
cerebral  aneurism  unassociated  with  fungating  endocarditis.  The  em- 
bolus disappears,  and  dilatation  follows  the  secondary  inflammatory  changes 
in  the  coats  of  the  vessel. 

Morbid  Anatomy. — The  middle  cerebral  branches  are  most  fre- 
quently involved.  In  my  13  cases  the  distribution  on  the  arteries  was  as 
follows:  Internal  carotid,  1;  middle  cerebral,  5;  basilar,  3;  anterior  com- 
municating, 3.  Except  in  one  case  they  were  saccular  and  communicated 
with  the  lumen  of  the  vessel  by  an  orifice  smaller  than  the  circumference 
of  the  sac.  In  the  154  cases  which  make  up  the  statistics  of  Lebert, 
Durand,  and  Bartholow  the  middle  cerebral  was  involved  in  44,  the  basilar 
in  41,  internal  carotid  in  23,  anterior  cerebral  in  14,  posterior  communi- 
cating in  8,  anterior  communicating  in  8,  vertebral  in  7,  posterior  cere- 
bral in  6,  inferior  cerebellar  in  3  (Gowers).  The  size  of  the  aneurism 
varies  from  that  of  a  pea  to  that  of  a  walnut.  The  heemorrhage  may  be 
entirely  meningeal  with  very  slight  laceration  of  the  brain  substance,  but 
the  bleeding  may  be,  as  Coats  has  shown,  entirely  within  the  substance. 

Symptoms. — The  aneurism  may  attain  considerable  size  and  cause 
no  symptoms.  In  a  majority  of  the  cases  the  first  intimation  is  the  rupture 
and  the  fatal  apoplexy.  Distinct  symptoms  are  most  frequently  caused  by 
aneurism  of  the  internal  carotid,  which  may  compress  the  optic  nerve  or  the 
commissure,  causing  neuritis  or  paralysis  of  the  third  nerve.  A  murmur 
may  be  audible  on  auscultation  of  the  skull.  Aneurism  in  this  situation 
may  give  rise  to  irritative  and  pressure  symptoms  at  the  base  of  the  brain 
or  to  hemianoi^sia.  In  the  remarkable  case  reported  by  Weir  Mitchell  and 
Dercum'  an  aneurism  compressed  the  chiasma  and  produced  bilateral  tem- 
poral hemianopsia. 

Aneurism  of  the  vertebral  or  of  the  basilar  may  involve  the  nerves  from 
the  fifth  to  the  twelfth.  A  large  sac  at  the  termination  of  the  basilar  may 
compress  the  third  nerves  or  the  crura. 

The  diagnosis  is,  as  a  rule,  impossible.  The  larger  sacs  produce  the 
symptoms  of  tumor,  and  their  rupture  is  usually  fatal. 

7.  Endaeteritis. 

In  no  group  of  vessels  do  we  more  frequently  see  chronic  degenera- 
tive changes  than  in  those  of  the  circle  of  Willis.    The  condition  occurs  as: 

(a)  Arterio-sderosis,  producing  localized  or  diffused  thickening  of  the 
intima  with  the  formation  of  atheromatous  patches  or  areas  of  calcification. 
In  the  later  stages,  as  seen  in  elderly  people,  the  arteries  of  the  circle  of 
Willis  may  be  dilated,  stiff,  or  almost  universally  calcified. 

(h)  SypliiUtic  Endarferitis. — As  already  mentioned  under  the  section 
of  syphilis,  gummatous  endarteritis  is  specially  prone  to  attack  the  cere- 
bral vessels.    It  has  in  itself  no  specific  characters — that  is  to  say,  it  is  im- 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  1015 

possible  in  given  sections  to  pick  out  an  endarteritis  syphilitica  from  an 
ordinary  endarteritis  obliterans.  On  the  other  hand,  as  already  stated,  the 
nodular  periarteritis  is  never  seen  except  in  syphilis. 

8.  Thkombosis  of  the  Ceeebeal  Sinuses  and  Veins. 

The  condition  may  be  primary  or  secondary.  Lebert  (1854)  and  Ton- 
nele  were  among  the  first  to  recognize  the  condition  clinically. 

Primary  thrombosis  of  the  sinuses  and  veins  is  rare,  it  occurs  (a)  in 
children,  particularly  during  the  fii'st  six  months  of  life,  usually  in  con- 
nection with  diarrhoea.  It  has,  in  my  experience,  been  a  rare  condition. 
I  have  never  seen  an  example  of  spontaneous  thrombosis  of  the  sinuses  in 
a  child,  and  only  two  instances,  both  in  connection  with  meningitis,  in 
which  the  cortical  veins  contained  clots.  Gowers  believes  that  it  is  of  fre- 
quent occurrence,  and  that  thrombosis  of  the  veins  is  not  an  uncommon 
cause  of  infantile  hemiplegia. 

(&)  In  connection  with  chlorosis  and  aneemia,  the  so-called  autochthonous 
sinus-thrombosis.  Of  82  cases  of  thrombosis  in  chlorosis,  78  were  in  the 
veins  and  32  in  the  cerebral  sinuses.  The  longitudinal  sinus  is  most  fre- 
quently involved.  The  thrombosis  is  usually  associated  with  venous 
thromboses  in  other  parts  of  the  body,  and  the  patients  die,  as  a  rule, 
in  from  one  to  three  weeks,  but  botl^  Bristowe  and  Buzzard  report  re- 
coveries. 

(c)  In  the  terminal  stages  of  cancer,  phthisis,  and  other  chronic  dis- 
eases thrombosis  may  gradually  occur  in  the  sinuses  and  cortical  veins.  To 
the  coagulum  developing  in  these  conditions  the  term  marantic  thrombus 
is  applied. 

Secondary  thrombosis  is  much  more  frequent  and  follows  extension  of 
inflammation  from  contiguous  parts  to  the  sinus  wall.  The  common  causes 
are  disease  of  the  internal  ear,  fracture,  compression  of  the  sinuses  by 
tumor,  or  suppurative  disease  outside  the  skull,  particularly  erysipelas,  car- 
buncle, and  parotitis.  In  secondar}'  cases  the  lateral  sinus  is  most  frequently 
involved.  Of  57  fatal  cases  in  which  ear-disease  caused  death  with  cerebral 
lesions,  there  were  22  in  which  thrombosis  existed  in  the  lateral  sinuses 
(Pitt).  Tuberculous  caries  of  the  temporal  bone  is  often  directly  responsible. 
The  thrombus  may  be  small,  or  may  fill  the  entire  sinus  and  extend  into 
the  internal  jugular  vein.  In  more  than  one  half  of  these  instances  the 
thrombus  was  suppurating.  The  disease  spreads  directly  from  the  necrosis 
on  the  posterior  wall  of  the  tympanum.  According  to  Voltolini,  the  in- 
flammation extends  by  way  of  the  petroso-mastoid  canal.  It  is  not  so  com- 
mon in  disease  of  the  mastoid  cells. 

Symptoms. — Primary  thrombosis  of  the  longitudinal  sinus  may  occur 
without  exciting  s3anptoms  and  is  found  accidentally  at  the  post  mortem. 
There  may  be  mental  dulness  with  headache.  Convulsions  and  vomiting 
may  occur.  In  other  instances  there  is  nothing  distinctive.  In  a  patient 
who  died  under  my  care,  at  the  Philadelphia  Hospital,  of  phthisis,  there 
was  a  gradual  torpor,  deepening  to  coma,  without  convulsions,  localizing 
symptoms,  or  optic  neuritis.     The  condition  was  thought  to  be  due  to  a 


1016  DISEASES  OP  THE  NERVOUS  SYSTEM. 

terminal  meningitis.  In  the  chlorosis  cases  the  head  symptoms  have^  as  a 
rule,  been  marked.  Ball's  patient  was  dull  and  stupid,  had  vomiting, 
dilatation  of  the  pupils,  and  double  choked  disks.  Slight  paresis  of  the 
left  side  occurred.  An  interesting  feature  in  this  case  was  the  develop- 
ment of  swelling  of  the  left  leg.  In  the  cases  reported  by  Andrews,  Church, 
Tuckwell,  Isambard  Owen,  and  Wilks  the  patients  had  headache,  vomit- 
ing, and  delirium.  Paralysis  was  not  present.  In  Douglas  Powell's  case, 
with  similar  symptoms,  there  was  loss  of  power  on  the  left  side.  Bristowe 
reports  a  case  of  great  interest  in  an  anaemic  girl  of  nineteen,  who  had  con- 
vulsions, drowsiness,  and  vomiting.  Tenderness  and  swelling  developed 
in  the  position  of  the  right  internal  jugular  vein,  and  a  few  days  later  on 
the  opposite  side.  The  diagnosis  was  rendered  definite  by  the  occurrence 
of  phlebitis  in  the  veins  of  the  right  leg.     The  patient  recovered. 

The  onset  of  such  symptoms  as  have  been  mentioned  in  an  anemic  or 
chlorotic  girl  should  lead  to  the  suspicion  of  cerebral  thrombosis.  In  in- 
fants the  diagnosis  can  rarely  be  made.  Involvement  of  the  cavernous  sinus 
may  cause  oedema  about  the  eyelids  or  prominence  of  the  eyes. 

In  the  secondary  tliroTnbi  the  symptoms  are  commonly  those  of  septi- 
caemia. For  instance,  in  over  70  per  cent  of  Pitt's  cases  the  mode  of  death 
was  by  pulmonary  pyaemia.  This  author  draws  the  following  important 
conclusions:  (1)  The  disease  spreads  oftener  from  the  posterior  wall  of 
the  middle  ear  than  from  the  mastoid  cells.  (2)  The  otorrhcea  is  gener- 
ally of  some  standing,  but  not  always.  (3)  The  onset  is  sudden,  the  chief 
symptoms  being  pyrexia,  rigors,  pains  in  the  occipital  region  and  in  the 
neck,  associated  with  a  septicaemic  condition.  (4)  Well-marked  optic  neu- 
ritis may  be  present.  (5)  The  appearance  of  acute  local  pulmonary  mis- 
chief or  of  distant  suppuration  is  almost  conclusive  of  thrombosis.  (6) 
The  average  duration  is  about  three  weeks,  and  death  is  generally  from 
pulmonary  pyaemia.  The  chief  points  in  the  diagnosis  may  be  gathered 
from  these  statements. 

Pitt  records  an  interesting  case  of  recovery  in  a  boy  of  ten,  who  had 
otorrhcea  for  years  and  was  admitted  with  fever,  earache,  tenderness,  and 
oedema.  A  week  later  he  had  a  rigor,  and  optic  neuritis  developed  on  the 
right  side.  The  mastoid  was  explored  unsuccessfully.  The  fever  and 
chills  persisting,  two  days  later  the  lateral  sinus  was  explored.  A  mass  of 
foul  clot  was  removed  and  the  jugular  vein  was  tied,  after  which  the  boy 
made  a  satisfactory  recovery. 

According  to  Griesinger  there  is  often  associated  with  thrombosis  of 
the  lateral  sinus  venous  stasis  and  painful  oedema  behind  the  ear  and  in  the 
neck.  The  external  jugular  vein  on  the  diseased  side  may  be  less  dis- 
tended than  on  the  opposite  side,  since  owing  to  the  thrombus  in  the  lateral 
sinus  the  internal  jugular  vein  is  less  full  than  on  the  normal  side,  and  the 
blood  from  the  external  jugular  can  flow  more  easily  into  it  (Gerhardt). 

Treatment. — In  marantic  individuals  roborants  and  stimulants  are  in- 
dicated. The  position  assumed  in  bed  should  favor  both  the  arterial  and 
venous  circulation.  The  clothing  should  not  restrict  the  neck,  and  care 
should  be  taken  to  avoid  lending  of  the  neck. 

The  internal  administration  of  potassium  iodide  and  calomel  has  been 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  1017 

recommended  in  the  autochthonous  forms,  but  no  treatment  is  likely  to  be 
of  any  avail. 

The  secondary  forms,  especially  those  following  upon  disease  of  the 
middle  ear,  are  often  amenable  to  operation,  and,  especially  recently,  many 
lives  have  been  saved  by  surgical  intervention  after  extensive  sinus  throm- 
bosis. Macewen's  work  On  Pyogenic  Infective  Diseases  of  the  Brain  and 
Spinal  Cord  contains  the  most  exhaustive  presentation  of  the  subject  of 
sinus  thrombosis  and  its  treatment. 

9.  Hemiplegia  in  Children. 

Etiology. — Of  135  cases,  60  were  in  boys  and  75  in  girls.  Right 
hemiplegia  occurred  in  79,  left  in  56.  In  15  cases  the  condition  was  said 
to  be  congenital. 

In  a  great  majority  the  disease  sets  in  during  the  first  or  second  year; 
thus  of  the  total  number  of  cases,  95  were  under  two.  Cases  above  the 
fifth  year  are  rare,  only  10  in  my  series.  Neither  alcoholism  nor  syphilis 
in  the  parents  appears  to  play  an  important  role  in  this  affection.  Diffi- 
cult or  abnormal  labor  is  responsible  for  certain  of  the  cases,  particularly 
injury  with  the  forceps.  Trauma,  such  as  falls  or  puncturing  wounds, 
is  more  rare.  The  condition  followed  ligation  of  the  common  carotid  in 
one  case. 

Infectious  diseases.  All  the  authors  lay  special  stress  upon  this  factor. 
In  19  cases  in  my  series  the  disease  came  on  during  or  just  after  one 
of  the  specific  fevers.  I  saw  one  case  in  which  during  the  height  of  vac- 
cination convulsions  developed,  followed  by  hemiplegia.  In  a  great  ma- 
jority of  the  cases  the  disease  sets  in  with  a  convulsion,  in  which  the  child 
may  remain  for  several  hours  or  longer,  and  after  recovery  the  paralysis 
is  noticed. 

Morbid  Anatomy. — In  an  analysis  which  I  have  made  of  90  au- 
topsies reported  in  the  literature,  the  lesions  may  be  grouped  under  three 
headings: 

(a)  Embolism,  thrombosis,  and  haemorrhage,  comprising  16  cases,  in 
7  of  which  there  was  blocking  of  a  Sylvian  artery,  and  in  9  haemorrhage. 
A  striking  feature  in  this  group  is  the  advanced  age  of  onset.  Ten  of  the 
cases  occurred  in  children  over  six  years  old. 

(b)  Atrophy  and  sclerosis,  comprising  50  cases.  The  wasting  is  either 
of  groups  of  convolutions,  an  entire  lobe,  or  the  whole  hemisphere.  The 
meninges  are  usually  closely  adherent  over  the  affected  region,  though 
sometimes  they  look  normal.  The  convolutions  are  atrophied,  firm,  and 
hard,  contrasting  strongly  with  the  normal  gyri.  The  sclerosis  may  be 
diffuse  and  widespread  over  a  hemisphere,  or  there  may  be  nodular  pro- 
jections— the  hypertrophic  sclerosis.  Some  of  the  cases  show  remarkable 
unilateral  atrophy  of  the  hemisphere.  In  one  of  my  cases  the  atrophied 
hemisphere  weighed  169  grammes  and  the  normal  one  653  grammes.  The 
brain  tissue  may  be  a  mere  shell  over  a  dilated  ventricle. 

(c)  Porcncephalus,  which  was  present  in  24  of  the  90  autopsies.  This 
term  was  applied  by  Ilcschcl  (1868)  to  a  loss  of  substance  in  the  form  of 


1018  DISEASES  OP  THE  NERVOUS  SYSTEM. 

cavities  and  cysts  at  the  surface  of  the  brain,  either  opening  into  and 
bounded  by  the  arachnoid,  and  even  jaassing  deeply  into  the  hemisphere, 
or  reaching  to  the  ventricle.  In  the  study  by  Audrey  of  103  cases  of 
porencephalus,  hemiplegia  was  mentioned  in  68  cases. 

Practically,  then,  in  infantile  hemiplegia  cortical  sclerosis  and  poren- 
cephalus are  the  important  anatomical  conditions.  The  primary  change 
in  the  majority  of  these  cases  is  still  unknown.  Porencephalia  may  result 
from  a  defect  in  development  or  from  hgemorrhage  at  birth.  The  etiology 
is  clear  in  the  limited  number  of  cases  of  haemorrhage,  embolism,  and 
thrombosis,  but  there  remains  the  large  group  in  which  the  final  change 
is  sclerosis  and  atrophy.  What  is  the  primary  lesion  in  these  instances? 
The  clinical  history  shows  that  in  nearly  all  these  cases  the  onset  is  sud- 
den, with  convulsions — often  with  slight  fever.  Striimpell  believes  that 
this  condition  is  due  to  an  inflammation  of  the  gray  matter — polio-en- 
cephalitis— a  view  which  has  not  been  very  widely  accepted,  as  the  ana- 
tomical proofs  are  wanting.  Gowers  suggests  that  thrombosis  may  be  pres- 
ent iu'  some  instances.  This  might  probably  account  for  the  final  condi- 
tion of  sclerosis,  but  clinically  thrombosis  of  the  veins  rarely  occurs  in 
healthy  children,  which  appear  to  be  those  most  frequently  attacked  by 
infantile  hemiplegia,  and  post-mortem  proof  is  yet  wanting  of  the  associa- 
tion of  thrombosis  with  the  disease. 

Symptoms. — (a)  The  onset.  The  disease  may  set  in  suddenly  with- 
out spasms  or  loss  of  consciousness.  In  more  than  half  the  cases  the  child 
is  attacked  with  partial  or  general  convulsions  and  loss  of  consciousness, 
which  may  last  from  a  few  hours  to  many  days.  This  is  one  of  the  most 
striking  features  in  the  disease.  Fever  is  usually  present.  The  hemi- 
plegia, noticed  as  the  child  recovers  consciousness,  is  generally  complete. 
Sometimes  the  paralysis  is  not  complete  at  first,  but  develops  after  subse- 
quent convulsions.  The  right  side  is  more  frequently  afEected  than  the 
left.     The  face  is  commonly  not  involved. 

(h)  Eesidual  symptoms.  In  some  eases  the  paralysis  gradually  disap- 
pears and  leaves  scarcely  a  trace  as  the  child  grows  up.  The  leg,  as  a 
rule,  recovers  more  rapidly  and  more  fully  than  the  arm,  and  the  paraly- 
sis may  be  scarcely  noticeable.  In  a  majority  of  cases,  however,  there  is 
a  characteristic  hemiplegic  gait.  The  paralysis  is  most  marked  in  the 
arm,  which  is  usually  wasted;  the  forearm  is  flexed  at  right  angles,  the 
hand  is  flexed,  and  the  fingers  are  contracted.  Motion  may  be  almost  com- 
pletely lost;  in  other  instances  the  arm  can  be  lifted  above  the  head.  Late 
rigidity,  which  almost  always  develops,  is  the  symptom  which  suggested 
the  name  hemiplegia  spastica  cerehralis  to  Heine,  the  orthopaedic  surgeon 
who  first  accurately  described  these  cases.  It  is,  however,  not  constant. 
The  limbs  may  be  quite  relaxed  even  years  after  the  onset.  The  reflexes 
are  usually  increased.  In  several  instances,  however,  I  have  known  them 
to  be  absent.     Sensation  is,  as  a  rule,  not  disturbed. 

Aphasia  is  a  not  uncommon  symptom,  and  occurred  in  16  cases  of  my 
series — a  smaller  number  than  that  given  in  the  series  of  Wallenberg, 
Gaudard,  and  Sachs. 

Mental  Defects. — One  of  the  most  serious   consequences   of  infantile 


AFFECTIONS  OF  THE  BLOOD-VESSELS.  1019 

hemiplegia  is  the  failure  of  mental  development.  A  considerable  number 
of  these  cases  drift  into  the  institutions  for  feeble-minded  children.  Three 
grades  may  be  distinguished — idiocy,  which  is  most  common  when  the 
hemiplegia  has  existed  from  birth;  imbecility,  which  often  increases  with 
the  development  of  epilepsy;  and  feeble-mindedness,  a  retarded  rather 
than  an  arrested  development. 

Epilepsy. — Of  the  cases  in  my  series,  41  were  subjects  of  convulsive 
seizures,  one  of  the  most  distressing  sequels  of  the  disease.  The  seizures 
may  be  either  transient  attacks  of  petit  mal,  true  Jacksonian  fits,  begin- 
■  ning  in  and  confined  to  the  affected  side,  or  general  convulsions. 

Post-hemiplegic  Movements. — It  was  in  cases  of  this  sort  that  Weir 
Mitchell  first  described  the  post-hemiplegic  movements.  They  are  ex- 
tremely common,  and  were  present  in  34  of  my  series.  There  may  be 
either  slight  tremor  in  the  affected  muscles,  or  incoordinate  choreiform 
movements — the  so-called  post-hemiplegic  chorea — or,  lastly. 

Athetosis. — In  this  condition,  described  by  Hammond,  there  are  remark- 
able spasms  of  the  paralyzed  extremities,  chiefly  of  the  fingers  and  toes, 
and  in  rare  instances  of  the  muscles  of  the  mouth.  The  movements  are 
involuntary  and  somewhat  rhythmical;  in  the  hand,  movements  of  adduc- 
tion or  abduction  and  of  supination  and  pronation  follow  each  other  in 
orderly  sequence.  There  may  be  hyperextension  of  the  fingers,  during 
which  they  are  spread  wide  apart.  This  condition  is  much  more  frequent 
in  children  than  in  adults.  In  the  latter  it  may  be  combined  with  hemi- 
angesthesia,  and  the  lesion  is  not  cortical,  but  basic  in  the  neighborhood  of 
the  thalamus.  The  movements  are  sometimes  increased  by  emotion.  They 
usually  persist  during  sleep. 

Treatment. — The  possibility  of  injury  to  the  brain  in  protracted 
labor  and  in  forceps  cases  should  be  borne  in  mind  by  the  practitioner. 
The  former  entails  the  greater  risk.  In  infantile  hemiplegia  the  physician 
at  the  outset  sees  a  case  of  ordinary  convulsions,  perhaps  more  protracted 
and  severe  than  usual.  These  should  be  checked  as  rapidly  as  possible 
by  the  use  of  the  bromides,  the  "application  of  cold  or  heat,  and  a  brisk 
purge.  During  convulsions  chloroform  may  be  administered  with  safety 
even  to  the  youngest  children.  When  the  paralysis  is  established  not  much 
can  be  hoped  from  medicines.  In  only  rare  instances  does  the  paralysis 
entirely  disappear.  When  the  recovery  is  partial  the  "  residual  paralysis  " 
is  similar  to  that  seen  in  other  lesions  of  the  upper  motor  segment.  Thus 
in  the  lower  extremity  it  is  the  flexors  of  the  leg  and  the  dorsal  flexors  of 
the  foot  which  are  most  often  permanently  paralyzed  (Wernicke).  The 
indications  are  to  favor  the  natural  tendency  to  improve  by  maintaining  the 
general  nutrition  of  the  child,  to  lessen  the  rigidity  and  contractures  by 
massage  and  passive  motion,  and  if  necessary  to  correct  deformities  by 
mechanical  or  surgical  measures.  Much  may  be  done  by  careful  manipula- 
tion and  rubbing  and  the  api)lication  of  a  proper  apparatus.  In  children 
the  aphasia  usually  disappears.  The  epilepsy  is  a  distressing  and  obstinate 
symptom,  for  which  a  cure  can  rarely  be  anticipated.  Prolonged  periods 
of  quiescence  are,  however,  not  uncommon.  In  the  Jacksonian  fits  the 
bromides  rarely  do  good,  unless  there  is  much  irritability  and  excitement. 


1020  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Operative  measures,  which  have  been  carried  out  in  several  cases,  have  not, 
as  a  rule,  been  successful.  The  liability  to  feeble-mindedness  is  the  most 
serious  outlook  in  the  infantile  cerebral  palsies.  In  many  cases  the  damage 
is  irreparable,  and  idiocy  and  imbecility  result.  With  patient  training  and 
with  care  many  of  the  children  reach  a  fair  measure  of  intelligence  and 
self-reliance. 


IV.    TUMORS,    INFECTIOUS    GRANULOMATA,   AND    CYSTS 

OF   THE    BRAIN. 

The  following  are  the  most  common  varieties  of  new  growths  within 
the  cranium: 

(1)  Infectious  Granulomata. — (a)  Tubercle,  which  may  form  large  or 
small  growths,  usually  multiple.  Tuberculosis  of  the  glands  or  bones  may 
be  coexistent,  but  the  tuberculous  disease  of  the  brain  may  occur  in  the 
absence  of  other  clinically  recognizable  tuberculous  lesions.  The  disease  is 
most  frequent  early  in  life.  Three  fourths  of  the  cases  occur  under  twenty, 
and  one  half  of  the  patients  are  under  ten  years  of  age  (Gowers).  Of  299 
cases  of  tumor  in  persons  under  nineteen  collected  from  various  sources 
by  Starr,  152  were  tubercle.  The  nodules  are  most  numerous  in  the  cere- 
bellum and  about  the  base. 

(h)  Syphiloma  is  most  commonly  found  in  the  hemispheres  or  about 
the  pons.  The  tumors  are  superficial,  attached  to  the  arteries  or  the  me- 
ninges, and  rarely  grow  to  a  large  size.  They  may  be  multiple.  The  third 
nerve  is  particularly  prone  to  syphilitic  infiltration,  and  ptosis  is  common. 

(2)  Tumors.^ — (c)  Glioma  and  Neuroglioma. — These  vary  greatly  in  ap- 
pearance. They  may  be  firm  and  hard,  almost  like  an  area  of  sclerosis, 
or  soft  and  very  vascular.  They  persist  remarkably  for  many  years.  Klebs 
has  called  attention  to  the  occurrence  of  elements  in  them  not  unlike  gan- 
glion-cells. Tumors  of  this  character  may  contain  the  "  Spinnen  "  or  spider 
cells;  enormous  spindle-shaped  cells  with  single  large  nuclei;  cells  like  the 
ganglion-cells  of  nerve-centres  with  nuclei  and  one  or  more  processes;  and 
translucent,  band-like  fibres,  tapering  at  each  end,  which  result  from  a 
vitreous  or  hyaline  transformation  of  the  large  spindle-cells.  A  separate 
type  is  also  recognizable,  in  which  the  cells  resemble  the  ependymal  epi- 
thelium. 

(d)  Sarcoma  occurs  most  commonly  in  the  membranes  of  the  brain  and 
in  the  pons.  It  forms  some  of  the  largest  and  most  diffusely  infiltrating 
of  intracranial  growths.  Like  carcinoma,  sarcoma  of  the  brain  is  usually 
of  very  rapid  growth. 

(e)  Carcinoma  not  infrequently  is  secondary  to  cancer  in  other  parts. 
It  is  seldom  primary.  Occasionally  cancerous  tumors  have  been  found  in 
symmetrical  parts  of  the  brain. 

(/)  Other  varieties  occur,  such  as  fibroid  growths,  which  usually  develop 
from  the  membranes;  bony  tumors,  which  grow  sometimes  from  the  falx, 
psammoma,  and  cholesteatoma.  Fatty  tumors  are  occasionally  found  on 
the  corpus  callosum. 


TUMORS,  INFECTIOUS  GRANULOMATA,  AND  CYSTS  OF  THE  BRAIN.  1021 

(3)  Cysts. — (g)  These  occur  between  the  membranes  and  the  brain,  as 
a  result  of  hgemorrhage  or  of  softening.  Porencephalus  is  a  sequel  of  con- 
genital atrophy  or  of  haemorrhage,  or  may  be  due  to  a  developmental  de- 
fect. Hydatid  cysts  have  been  referred  to  in  the  section  on  parasites.  An 
interesting  variety  of  cyst  is  that  which  follows  severe  injury  to  the  skuU 
in  early  life. 

Symptoms. — (1)  General. — The  following  are  the  most  important: 
Headache,  either  dull,  aching,  and  continuous,  or  sharp,  stabbing,  and  par- 
oxysmal. It  may  be  diffused  over  the  entire  head;  sometimes  it  is  limited 
to  the  back  or  front.  When  in  the  back  of  the  head  it  may  extend  down 
the  neck  (especially  in  tumors  in  the  posterior  fossa),  and  when  in  the  front 
it  may  be  accompanied  with  neuralgic  pains  in  the  face.  Occasionally  the 
pain  may  be  very  localized  and  associated  with  tenderness  on  pressure. 

Optic  neuritis  occurs  in  four  fifths  of  all  the  cases  (Gowers).  It  is  usu- 
ally double,  but  occasionally  is  found  in  only  one  eye.  A  growth  may  de- 
velop slowly  and  attain  considerable  size  without  producing  optic  neuritis. 
On  the  other  hand,  it  may  occur  with  a  very  small  tumor.  J.  A.  Martin, 
from  an  extensive  analysis  of  the  literature  with  reference  to  the  localizing 
value,  concludes:  When  there  is  a  difference  in  the  amount  of  the  neuritis 
in  each  eye  it  is  more  than  twice  as  probable  that  the  tumor  is  on  the  side 
of  the  most  marked  neuritis.  It  is  constant  in  tumors  of  the  corpora 
quadrigemina,  present  in  89  per  cent  of  cerebellar  tumors,  and  absent  in 
nearly  two  thirds  of  the  cases  of  tumor  of  the  pons,  medulla,  and  of  the 
corpus  callosum.  It  is  least  frequent  in  cases  of  tuberculous  tumor;  most 
common  in  cases  of  glioma  and  cystic  tumors. 

Vomiting  is  a  common  feature,  and  with  headache  and  optic  neuritis 
makes  up  the  characteristic  clinical  picture  of  cerebral  tumor.  An  impor- 
tant point  is  the  absence  of  definite  relation  to  the  meals.  A  chemical  ex- 
amination shows  that  the  vomiting  is  independent  of  digestive  disturbances. 
It  may  be  very  obstinate,  particularly  in  growths  of  the  cerebellum  and 
the  pons. 

Giddiness  is  often  an  early  symptom.  The  patient  complains  of  vertigo 
on  rising  suddenly  or  on  turning  quickly.  Mental  Disturbance. — The  pa- 
tient may  act  in  an  odd,  unnatural  manner,  or  there  may  be  stupor  and 
heaviness.  The  patient  may  become  emotional  or  silly,  or  symptoms  re- 
sembling hysteria  may  develop.  Convulsions,  either  general  and  resembling 
true  epilepsy  or  localized  (Jacksonian)  in  character.  There  may  be  slowing 
of  the  pulse,  as  in  all  cases  of  increased  intracranial  pressure. 

(2)  Localizing  Sjnnptoms. — Focal  symptoms  often  occur,  but  it  must  not 
be  forgotten  that  these  may  be  indirectly  produced.  The  smaller  the  tumor 
and  the  less  marked  the  general  symptoms  of  cerebral  compression,  the 
more  likely  is  it  that  any  focal  symptoms  occurring  are  of  direct  origin. 

(a)  Central  Motor  Area. — The  symptoms  are  either  irritative  or  destruc- 
tive in  character.  Irritation  in  the  lower  third  may  produce  spasm  in  the 
muscles  of  the  face,  in  the  angle  of  the  mouth,  or  in  the  tongue.  The 
spasm  with  tingling  may  be  strictly  limited  to  one  muscle  group  before  ex- 
tending to  others,  and  this  Seguin  terms  the  signal  symptom.  The  middle 
third  of  the  motor  area  contains  the  centres  controlling  the  arm,  and  here, 
64 


1022  DISEASES  OF  THE  NERVOUS  SYSTEM. 

too,  the  spasm  may  begin  in  the  fingers,  in  the  thumb,  in  the  muscles  of 
the  wrist,  or  in  the  shoulder.  In  the  upper  third  of  the  motor  areas  the 
irritation  may  produce  spasm  beginning  in  the  toes,  in  the  ankles,  or  in  the 
muscles  of  the  leg.  In  many  instances  the  patient  can  determine  accu- 
rately the  point  of  origin  of  the  spasm,  and  there  are  important  sensory 
disturbances,  such  as  numbness  and  tingling,  which  may  be  felt  first  at 
the  region  affected. 

In  all  cases  it  is  important  to  determine,  first,  the  point  of  origin,  the 
signal  symptom;  second,  the  order  or  march  of  the  spasm;  and  third,  the 
subsequent  condition  of  the  parts  first  affected,  whether  it  is  a  state  of 
paresis  or  anaesthesia. 

Destructive  lesions  in  the  motor  zone  cause  paralysis,  which  is  often 
preceded  by  local  convulsive  seizures;  there  may  be  a  monoplegia,  as  of, 
the  leg,  and  convulsive  seizures  in  the  arm,  often  due  to  irritation  in  these 
centres.  Tumors  in  the  neighborhood  of  the  motor  area  may  cause  local- 
ized spasms  and  subsequently,  as  the  centres  are  invaded  by  the  growth, 
paralysis  occurs.  On  the  left  side,  growths  in  the  third  frontal  or  Broca's 
convolution  may  cause  motor  aphasia. 

(h)  Prefrontal  Region. — ^Neither  motor  nor  sensory  disturbance  may 
be  present.  The  general  symptoms  are  often  well  marked.  The  most 
striking  feature  of  growths  in  this  region  is  mental  torpor  and  gradual 
imbecility.  In  its  extension  downward  the  tumor  may  involve  on  the  left 
side  the  lower  frontal  convolution  and  produce  aphasia,  or  in  its  progress 
backward  cause  irritative  or  destructive  lesions  of  the  motor  area.  Ex- 
ophthalmos on  the  side  of  the  tumor  may  occur  and  be  helpful  in  diagnosis, 
as  in  the  case  reported  by  Thomas  and  Keene. 

(c)  Tumors  in  the  parieto-occipital  lohe  may  grow  to  a  large  size  without 
causing  any  symptoms.  There  may  be  word-blindness  and  mind-blindness 
when  the  angular  gyrus  and  its  underlying  white  matter  is  involved,  and 
paraphasia. 

(d)  Tumors  of  the  occipital  lole  produce  hemianopia,  and  a  bilateral 
lesion  may  produce  blindness.  Tumors  in  this  region  on  the  left  hemi- 
sphere may  be  associated  with  word-blindness  and  mind-blindness. 

(e)  Tumors  in  the  temporal  lohe  may  attain  a  large  size  without  produc- 
ing symptoms.  In  their  growth  they  involve  the  lower  motor  centres.  On 
the  left  side  involvement  of  the  first  gyrus  and  the  transverse  temporal 
gyri  (auditory  sense  area)  may  be  associated  with  word-deafness. 

(/)  Tumors  growing  in  the  neigliborhood  of  the  hasal  ganglifi  produce 
hemiplegia  from  involvement  of  the  internal  capsule.  Limited  growths  in 
either  the  nucleus  caudatus  or  the  nucleus  lentif  ormis  of  the  corpus  striatum 
do  not  necessarily  cause  paralysis.  Tumors  in  the  thalamus  opticus  may 
also,  when  small,  cause  no  sjnnptoms,  but  increasing  they  may  involve  the 
fibres  of  the  sensory  portion  of  the  internal  capsule,  producing  hemianopia 
and  sometimes  hemianaesthesia.  Growths  in  this  situation  are  apt  to  cause 
early  optic  neuritis,  and,  growing  into  the  third  ventricle,  may  cause  a  dis- 
tention of  the  lateral  ventricles.  In  fact,  pressure  symptoms  from  this 
cause  and  paralysis  due  to  involvement  of  the  internal  capsule  are  the  chief 
symptoms  of  tumor  in  and  about  these  ganglia.     If  the  ventrolateral  group 


TUMORS,  INFECTIOUS  GRANULOMATA,  AND  CYSTS  OF  THE  BRAIN.  1023 

of  nuclei  in  the  thalamus  be  involved  there  may  be  unilateral  disturbances 
of  cutaneous  and  muscular  sense,  hemichorea,  or  movement  ataxia. 

Growths  in  the  corpora  quadrigemina  are  rarely  limited,  but  m«st  com- 
monly involve  the  crura  cerebri  as  well.  Ocular  symptoms  are  marked. 
The  pupil  reflex  is  lost  and  there  is  nystagmus.  In  the  gradual  growth 
the  third  nerve  is  involved  as  it  passes  through  the  crus,  in  which  case  there 
will  be  oculo-motor  paralysis  on  one  side  and  hemiplegia  on  the  other,  a 
combination  almost  characteristic  of  unilateral  disease  of  the  crus. 

{g)  Tumors  of  the  pons  and  medulla.  The  symptoms  are  chiefly  those 
of  pressure  upon  the  nerves  emerging  in  this  region.  In  disease  of  the 
pons  the  nerves  may  be  involved  alone  or  with  the  pyramidal  tract.  Of  52 
cases  analyzed  by  Mary  Putnam  Jacobi,  there  were  13  in  which  the  cerebral 
nerves  were  involved  alone,  13  in  which  the  limbs  were  afl^eeted,  and  26  in 
which  there  was  hemiplegia  and  involvement  of  the  nerves.  Twenty-two 
of  the  latter  had  what  is  known  as  alternate  paralysis — i.  e.,  involvement 
of  the  nerves  on  one  side  and  of  the  limbs  on  the  opposite  side.  In  4  cases 
there  were  no  motor  symptoms.  In  tuberculosis  (or  syphilis)  a  growth 
at  the  inferior  and  inner  aspects  of  the  crus  may  cause  paralysis  of  the 
third  nerve  on  one  side,  and  of  the  face,  tongue,  and  limbs  on  the  opposite 
side  (syndrome  of  Weber).  A  tumor  growing  in  the  lower  part  of  the  pons 
usually  involves  the  sixth  nerve,  producing  internal  strabismus;  the  seventh 
nerve,  producing  facial  paralysis;  and  the  auditory  nerve,  causing  deaf- 
ness. Conjugate  deviation  of  the  eyes  to  the  side  opposite  that  on  which 
there  is  facial  paralysis  also  occurs.  When  the  motor  cerebral  nerves  are 
involved  the  paralyses  are  of  the  peripheral  type  (lower  segment  paralyses). 

Tumors  of  the  medulla  may  involve  the  cerebral  nerves  alone  or  cause 
in  some  instances  a  combination  of  hemiplegia  with  paralysis  of  the  nerves. 
Paralyses  of  the  nerves  are  helpful  in  topical  diagnosis,  but  the  fact  must  not 
be  overlooked  that  one  or  more  of  the  cerebral  nerves  may  be  paralyzed  as 
a  result  of  a  much  increased  general  intracranial  pressure.  Signs  of  irrita- 
tion in  the  ninth,  tenth,  and  eleventh  nerves  are  usually  present,  and  pro- 
duce difficulty  in  swallowing,  irregular  action  of  the  heart,  irregular  respira- 
tion, vomiting,  and  sometimes  retraction  of  the  head  and  neck.  The  hypo- 
glossal nerve  is  least  often  affected.  The  gait  may  be  unsteady  or,  if 
there  is  pressure  on  the  cerebellum,  ataxic.  Occasionally  there  are  sen- 
sory symptoms,  numbness,  and  tingling.  Toward  the  end  convulsions  may 
occur. 

Diagnosis. — From  the  general  symptoms  alone  the  existence  of  tumor 
may  be  determined,  for  the  combination  of  headache,  optic  neuritis,  and 
vomiting  is  distinctive.  A  gradual  increase  in  the  intensity  of  the  symp- 
toms is  usually  seen.  It  must  not  be  forgotten  that  severe  headache  and 
neuro-retinitis  may  be  caused  by  Bright's  disease.  The  localization  must 
be  gathered  from  the  consideration  of  the  symptoms  above  detailed  and 
from  the  data  given  in  the  section  on  Topical  Diagnosis  of  Diseases  of  the 
Brain.  Mistakes  are  most  likely  to  occur  in  connection  with  urasmia,  hys- 
teria, and  general  paralysis;  but  careful  consideration  of  all  the  circum- 
stances of  the  case  usually  enables  the  practitioner  to  avoid  error.  Auscul- 
tatory percussion  is  occasionally  of  service  in  localization. 


IQ24:  DISEASES  OP  THE  NERVOUS  SYSTEM. 

Prognosis. — Syphilitic  tumors  alone  are  amenable  to  medical  treat- 
ment. Tuberculous  growths  occasionally  cease  to  grow  and  become  calci- 
fied. The  gliomata  and  fibromata,  particularly  when  the  latter  grow  from 
the  membranes,  may  last  for  years.  I  have  described  a  case  of  small,  hard 
glioma,  in  which  the  Jacksonian  epilepsy  persisted  for  fourteen  years. 
Hughlings  Jackson  has  reported  cases  of  glioma  in  which  the  symptoms 
lasted  for  over  ten  years.  The  more  rapidly  growing  sarcomata  usually 
prove  fatal  in  from  six  to  eighteen  months.  Death  may  be  sudden,  par- 
ticularly in  growths  near  the  medulla;  more  commonly  it  is  due  to  coma 
in  consequence  of  gradual  increase  in  the  intracranial  pressure. 

Treatment. — (a)  Medical. — If  there  is  a  suspicion  of  syphilis  the 
iodide  of  potassium  and  mercury  should  be  given.  Nowhere  do  we  see 
more  brilliant  therapeutical  effects  than  in  certain  cases  of  cerebral  gum- 
mata.  The  iodide  should  be  given  in  increasing  doses.  In  tuberculous 
tumors  the  outlook  is  less  favorable,  though  instances  of  cure  are  reported, 
and  there  is  post-mortem  evidence  to  show  that  the  solitary  tuberculous 
tumors  may  undergo  changes  and  become  obsolete.  A  general  tonic  treat- 
ment is  indicated  in  these  cases.  The  headache  usually  demands  prompt 
treatment.  The  iodide  of  potassium  in  full  doses  sometimes  gives  marked 
relief.  An  ice-cap  for  the  head  or,  in  the  occipital  headache,  the  appli- 
cation of  the  Paquelin  cautery  may  be  tried.  The  bromides  are  not  of 
much  use  in  the  headache  from  this  cause,  and,  as  the  last  resort,  mor- 
phia must  be  given.  For  the  convulsions  bromide  of  potassium  is  of  little 
service. 

(&)  Surgical. — Tumors  of  the  brain  have  been  successfully  removed  by 
Macewen,  Horsley,  Keen,  and  others.  The  number  of  cases  for  operation, 
however,  is  small.  Four  fifths  at  least  of  all  the  cases  are  probably  un- 
suitable, or  of  such  a  nature  as  to  render  an  operation  fatal.  The  most 
advantageous  cases  are  the  localized  fibromata  growing  from  the  dura  and 
only  compressing  the  brain  substance,  as  in  Keen's  remarkable  case.  The 
safety  with  which  the  exploratory  operation  can  be  made  warrants  it  in  all 
doubtful  cases. 


V.    INFLAMMATION    OF   THE    BRAIN. 

1.  Acute  Encephalitis. 

A  focal  or  diffuse  inflammation  of  the  brain  substance,  usually  of  the 
gray  matter  (poliencephalitis),  is  met  with  (a)  as  a  result  of  trauma;  (b) 
in  certain  intoxications,  alcohol,  food  poisoning,  and  gas  poisoning;  and  (c) 
following  the  acute  infections.  The  anatomical  features  are  those  of  an 
acute  haemorrhagic  poliencephalitis,  corresponding  in  histological  details 
with  acute  polio-myelitis.  Focal  forms  are  seen  in  ulcerative  endocarditis, 
in  which  the  gray  matter  may  present  deeply  haemorrhagic  areas,  firmer 
than  the  surrounding  tissue.  In  the  fevers  there  may  be  more  extensive 
regions,  involving  two  or  three  convolutions.  This  acute  hemorrhagic 
poliencephalitis  superior  is  thought  by  Striimpell  to  be  the  essential  lesion 
in  infantile  hemiplegia.    Localizing  symptoms  are  usually  present,  though 


INFLAMMATION  OF  THE  BRAIN.  1025 

they  may  be  obscured  in  the  severity  of  the  general  infection.  The  most 
typical  encephalitis  accompanies  the  meningitis  in  cerebro-spinal  fever. 

In  acute  mania,  in  delirium  tremens,  in  chorea  insaniens,  in  the  mani- 
acal form  of  exophthalmic  goitre,  and  in  the  so-called  cerebral  forms  of  the 
malignant  fevers  the  gray  cortex  is  deeply  congested,  moist,  and  swollen, 
and  with  the  recent  finer  methods  of  research  will  probably  show  changes 
which  may  be  classed  as  encephalitis. 

The  symptoms  are  not  very  definite.  In  severe  forms  they  are  those  of 
an  acute  infection;  some  cases  have  been  mistaken  for  typhoid  fever.  The 
onset  may  be  abrupt  in  an  individual  apparently  healthy.  Other  cases 
have  occurred  in  the  convalescence  from  the  fevers,  particularly  influenza. 
One  of  J.  J.  Putnam's  cases  followed  mumps.  The  general  symptoms  are 
those  which  accompany  all  severe  acute  affections  of  the  brain — headache, 
somnolence,  coma,  delirium,  vomiting,  etc.  The  local  symptoms  are  very 
varied,  depending  on  the  extent  of  the  lesions,  and  may  be  irritative  or 
paralytic.  Usually  fatal  within  a  few  weeks,  cases  may  drag  on  for  weeks 
or  months  and  recover. 

2.  Abscess  of  the  Beain. 

Etiology. — Suppuration  of  the  brain  substance  is  rarely  if  ever  pri- 
mary, but  results,  as  a  rule,  from  extension  of  inflammation  from  neigh- 
boring parts  or  infection  from  a  distance  through  the  blood.  The  question 
of  idiopathic  brain  abscess  need  scarcely  be  considered,  though  occasion- 
ally instances  occur  in  which  it  is  extremely  difficult  to  assign  a  cause. 
There  are  three  important  etiological  factors: 

(1)  Trauma.  Falls  upon  the  head  or  blows,  with  or  without  abrasion 
of  the  skin.  More  commonly  it  follows  fracture  or  punctured  wounds.  In 
this  group  meningitis  is  frequently  associated  with  the  abscess. 

(3)  By  far  the  most  important  infective  foci  are  those  which  arise  in 
direct  extension  from  disease  of  the  middle  ear  or  of  the  mastoid  cells. 
From  the  roof  of  the  mastoid  antrum  the  infection  readily  passes  to  the 
sigmoid  sinus  and  induces  an  infective  thrombosis.  In  other  instances  the 
dura  becomes  involved,  and  a  sub-dural  abscess  is  formed,  which  may 
readily  involve  the  arachnoid  or  the  pia  mater.  In  another  group  the  in- 
flammation extends  along  the  lymph  spaces,  or  the  thrombosed  veins,  into 
the  substance  of  the  brain  and  causes  suppuration.  Macewen  thinks  that 
without  local  areas  of  meningitis  the  infective  agents  may  be  carried 
through  the  lymph  and  blood  channels  into  the  cerebral  substance.  In- 
fection which  extends  from  the  roof  of  the  mastoid  process  is  most  likely 
to  be  followed  by  abscess  in  the  temporal  lobe,  while  infection  extending 
from  the  posterior  wall  causes  most  frequently  sinus  thrombosis  and  cere- 
bellar abscess. 

(3)  In  septic  processes.  Abscess  of  the  brain  is  not  often  found  in 
pyaemia.  In  ulcerative  endocarditis  multiple  foci  of  suppuration  are  com- 
mon. Localized  bone-disease  and  suppuration  in  the  liver  are  occasional 
causes.  Certain  inflammations  in  the  lungs,  particularly  bronchiectasis, 
which  was  present  in  17  of  38  cases  of  these  so-called  "  pulmonal  cerebral 


1026  DISEASES  OF  THE  NERVOUS  SYSTEM. 

abscesses  "  collected  by  E.  T.  Williamson,  are  liable  to  be  followed  by  ab- 
scess. It  is  an  occasional  complication  of  empyema.  Abscess  of  the  brain 
may  follow  the  specific  fevers.  Bristowe  has  called  attention  to  its  occur- 
rence as  a  sequel  of  influenza.  The  largest  number  of  cases  occur  between 
the  twentieth  and  fortieth  years,  and  the  condition  is  more  frequent  in  men 
than  in  women.  Holt  has  collected  25  cases  in  children  under  five  years 
of  age,  the  chief  causes  of  which  were  otitis  media  and  trauma. 

Morbid  Anatomy. — The  abscess  may  be  solitary  or  multiple,  dif- 
fuse or  circumscribed.  Practically  any  one  of  the  difEerent  varieties  of 
pyogenic  bacteria  may  be  concerned.  The  bacteriological  examination 
often  shows  a  mixture  of  difEerent  varieties.  Occasionally  cultures  are 
sterile,  owing  to  death  of  the  bacteria.  In  the  acute,  rapidly  fatal  cases 
following  injury  the  suppuration  is  not  limited;  but  in  long-standing  cases 
the  abscess  is  enclosed  in  a  definite  capsule,  which  may  have  a  thickness  of 
from  3  to  5  mm.  The  pus  varies  much  in  appearance,  depending  upon 
the  age  of  the  abscess.  In  early  cases  it  may  be  mixed  with  reddish  debris 
and  softened  brain  matter,  but  in  the  solitary  encapsulated  abscess  the  pus 
is  distinctive,  having  a  greenish  tint,  an  acid  reaction,  and  a  peculiar  odor, 
sometimes  like  that  of  sulphuretted  hydrogen.  The  brain  substance  sur- 
rounding the  abscess  is  usually  cedematous  and  infiltrated.  The  size  varies 
from  that  of  a  walnut  to  that  of  a  large  orange.  There  are  eases  on  record 
in  which  the  cavity  has  occupied  the  greater  portion  of  a  hemisphere.  Mul- 
tiple abscesses  are  usually  small.  In  four  fifths  of  all  cases  the  abscess  is 
solitary.  Suppuration  occurs  most  frequently  in  the  cerebrum,  and  the 
temporal  lobe  is  more  often  involved  than  other  parts.  The  cerebellum  is 
the  next  most  common  seat,  particularly  in  connection  with  ear-disease. 

Symptoms. — Following  injury  or  operation  the  disease  may  run  an 
acute  course,  with  fever,  headache,  delirium,  vomiting,  and  rigors.  The 
symptoms  are  those  of  an  acute  meningo-encephalitis,  and  it  may  be  very 
difficult  to  determine,  unless  there  are  localizing  symptoms,  whether  there 
is  really  suppuration  in  the  brain  substance.  In  the  cases  following  ear 
disease  the  symptoms  may  at  first  be  those  of  meningeal  irritation.  There 
may  be  irritability,  restlessness,  severe  headache,  and  aggravated  earache. 
Other  striking  symptoms,  particularly  in  the  more  prolonged  cases,  are 
drowsiness,  slow  cerebration,  vomiting,  and  optic  neuritis.  In  the  chronic 
form  of  brain  abscess  which  may  follow  injury,  otorrhoea,  or  local  lung 
trouble,  there  may  be  a  latent  period  ranging  from  one  or  two  weeks  to 
several  months,  or  even  a  year  or  more.  In  the  "  silent "  regions,  when 
the  abscess  becomes  encapsulated  there  may  be  no  symptoms  whatever 
during  the  latent  period.  During  all  this  time  the  patient  may  be  under 
careful  observation  and  no  suspicion  be  aroused  of  the  existence  of  sup- 
puration. Then  severe  headache,  vomiting,  fever,  set  in,  perhaps  with  a 
chill.  So,  too,  after  a  blow  upon  the  head  or  a  fracture  the  symptoms  of 
the  lesion  may  be  transient,  and  months  afterward  cerebral  symptoms  of  the 
most  aggravated  character  may  develop. 

The  localization  of  the  lesion  is  often  difficult.  In  or  near  the  motor 
region  there  may  be  convulsions  or  paralysis,  and  it  is  to  be  remembered 
that  an  abscess  in  the  temporal  lobe  may  compress  the  lower  motor  centres 


INFLAMMATION  OF  THE  BRAIN.  1027 

and  produce  paralysis  of  the  arm  and  face  and  on  the  left  side  cause  aphasia. 
A  large  abscess  may  exist  in  the  frontal  lobe  without  causing  paralysis,  but 
in  these  cases  there  is  almost  always  some  mental  dulness.  In  the  temporal 
lobe,  the  common  seat,  there  may  be  no  focalizing  symptoms.  So  also  in 
the  parieto-occipital  region;  though  here  early  examination  may  lead  to 
the  detection  of  hemianopia.  In  abscess  of  the  cerebellum  vomiting  is  com- 
mon. If  the  middle  lobe  is  affected  there  may  be  staggering — cerebellar 
incoordination.  Localizing  symptoms  in  the  pons  and  other  parts  are  still 
more  uncertain. 

Diagnosis. — In  the  acute  cases  there  is  rarely  any  doubt.  A  considera- 
tion of  possible  etiological  factors  is  of  the  highest  importance.  The  history 
of  injury  followed  by  fever,  marked  cerebral  symptoms,  the  development 
of  rigors,  delirium,  and  perhaps  paralysis,  make  the  diagnosis  certain.  In 
chronic  ear-disease,  such  cerebral  symptoms  as  drowsiness  and  torpor,  with 
irregular  fever,  supervening  upon  the  cessation  of  a  discharge,  should  ex- 
cite the  suspicion  of  abscess.  Cases  in  which  suppurative  processes  exist 
in  the  orbit,  nose,  or  naso-pharynx,  or  in  which  there  has  been  subcutaneous 
phlegmon  of  the  head  or  neck,  a  parotitis,  a  facial  erysipelas,  or  tuberculous 
or  syphilitic  disease  of  the  bones  of  the  skull,  should  be  carefully  watched, 
and  immediately  investigated  should  cerebral  symptoms  appear.  It  is  par- 
ticularly in  the  chronic  cases  that  difficulties  arise.  The  symptoms  resem- 
ble those  of  tumor  of  the  brain;  indeed,  they  are  those  of  tumor  plus  fever. 
Choked  disk,  however,  so  commonly  associated  with  tumor,  is  very  fre- 
quently absent  in  abscess  of  the  brain.  In  a  patient  with  a  history  of  trauma 
or  with  localized  lung  or  pleural  trouble,  who  for  weeks  or  months  has  had 
slight  headache  or  dizziness,  the  onset  of  a  rapid  fever,  especially  if  it  be  in- 
termittent and  associated  with  rigors,  intense  headache,  and  vomiting,  point 
strongly  to  abscess.  The  pulse-rate  in  cases  of  cerebral  abscess  is  usually 
accelerated,  but  cases  are  not  rare  in  which  it  is  slowed.  Macewen  lays  stress 
upon  the  value  of  percussion  of  the  skull  as  an  aid  in  diagnosis.  The  note, 
which  is  uniformly  dull,  becomes  much  more  resonant  when  the  lateral 
ventricles  are  distended  in  cerebellar  abscess  and  in  conditions  in  which  the 
venae  Galeni  are  compressed. 

It  is  not  always  easy  to  determine  whether  the  meninges  are  involved 
with  the  abscess.  Often  in  ear-disease  the  condition  is  that  of  meningo- 
encephalitis. Sometimes  in  association  with  acute  ear-disease  the  symp- 
toms may  simulate  closely  cerebral  meningitis  or  even  abscess.  Indeed, 
Cowers  states  that  not  only  may  these  general  symptoms  be  produced  by 
ear-disease,  but  even  distinct  optic  neuritis. 

Treatment. — A  remarkable  advance  has  been  made  of  late  years  in 
dealing  with  these  cases,  owing  to  the  impunity  with  which  the  brain  can 
be  explored.  In  ear-disease  free  discharge  of  the  inflammatory  products 
should  be  promoted  and  careful  disinfection  practised.  The  treatment  of 
injuries  and  fractures  comes  within  the  scope  of  the  surgeon.  The  acute 
symptoms,  such  as  fever,  headache,  and  delirium,  must  be  treated  by  rest, 
an  ice-cap,  and,  if  necessary,  local  depletion.  In  all  cases,  when  a  reason- 
able suspicion  exists  of  the  occurrence  of  abscess,  the  trephine  should  be 
used  and  the  brain  explored.     The  cases  following  ear-disease,  in  which 


1028  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  suppuration  is  in  the  temporal  lobe  or  in  the  cerebellum,  ofEer  the  most 
favorable  chances  of  recovery.  The  localization  can  rarely  be  made  ac- 
curately in  these  cases,  and  the  operator  must  be  guided  more  by  general 
anatomical  and  pathological  knowledge.  In  cases  of  injury  the  trephine 
should  be  applied  over  the  seat  of  the  blow  or  the  fracture.  In  ear-disease 
the  suppuration  is  most  frequent  in  the  temporal  lobe  or  in  the  cerebellum, 
and  the  operation  should  be  performed  at  the  points  most  accessible  to  these 
regions.  And,  lastly,  a  most  important,  one  might  almost  say  essential, 
factor  in  the  successful  treatment  of  intracranial  suppuration  is  an  intelli- 
gent knowledge  on  the  part  of  the  surgeon  of  the  work  and  works  of  William 
Macewen. 

VI.    HYDROCEPHALUS. 

Definition. — A  condition,  congenital  or  acquired,  in  which  there  is 
a  great  accumulation  of  fluid  within  the  ventricles  of  the  brain. 

The  term  hydrocephalus  has  also  been  applied  to  the  collection  of  fluid 
between  the  cortex  of  the  brain  and  the  skull,  known  in  this  situation  as 
]i.  externus  or  h.  ex  vacuo,  a  condition  common  in  cases  of  atrophy  of  the 
brain  substance,  met  with  in  old  age,  after  hasmorrhages,  softenings,  or 
scleroses,  in  lingering  and  cachectic  diseases,  as  cancer,  chronic  nephritis, 
chronic  alcoholism,  and  sometimes  in  rickets.  Occasionally  the  disease  is 
caused  by  meningeal  cysts.  A  true  dropsy,  however,  of  the  arachnoid  sac 
probably  does  not  occur. 

The  cases  may  be  divided  into  three  groups — idiopathic  internal  hydro- 
cephalus (serous  meningitis),  congenital  or  infantile,  and  secondary  or  ac- 
quired. 

(1)  Serous  Meningitis  (Quincke)  (Idiopathic  Internal  Hydrocephalus; 
Angio-neurotic  Hydrocephalus). — This  remarkable  form,  described  by 
Quincke,  is  very  important,  since  a  knowledge  of  the  condition  may  explain 
very  anomalous  and  puzzling  cases.  It  is  an  ependymitis  causing  a  serous 
effusion  into  the  ventricles,  with  distention  and  pressure  effects.  It  may  be 
compared  to  the  serous  exudates  in  the  pleura  or  in  synovial  membranes. 
It  is  not  certain  that  the  process  is  inflammatory,  and  Quincke  likens  it  to 
the  angio-neurotic  oedema  of  the  skin.  In  very  acute  cases  the  ependyma 
may  be  smooth  and  natural  looking;  in  more  chronic  cases  it  may  be  thick- 
ened and  sodden.  The  exudate  does  not  differ  from  the  normal,  and  if  on 
lumbar  puncture  a  fluid  is  removed  of  a  specific  gravity  above  1.009,  with 
albumin  above  two  per  one  thousand,  the  condition  is  more  likely  to  be 
hydrocephalus  from  stasis,  secondary  to  tumor,  etc. 

Both  children  and  adults  are  affected,  the  latter  more  frequently.  In 
the  acute  form  the  condition  is  mistaken  for  tuberculous  or  purulent  men- 
ingitis. There  are  headache,  retraction  of  the  neck,  and  signs  of  increased 
intracranial  pressure,  choked  disks,  slow  pulse,  etc.  Fever  is  usually  ab- 
sent, but  I  have  seen  one  case  with  recurring  paroxysms  of  fever,  and  Morton 
Prince  has  described  a  similar  one.  In  both  the  exudate  was  clear  and  the 
ependyma  not  acutely  inflamed.  Quincke  has  reported  cases  of  recovery. 
In  the  chronic  form  the  symptoms  are  those  of  tumor — general,  such  as 


HYDROCEPHALUS.  1029 

headache,  slight  fever,  somnolence,  and  delirium;  and  local,  as  exophthal- 
mos, optic  neuritis,  spasms,  and  rigidity  of  muscles  and  paralysis  of  the 
cerebral  nerves.  Eemarkable  exacerbations  occur,  and  the  symptoms  vary 
in  intensity  from  day  to  day.  Kecovery  may  follow  after  an  illness  of  many 
weeks,  and  some  of  the  reported  cases  of  disappearance  of  all  symptoms  of 
brain  tumor  belong  in  this  category. 

(3)  Congenital  Hydroceplialus. — The  enlarged  head  may  obstruct  labor; 
more  frequently  the  condition  is  noticed  some  time  after  birth.  The  cause 
is  unknown.    It  has  occurred  in  several  members  of  the  same  family. 

The  anatomical  condition  in  these  cases  offers  no  clew  to  the  nature  of 
the  trouble.  The  lateral  ventricles  are  enormously  distended,  but  the 
ependyma  is  usually  clear,  sometimes  a  little  thickened  and  granular,  and 
the  veins  large.  The  choroid  plexuses  are  vascular,  sometimes  sclerotic,  but 
often  natural  looking.  The  third  ventricle  is  enlarged,  the  aqueduct  of 
Sylvius  dilated,  and  the  fourth  ventricle  may  be  distended.  The  quantity 
of  fluid  may  reach  several  litres.  It  is  limpid  and  contains  a  trace  of  albu- 
min and  salts.  The  changes  in  consequence  of  this  enormous  ventricular 
distention  are  remarkable.  The  cerebral  cortex  is  greatly  stretched,  and 
over  the  middle  region  the  thickness  may  amount  to  no  more  than  a  few 
millimetres  without  a  trace  of  the  sulci  or  convolutions.  The  basal  ganglia 
are  flattened.  The  skull  enlarges,  and  the  circumference  of  the  head  of 
a  child  of  three  or  four  years  may  reach  35  or  even  30  inches.  The  sutures 
widen.  Wormian  bones  develop  in  them,  and  the  bones  of  the  cranium 
become  exceedingly  thin.  The  veins  are  marked  beneath  the  skin.  A  fluc- 
tuation wave  may  sometimes  be  obtained,  and  Fisher's  brain  murmur  may 
be  heard.  The  orbital  plates  of  the  frontal  bone  are  depressed,  causing 
exophthalmos,  so  that  the  eyeballs  cannot  be  covered  by  the  eyelids.  The 
small  size  of  the  face,  widening  somewhat  abov^,  is  striking  in  comparison 
with  the  enormously  expanded  skull. 

Convulsions  may  occur.  The  reflexes  are  increased,  the  child  learns  to 
walk  late,  and  ultimately  in  severe  cases  the  legs  become  feeble  and  some- 
times spastic.  Sensation  is  much  less  affected  than  motility.  Choked  disk 
is  not  uncommon.  The  mental  condition  is  variable;  the  child  may  be 
bright,  but,  as  a  rule,  there  is  some  grade  of  imbecility.  The  congenital 
cases  usually  die  within  the  first  four  or  five  years.  The  process  may  be 
arrested  and  the  patient  may  reach  adult  life.  Cases  of  this  sort  are  not 
very  uncommon.  Even  when  extreme,  the  mental  faculties  may  be  retained, 
as  in  Bright's  celebrated  patient,  Cardinal,  who  lived  to  the  age  of  twenty- 
nine,  and  whose  head  was  translucent  when  the  sun  was  shining  behind 
him.  Care  must  be  taken  not  to  mistake  the  rachitic  head  for  hydro- 
cephalus. 

(3)  Acquired  Chronic  Hydrocephalus.— This  is  stated  to  be  occasionally 
primary  (idiopathic) — that  is  to  say,  it  comes  on  spontaneously  in  the 
adult  without  observable  lesion.  Dean  Swift  is  said  to  have  died  of  hydro- 
cephalus, but  this  seems  very  unlikely.  It  is  based  upon  the  statement 
that  "  he  (Mr.  Whiteway)  opened  the  skull  and  found  much  water  in  the 
brain,"  a  condition  no  doubt  of  h.  ex  vacuo,  due  to  the  wasting  associated 
with  his  prolonged  illness  and  paralysis.    In  nearly  all  cases  there  is  either 


1030  DISEASES  OF  THE  NERVOUS  SYSTEM. 

a  tumor  at  the  base  of  the  brain  or  in  the  third  ventricle,  which  compresses 
the  vense  Galeni.  The  passage  from  the  third  to  the  fourth  ventricle  may 
be  closed,  either  by  a  tumor  or  by  parasites.  More  rarely  the  foramen  of 
Magendie,  through  which  the  ventricles  communicate  with  the  cerebro- 
spinal meninges,  becomes  closed  by  meningitis.  These  conditions,  occur- 
ring in  adults,  may  produce  the  most  extreme  hydrocephalus  without  any 
enlargement  of  the  head.  Even  when  the  tumor  begins  early  in  life  there 
may  be  no  expansion  of  the  skull.  In  the  case  of  a  girl  aged  sixteen,  blind 
from  her  third  year,  the  head  was  not  unusually  large,  the  ventricles  were 
enormously  distended,  and  in  the  Rolandic  region  the  brain  substance  was 
only  5  mm.  in  thickness.  A  tumor  occupied  the  third  ventricle.  In  a  case 
of  cholesteatoma  of  the  floor  of  the  third  ventricle,  in  which  the  symptoms 
persisted  at  intervals  for  eight  or  nine  years,  the  ventricles  were  enormously 
distended  without  enlargement  of  the  skull.  In  other  instances  the  sutures 
separate  and  the  head  gradually  enlarges.  ^ 

The  symptoms  of  hydrocephalus  in  the  adult  are  curiously  variable. 
In  the  first  case  mentioned  there  were  early  headaches  and  gradual  blind- 
ness; then  a  prolonged  period  in  which  she  was  able  to  attend  to  her  studies. 
Headaches  again  supervened,  the  gait  became  irregular  and  somewhat 
ataxic.  Death  occurred  suddenly.  In  the  other  case  there  were  prolonged 
attacks  of  coma  with  a  slow  pulse,  and  on  one  occasion  the  patient  remained 
unconscious  for  more  than  three  months.  Gradually  progressing  optic 
neuritis  without  focalizing  symptoms,  headache,  and  attacks  of  somnolence 
or  coma  are  suggestive  symptoms.  These  cases  of  acquired  chronic  hydro- 
cephalus cannot  be  certainly  diagnosed  during  life,  though  in  certain  in- 
stances the  condition  may  be  suspected. 

Treatment. — Very  little  can  be  done  to  relieve  hydrocephalus.  Medi- 
cines are  powerless  to  cause  the  absorption  of  the  fluid.  More  rational  is 
the  system  of  gradual  compression,  with  or  without  the  withdrawal  of  small 
quantities  of  the  fluid.  The  compression  may  be  made  by  means  of  broad 
plasters,  so  applied  as  to  cross  each  other  on  the  vertex,  and  another  may 
be  placed  round  the  circumference.  In  the  meningitis  serosa  Quincke  ad- 
vises the  use  of  mercury. 

Of  late  years  puncture  of  the  ventricles,  an  operation  which  has  been 
abandoned,  has  been  revived;  it  has  been  resorted  to  in  the  meningitis 
serosa.  When  pressure  symptoms  are  marked  Quincke's  procedure  may  be 
used.  He  recommends  puncture  of  the  subarachnoid  sac  between  the  third 
and  the  fourth  lumbar  vertebrse.  At  this  point  the  spinal  cord  cannot  be 
touched.  The  advantages  are  9,  slower  removal  of  fluid  and  less  danger  of 
collapse. 


NEURITIS.  1031 

YI.    DISEASES   OF  THE  PEKIPHERAL  NEEYES. 

I .    NEURITIS   {Inflammation  of  the  Bundles  of  Nerve  Fibres). 

Neuritis  may  be  localized  in  a  single  nerve,  or  general,  involving  a  large 
number  of  nerves,  in  which  case  it  is  usually  known  as  multiple  neuritis  or 
polyneuritis. 

Etiology. — Localized  neuritis  arises  from  {a)  cold,  which  is  a  very  fre- 
quent cause,  as,  for  example,  in  the  facial  nerve.  This  is  sometimes  known 
as  rheumatic  neuritis,  (h)  Traumatism — wounds,  blows,  direct  pressure  on 
the  nerves,  the  tearing  and  stretching  which  follow  a  dislocation  or  a  frac- 
ture, and  the  hypodermic  injection  of  ether.  Under  this  section  come  also 
the  professional  palsies,  due  to  pressure  in  the  exercise  of  certain  occupa- 
tions, (c)  Extension  of  inflammation  from  neighboring  parts,  as  in  a  neuri- 
tis of  the  facial  nerve  due  to  caries  in  the  temporal  bone,  or  in  that  met 
with  in  syphilitic  disease  of  the  bones,  disease  of  the  joints,  and  occasionally 
in  tumors. 

Multiple  neuritis  has  a  very  complex  etiology,  the  causes  of  which  may 
be  classified  as  follows:  (a)  The  poisons  of  infectious  diseases,  as  in  leprosy, 
diphtheria,  typhoid  fever,  small-pox,  scarlet  fever,  and  occasionally  in  other 
forms;  (b)  the  organic  poisons,  comprising  the  diffusible  stimulants,  such 
as  alcohol  and  ether,  bisulphide  of  carbon  and  naphtha,  and  the  metallic 
bodies,  such  as  lead,  arsenic,  and  mercury;  (c)  cachectic  conditions,  such  as 
occur  in  angemia,  cancer,  tuberculosis,  or- marasmus  from  any  cause;  (d)  the 
endemic  neuritis  or  beri-beri;  and  (e)  lastly,  there  are  cases  in  which  none 
of  these  factors  prevail,  but  the  disease  sets  in  suddenly  after  overexertion 
or  exposure  to  cold. 

Morbid  Anatomy. — In  neuritis  due  to  the  extension  of  inflamma- 
tion the  nerve  is  usually  swollen,  infiltrated,  and  red  in  color.  The  inflam- 
mation may  be  chiefly  perineural  or  it  may  pass  into  the  deeper  portion — 
interstitial  neuritis — in  which  form  there  is  an  accumulation  of  lymphoid 
elements  between  the  nerve  bundles.  The  nerve  fibres  themselves  may  not 
appear  involved,  but  there  is  an  increase  in  the  nuclei  of  the  sheath  of 
Schwann.  The  myelin  is  fragmented,  the  nuclei  of  the  internodal  cells  are 
swollen,  and  the  axis  cylinders  present  varicosities  or  undergo  granular  de- 
generation. Ultimately  the  nerve  fibres  may  be  completely  destroyed  and 
replaced  by  a  fibrous  connective  tissue  in  which  much  fat  is  sometimes  de- 
posited— the  lipomatous  neuritis  of  Leyden. 

In  other  instances  the  condition  is  termed  parenchymatous  neuritis,  in 
which  the  changes  are  like  those  met  with  in  the  secondary  or  Wallerian 
degeneration,  which  follows  when  the  nerve  fibre  is  cut  off  from  the  cell 
body  of  the  neurone  to  which  it  belongs.  The  medullary  substance  and  the 
axis  cylinders  are  chiefly  involved,  the  interstitial  tissue  being  but  little 
altered  or  only  affected  secondarily.  The  myelin  becomes  segmented  and 
divides  into  small  globules  and  granules,  and  the  axis  cylinders  become 
granular,  broken,  subdivided,  and  ultimately  disappear.  The  nuclei  of  the 
sheath  of  Schwann  proliferate  and  ultimately  the  fibres  are  reduced  to  a 


1032  DISEASES  OF  THE  NERVOUS  SYSTEM. 

state  of  atrophic  tubes  without  a  trace  of  the  normal  structure.  The  mus- 
cles connected  with  the  degenerated  nerves  usually  show  marked  atrophic 
changes,  and  in  some  instances  the  change  in  the  nerve  sheath  appears  to 
estend  directly  to  the  interstitial  tissue  of  the  muscles — the  neuritis  fascians 
of  Eichhorst. 

Symptoms. — («)  Localized  Neuritis. — As  a  rule  the  constitutional 
disturbances  are  slight.  The  most  important  symptom  is  pain  of  a  boring 
or  stabbing  character,  usually  felt  in  the  course  of  the  nerve  and  in  the 
parts  to  which  it  is  distributed.  The  nerve  itself  is  sensitive  to  pressure, 
probably,  as  TTeir  Mitchell  suggests,  owing  to  the  irritation  of  its  nervi 
nervorum.  The  skin  may  be  slightly  reddened  or  even  oedematous  over 
the  seat  of  the  inflammation.  Mitchell  has  described  increase  in  the  tem- 
perature and  sweating  in  the  affected  region,  and  such  trophic  disturbances 
as  effusion  into  the  Joints  and  herpes.  The  function  of  the  muscle  to  which 
the  nerve  fibres  are  distributed  is  impaired,  motion  is  painful,  and  there 
may  be  twitchings  or  contractions.  The  tactile  sensation  of  the  part  may 
be  somewhat  deadened,  even  when  the  pain  is  greatly  increased.  In  the 
more  chronic  cases  of  local  neuritis,  such,  for  instance,  as  follow  the  dis- 
location of  the  humerus,  the  localized  pain,  which  at  first  may  be  severe, 
gradually  disappears,  though  some  sensitiveness  of  the  brachial  plexus  may 
persist  for  a  long  time,  and  the  nerve  cords  may  be  felt  to  be  swollen  and 
firm.  The  pain  is  variable — sometimes  intense  and  distressing;  at  others 
not  causing  much  inconvenience.  Xumbness  and  formication  may  be  pres- 
ent and  the  tactile  sensation  may  be  greatly  impaired.  The  motor  disturb- 
ances are  marked.  Ultimately  there  is  extreme  atrophy  of  the  muscles. 
Contractures  may  occur  in  the  fingers.  The  skin  may  be  reddened  or  glossy, 
the  subcutaneous  tissue  oedematous,  and  the  nutrition  of  the  nails  may  be 
defective.  In  the  rheumatic  neuritis  subcutaneous  fibroid  nodules  may 
develop. 

A  neuritis  limited  at  first  to  a  peripheral  nerve  may  extend  upward — 
the  so-called  ascending  or  migratory  neuritis — and  involve  the  larger  nerve 
trunks,  or  even  reach  the  spinal  cord,  causing  subacute  myelitis  (Gowers). 
The  condition  is  rarely  seen  in  the  neuritis  from  cold,  or  in  that  which 
follows  fevers;  but  it  occurs  most  frequently  in  traumatic  neuritis.  J.  K. 
Mitchell,  in  his  monograph  On  Injuries  of  Xerves  (1895),  concludes  that 
the  larger  nerve  trunks  are  most  susceptible,  and  that  the  neuritis  may 
spread  either  up  or  down,  the  former  being  the  most  common.  The  paraly- 
sis secondary  to  visceral  disease,  as  of  the  bladder,  may  be  due  to  an  ascend- 
ing neuritis.  The  inflammation  may  extend  to  the  nerves  of  the  other  side, 
either  through  the  spinal  cord  or  its  membranes,  or  without  any  involve- 
ment of  the  nerve  centres,  the  so-called  sympathetic  neuritis.  The  elec- 
trical changes  in  localized  neuritis  vary  a  great  deal,  depending  upon  the 
extent  to  which  the  nerve  is  injured.  The  lesion  may  be  so  slight  that  the 
nerve  and  the  muscles  to  which  it  is  distributed  may  react  normally  to  both 
currents;  or  it  may  be  so  severe  that  the  typical  reaction  of  degeneration 
develops  within  a  few  days — i.  e.,  the  nerve  does  not  respond  to  stimula- 
tion by  either  current,  while  the  muscle  reacts  only  to  the  galvanic  current 
and  in  a  peculiar  manner.    The  contraction  caused  is  slow  and  lazy,  instead 


NEURITIS.  1033 

of  sharp  and  quick  as  in  the  normal  muscle,  and  the  AnC  contraction  is 
usually  stronger  than  the  CC  contraction.  Between  these  two  extremes 
there  are  many  different  grades,  and  a  careful  electrical  examination  is  most 
important  as  an  aid  to  diagnosis  and  prognosis.* 

The  duration  varies  from  a  few  days  to  weeks  or  months.  A  slight  trau- 
matic neuritis  may  pass  off  in  a  day  or  two,  while  the  severer  cases,  such  as 
follow  unreduced  dislocation  of  the  humerus,  may  persist  for  months  or 
never  be  completely  relieved. 

{i)  Multiple  Neuritis. — This  presents  a  complex  symptomatology.  The 
following  are  the  most  important  groups  of  cases: 

(1)  Acute  Febrile  Polyneuritis. — The  attack  follows  exposure  to  cold 
or  overexertion,  or,  in  some  instances,  comes  on  spontaneously.  The  onset 
resembles  that  of  an  acute  infectious  disease.  There  may  be  a  definite 
chill,  pains  in  the  back  and  limbs  or  Joints,  so  that  the  case  may  be  thought 
to  be  acute  rheumatism.  The  temperature  rises  rapidly  and  may  reach 
103°  or  104°.  There  are  headache,  loss  of  appetite,  and  the  general  symp- 
toms of  acute  infection.  The  limbs  and  back  ache.  Intense  pain  in  the 
nerves,  however,  is  by  no  means  constant.  Tingling  and  formication  are 
felt  in  the  fingers  and  toes,  and  there  is  increased  sensitiveness  of  the  nerve 
trunks  or  of  the  entire  limb.  Loss  of  muscular  power,  first  marked,  per- 
haps, in  the  legs,  gradually  comes  on  and  extends  with  the  features  of  an 
ascending  paralysis.  In  other  cases  the  paralysis  begins  in  the  arms.  The 
extensors  of  the  wrists  and  the  flexors  of  the  ankles  are  early  affected,  so 
that  there  is  foot  and  wrist  drop.  In  severe  cases  there  is  general  loss  of 
muscular  power,  producing  a  flabby  paralysis,  which  may  extend  to  the 
muscles  of  the  face  and  to  the  intercostals,  and  respiration  may  be  carried 
on  by  the  diaphragm  alone.  The  muscles  soften  and  waste  rapidly.  There 
may  be  only  hypersesthesia  with  soreness  and  stiffness  of  the  limbs;  in  some 
cases,  increased  sensitiveness  with  angesthesia;  in  other  instances  the  sen- 
sory disturbances  are  slight.  The  clinical  picture  is  not  to  be  distinguished, 
in  many  cases,  from  Landry's  paralysis;  in  others,  from  the  subacute  mye- 
litis of  Duchenne. 

The  course  is  variable.  In  the  most  intense  forms  the  patient  may  die 
in.  a  week  or  ten  days,  with  involvement  of  the  respiratory  muscles  or  from 
paralysis  of  the  heart.  As  a  rule  in  cases  of  moderate  severity,  after  per- 
sisting for  flve  or  six  weeks,  the  condition  remains  stationary  and  then  slow 
improvement  begins.  The  paralysis  in  some  muscles  may  persist  for  many 
months  and  contractures  may  occur  from  shortening  of  tlie  muscles,  but 
even  when  this  occurs  the  outlook  is,  as  a  rule,  good,  although  the  paralysis 
may  have  lasted  for  a  year  or  more. 

(2)  Bemrring  Multiple  Neuritis. — Under  the  term  polyneuritis  recurrent 
Mary  Sherwood  has  described  from  Eichhorst's  clinic  2  cases  in  adults — 
in  one  case  involving  the  nerves  of  the  right  arm,  in  the  other  botli  legs. 
In  one  patient  there  were  three  attacks,  in  the  other  two,  the  distribution 
in  the  various  attacks  being  identical.  The  subject  has  recently  been  fully 
discussed  by  IT.  M.  Thomas  (Phila.  Med.  Jour.,  1898,  i). 

*  Sco  under  Facial  Paralysis. 


1034  DISEASES  OP  THE  NERVOUS  SYSTEM. 

(3)  Alcoholic  Neuritis. — This,  perhaps  the  most  important  form  of  mul- 
tiple neuritis,  was  graphically  described  in  1822  by  James  Jackson,  Sr.,  of 
Boston.  Wnks  recognized  it  as  alcoholic  paraplegia,  but  the  starting-point 
of  the  recent  researches  on  the  disease  dates  from  the  observations  of 
Dumenil,  of  Eouen.  Of  late  years  our  knowledge  of  the  disease  has  ex- 
tended rapidly,  owing  to  the  researches  of  Huss,  Leyden,  James  Eoss,  Buz- 
zard, and  Henry  Hun.  It  occurs  most  frequently  in  women,  particularly  in 
steady,  quiet  tipplers.  Its  appearance  may  be  the  first  revelation  to  the 
physician  or  to  the  family  of  habits  of  secret  drinking.  The  onset  is  usually 
gradual,  and  may  be  preceded  for  weeks  or  months  by  neuralgic  pains  and 
tingling  in  the  feet  and  hands.  Convulsions  are  not  uncommon.  Fever  is 
rare.  The  paralysis  gradually  sets  in,  at  first  in  the  feet  and  legs,  and  then 
in  the  hands  and  forearms.  The  extensors  are  afi'ected  more  than  the  flexors, 
so  that  there  is  wrist-drop  and  foot-drop.  The  paralysis  may  be  thus  lim- 
ited and  not  extend  higher  in  the  limbs.  In  other  instances  there  is  para- 
plegia alone,  while  in  the  most  extreme  cases  all  the  extremities  are  in- 
volved. In  rare  instances  the  facial  muscles  and  the  sphincters  are  also 
affected.  The  sensory  symptoms  are  very  variable.  There  are  cases  in  which 
there  are  numbness  and  tingling  only,  without  great  pain.  In  other  cases 
there  are  severe  burning  or  boring  pains,  the  nerve  trunks  are  sensitive,  and 
the  muscles  are  sore  when  grasped.  The  hands  and  feet  are  frequently 
swollen  and  congested,  particularly  when  held  down  for  a  few  moments. 
The  cutaneous  reflexes  as  a  rule  are  preserved.  The  deep  reflexes  are  usually 
lost. 

The  course  of  these  alcoholic  cases  is,  as  a  rule,  favorable,  and  after  per- 
sisting for  weeks  or  months  improvement  gradually  begins,  the  muscles 
regain  their  power,  and  even  in  the  most  desperate  cases  recovery  may 
follow.  The  extensors  of  the  feet  may  remain  paralyzed  for  some  time, 
and  give  to  the  patient  a  distinctive  walk,  the  so-called  steppage  gait,  char- 
acteristic of  peripheral  neuritis.  It  is  sometimes  known  as  the  pseudo-tabetic 
gait,  although  in  reality  it  could  not  well  be  mistaken  for  the  gait  of  ataxia. 
The  foot  is  thrown  forcibly  forward,  the  toe  lifted  high  in  the  air  so  as  not 
to  trip  upon  it.  The  entire  foot  is  slapped  upon  the  ground  as  a  flail. 
It  is  an  awkward,  clumsy  gait,  and  gives  the  patient  the  appearance  of  con- 
stantly stepping  over  obstacles.  Among  the  most  striking  features  of  alco- 
holic neuritis  are  the  mental  symptoms.  Delirium  is  common,  and  there 
may  be  hallucinations  with  extravagant  ideas,  resembling  somewhat  those 
of  general  paralysis.  In  some  cases  the  picture  is  that  of  ordinary  delirium 
tremens,  but  the  most  peculiar  and  almost  characteristic  mental  disorder  is 
that  so  well  described  by  Wilks,  in  which  the  patient  loses  all  appreciation 
of  time  and  place,  and  describes  with  circumstantial  details  long  journeys 
which,  he  says,  he  has  recently  taken,  or  tells  of  persons  whom  he  has  just 
seen.    This  is  the  so-called  Korsakoff's  syndrome. 

(4)  Multiple  Neuritis  in  the  Infectious  Diseases. — This  has  been  already 
referred  to,  particularly  in  diphtheria,  in  which  it  is  most  common.  The 
peripheral  nature  of  the  lesion  in  these  instances  has  been  shown  by  post- 
mortem examination.  The  outlook  is  usually  favorable  and,  except  in  diph- 
theria, fatal  cases  are  uncommon.     Multiple  neuritis  in  tuberculosis,  dia- 


NEURITIS.  1035 

betes,  and  syphilis  is  of  the  same  nature,  being  probably  due  to  toxic  mate- 
rials absorbed  into  the  blood. 

(5)  The  Metallic  Poisons. — Neuritis  from  arsenic  may  follow:  (a)  The 
medicinal  use  particularly  of  Fowler's  solution.  I  have  reported  a  case  of 
Hodgkin's  disease  in  which  general  neuritis  was  caused  by  §  J  5  ij  of  the 
solution.  In  chorea  a  good  many  cases  have  been  reported.  (6)  The  acci- 
dental contamination  of  food  or  drink.  Chrome  yellow  may  be  used  to  color 
cakes,  as  in  the  cases  recorded  by  D.  D.  Stewart.  A  remarkable  epidemic 
of  neuritis  occurred  last  year  in  the  Midland  Counties  of  England,  which 
was  traced  to  the  use  of  beer  containing  small  quantities  of  arsenic,  a  con- 
tamination from  the  sulphuric  acid  used  in  making  glucose.  Some  hun- 
dreds of  cases  occurred.  The  general  features  have  been  referred  to  under 
arsenical  poisoning.  Lead  is  a  much  more  frequent  cause.  Neuritis  has 
followed  the  use  of  mercurial  inunctions.  Zinc  is  a  rare  cause.  I  saw  a 
case  with  Dr.  Urban  Smith  which  followed  the  use  of  two  grains  of  the 
sulpho-carbolate  taken  daily  for  three  years.  Tea,  coffee,  and  tobacco  are 
mentioned  as  rare  causes. 

(6)  Endemic  Neuritis,  Beri-beri,  has  been  considered  under  the  Infec- 
tious Diseases. 

Ansestliesia  Paralysis. — Here  perhaps  may  most  appropriately  be  con- 
sidered the  forms  of  paralysis  following  the  use  of  anesthetics,  or  of  too 
long-continued  compression  during  operations.  Much  has  been  written 
in  the  past  few  years  upon  this  subject,  which  has  been  very  fully  consid- 
ered by  Garrigues  (American  Journal  of  the  Medical  Sciences,  1897,  i). 
There  are  two  groups  of  cases: 

1.  During  an  operation  the  nerves  may  be  compressed,  either  the  bra- 
chial plexus  by  the  humerus  or  the  musculo-spiral  by  the  table.  The  pres- 
sure most  frequently  occurs  when  the  arm  is  elevated  alongside  the  head, 
as  in  laparotomy  done  in  the  Trendelenburg  position,  or  held  out  from  the 
body,  as  in  breast  amputations.  Instances  of  paralysis  of  the  crural  nerves 
by  leg-holders  are  also  reported.  The  too  firm  application  of  an  Esmarch 
bandage  may  be  followed  by  a  severe  paralysis. 

2.  Paralysis  from  cerebral  lesions  during  etherization.  In  one  of  Gar- 
rigues' cases  paralysis  followed  the  operation,  and  at  the  autopsy,  seven 
weeks  later,  softening  of  the  brain  was  found.  Apoplexy  or  embolism  may 
develop  during  anaesthesia.  In  Montreal  a  cataract  operation  was  per- 
formed on  an  old  man.  He  did  not  recover  from  the  anesthetic;  I  found 
post  mortem  a  cerebral  haemorrhage.  A  man  was  admitted  to  the  Phila- 
delphia Hospital,  completely  comatose,  who  on  the  previous  day  had  been 
given  ether  for  a  minor  operation.  He  never  recovered  consciousness,  but 
remained  deeply  comatose,  with  great  muscular  relaxation,  low  tempera- 
ture, 97.5°,  and  noisy  respirations;  he  died  two  days  later.  There  was, 
unfortunately,  no  autopsy.  Epileptic  convulsions  may  occur  during  the 
anaesthesia,  and  may  even  prove  fatal.  The  possibility  has  to  be  considered 
of  paralysis  from  loss  of  blood  in  prolonged  operations,  though  I  have  no 
personal  knowledge  of  any  such  cases. 

And,  lastly,  a  paralysis  might  result  from  the  toxic  effects  of  the  ether 
in  a  very  protracted  administration. 


1036  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Diagnosis. — The  electrical  condition  in  multiple  neuritis  is  thus  de- 
scribed by  Allen  Starr:  "  The  excitability  is  very  rapidly  and  markedly 
changed;  but  the  conditions  which  have  been  observed  are  quite  various. 
Sometimes  there  is  a  simple  diminution  of  excitability,  and  then  a  very 
strong  faradic  or  galvanic  current  is  needed  to  produce  contractions.  Fre- 
quently all  faradic  excitability  is  lost  and  then  the  muscles  contract  to  a 
galvanic  current  only.  In  this  condition  it  may  require  a  very  strong  gal- 
vanic current  to  produce  contraction,  and  thus  far  it  is  quite  pathognomonic 
of  neuritis.  For  in  anterior  polio-myelitis,  where  the  muscles  respond  to 
galvanism  only,  it  does  not  require  a  strong  current  to  cause  a  motion  until 
some  months  after  the  invasion. 

"  The  action  of  the  different  poles  is  not  uniform.  In  many  cases  the 
contraction  of  the  muscle  when  stimulated  with  the  positive  pole  is  greater 
than  when  stimulated  with  the  negative  pole,  and  the  contractions  may  be 
sluggish.  Then  the  reaction  of  degeneration  is  present.  But  in  some  cases 
the  normal  condition  is  found  and  the  negative  pole  produces  stronger 
contractions  than  the  positive  pole.  A  loss  of  faradic  irritability  and  a 
marked  decrease  in  the  galvanic  irritability  of  the  muscle  and  nerve  are 
therefore  important  symptoms  of  multiple  neuritis.^' 

There  is  rarely  any  difficulty  in  distinguishing  the  alcohol  cases.  The 
combination  of  wrist  and  foot  drop  with  congestion  of  the  hands  and  feet, 
and  the  peculiar  delirium  already  referred  to,  is  quite  characteristic.  The 
rapidly  advancing  cases  with  paralysis  of  all  extremities,  often  reaching 
to  the  face  and  involving  the  sphincters,  are  more  commonly  regarded  as 
of  spinal  origin,  but  the  general  opinion  seems  to  point  strongly  to  the 
fact  that  all  such  cases  are  peripheral.  The  less  acute  cases,  in  which  the 
paralysis  gradually  involves  the  legs  and  arms  with  rapid  wasting,  simu- 
late closely  and  are  usually  confounded  with  the  subacute  atrophic  spinal 
paralysis  of  Duchenne.  The  diagnosis  from  locomotor  ataxia  is  rarely 
difficult.  The  steppage  gait  is  entirely  different  from  that  of  tabes.  There 
is  rarely  positive  incoordination.  The  patient  can  usually  stand  well  with 
the  eyes  closed.  Foot-drop  is  not  common  in  locomotor  ataxia.  The  light- 
ning pains  are  absent  and  there  are  no  pupillary  symptoms.  The  etiology, 
too,  is  of  moment.  The  patient  is  recovering  from  a  paralysis  which  has 
been  more  extensive,  or  from  arsenical  poisoning,  or  he  has  diabetes. 

Treatment.' — Eest  in  bed  is  essential.  In  the  acute  cases  with  fever, 
the  salicylates  and  antipyrin  are  recommended.  To  allay  the  intense  pain 
morphia  or  the  hot  applications  of  lead  water  and  laudanum  are  often 
required.  Great  care  must  be  exercised  in  treating  the  alcoholic  form, 
and  the  physician  must  not  allow  himself  to  be  deceived  by  the  statements 
of  the  relatives.  It  is  sometimes  exceedingly  difficult  to  get  a  history  of 
spirit-drinking.  In  the  alcoholic  form  it  is  well  to  reduce  the  stimulants 
gradually.  If  there  is  any  tendency  to  bed-sores  an  air-bed  should  be  used 
or  the  patient  placed  in  a  continuous  bath.  Gentle  friction  of  the  mus- 
cles may  be  applied  from  the  outset,  and  in  the  later  stages,  when  the  atro- 
phy is  marked  and  the  pains  have  lessened,  massage  is  probably  the  most 
reliable  means  at  our  command.  Contractures  may  be  gradually  overcome 
by  passive  movements  and  extension.     Often,  with  the  most  extreme  de- 


NEUROMATA.  1037 

formity  from  contracture,  recovery  is,  in  time,  still  possible.     The  inter- 
rupted current  is  useful  when  the  acute  stage  is  passed. 

Of  internal  remedies,  strychnia  is  of  value  and  may  be  given  in  in- 
creasing doses.  Arsenic  also  may  be  employed,  and  if  there  is  a  history  of 
syphilis  the  iodide  of  potassium  and  mercury  may  be  given. 


II.    NEUROMATA. 

Tumors  situated  on  nerve  fibres  may  consist  of  nerve  substance  proper, 
the  true  neuromata,  or  of  fibrous  tissue,  the  false  neuromata.  The  true 
neuroma  usually  contains  nerve  fibres  only,  or  in  rare  instances  ganglion 
cells.  Cases  of  ganglionic  or  medullary  neuroma  are  extremely  rare;  some 
of  them,  as  Lancereaux  suggests,  are  undoubtedly  instances  of  malforma- 
tion of  the  brain  substance.  In  other  instances,  as  in  the  case  which  I 
reported,  the  tumor  is,  in  all  probability,  a  glioma  with  cells  closely  resem- 
bling those  of  the  central  nervous  system.  The  true  fascicular  neuroma 
occurs  in  the  form  of  the  small  subcutaneous  painful  tumor — tubercula 
dolorosa — which  is  situated  on  the  nerves  of  the  skin  about  the  Joints,  some- 
times on  the  face  or  on  the  breast.  It  is  not  always  made  up  of  nerve  fibres, 
but  may  be,  as  shown  by  Hoggan,  an  adenomatous  growth  of  the  sweat 
glands. 

The  true  neuromata,  as  a  rule,  are  not  painful,  and  occasionally  are 
found  associated  with  the  nerve  fibres  in  various  regions.  Those  which 
develop  at  the  ends  and  along  the  course  of  the  nerves  of  the  stump  after 
amputation  consist  of  connective  tissue  and  of  medullated  and  non-medul- 
lated  nerve  fibres.  The  most  remarkable  form  is  the  plexiform  neuroma, 
in  which  the  various  nerve  cords  are  occupied  by  many  hundreds  of  tumors. 
The  cases  are  usually  congenital.  The  tumors  occur  in  all  the  nerves  of 
the  body.  One  of  the  most  remarkable  is  that  described  by  Prudden,  the 
specimens  of  which  are  in  the  medical  museum  of  Columbia  College,  New 
York.  There  were  over  1,183  distinct  tumors  distributed  on  the  nerves 
of  the  body.  E.  W.  Smith's  splendid  monograph  on  neuromata  has  been 
reprinted  this  year  (1898)  by  the  New  Sydenham  Society. 

Neuromata  rarely  cause  symptoms,  except  the  subcutaneous  painful 
tumor  or  those  in  the  amputation  stump.  Here  they  may  be  very  painful 
and  cause  great  distress.  Motor  symptoms  are  sometimes  present,  particu- 
larly a  constant  twitching.  Epilepsy  has  sometimes  been  associated,  and 
relief  has  followed  removal  of  the  growths. 

The  only  available  treatment  is  excision.  The  subcutaneous  painful 
tumor  does  not  return,  and  excision  completely  relieves  the  symptoms.  On 
the  other  hand,  the  amputation  neuromata  may  recur. 


65 


1038  DISEASES  OF  THE  NERVOUS  SYSTEM. 

III.    DISEASES  OF  THE  CEREBRAL  NERVES. 

Olfactoet   Neeves   and   Teacts 

The  functions  of  the  olfactory  nerves  may  be  disturbed  at  their  origin, 
in  the  nasal  mucons  membrane,  at  the  bulb,  in  the  course  of  the  tract,  or 
at  the  centres  in  the  brain.  The  disturbances  may  be  manifested  in  sub- 
jective sensations  of  smell,  complete  loss  of  the  sense,  and  occasionally  in 
hypereesthesia. 

(a)  Subjective  Sensations;  Parosmia. — Hallucinations  of  this  kind  are 
found  in  the  insane  and  in  epilepsy.  The  aura  may  be  represented  by  an 
unpleasant  odor,  described  as  resembling  chloride  of  lime,  burning  rags, 
or  feathers.  In  a  few  cases  with  these  subjective  sensations  tumors  have 
been  found  in  the  hippocampi.  In  rare  instances,  after  injury  of  the  head 
the  sense  is  perverted — odors  of  the  most  different  character  may  be  alike, 
or  the  odor  may  be  changed,  as  in  a  patient  noted  by  Morell  Mackenzie, 
who  for  some  time  could  not  touch  cooked  meat,  as  it  smelt  to  her  exactly 
like  stinking  fish. 

(b)  Increased  sensitiveness,  or  liyperosmia,  occurs  chiefly  in  nervous,  hys- 
terical women,  in  whom  it  may  sometimes  be  developed  so  greatly  that,  like 
a  dog,  they  can  recognize  the  difference  between  individuals  by  the  odor 
alone. 

(c)  Anosmia;  Loss  of  the  Sense  of  Smell. — This  may  be  produced  by: 
(1)  Affections  of  the  origin  of  the  nerves  in  the  mucous  membrane,  which 
is  perhaps  the  most  frequent  cause.  It  is  by  no  means  uncommon  in  asso- 
ciation with  chronic  nasal  catarrh  and  polypi.  In  paralysis  of  the  fifth 
nerve,  the  sense  of  smell  may  be  lost  on  the  affected  side,  owing  to  inter- 
ference with  the  secretion. 

It  is  doubtful  whether  the  cases  of  loss  of  smell  following  the  inhala- 
tions of  very  foul  or  strong  odors  should  come  under  this  or  under  the 
central  division. 

(2)  The  lesions  of  the  bulbs  or  of  the  tracts.  In  falls  or  blows,  in  caries 
of  the  bones,  and  in  meningitis  or  tumor,  the  bulbs  or  the  olfactory  tracts 
may  be  involved.  After  an  injury  to  the  head  the  loss  of  smell  may  be  the 
only  symptom.  Mackenzie  notes  a  case  of  a  surgeon  who  was  thrown  from 
his  gig  and  lighted  on  his  head.  The  injury  was  slight,  but  the  anosmia 
which  followed  was  persistent.  In  locomotor  ataxia  the  sense  of  smell  may 
be  lost,  possibly  owing  to  atrophy  of  the  nerves. 

(3)  Lesions  of  the  olfactory  centres.  There  are  congenital  eases  in 
which  the  structures  have  not  been  developed.  Cases  have  been  reported 
by  Beevor,  Hughlings  Jackson,  and  others,  in  which  anosmia  has  been 
associated  with  disease  in  the  hemisphere.  The  centre  for  the  sense  of 
smell  is  placed  by  Ferrier  in  the  uncinate  gyrus.  Flechsig  describes  (1)  a 
frontal  centre  in  the  base  of  the  frontal  lobe  and  (3)  a  temporal  centre  in 
the  uncus. 

To  test  the  sense  of  smell  the  pungent  bodies,  such  as  ammonia,  which 
act  upon  the  fifth  nerve,  should  not  be  used,  but  such  substances  as  cloves, 
peppermint,  and  musk.    This  sense  is  readily  tested  as  a  routine  matter  in 


DISEASES  OF  THE  CEREBRAL  NERVES.  1039 

brain  cases  by  having  two  or  three  bottles  containing  the  essential  oils. 
In  all  instances  a  rhinoscopical  examination  should  be  made,  as  the  con- 
dition may  be  due  to  local,  not  central  causes.  The  treatment  is  unsatisfac- 
tory even  in  the  cases  due  to  local  lesions  in  the  nostrils. 

Optic  Nerve  and  Tract. 

(1)  Lesions  of  the  Retina. 

These  are  of  importance  to  the  physician,  and  information  of  the  great- 
est value  may  be  obtained  by  a  systematic  examination  of  the  eye-grounds. 
Only  a  brief  reference  can  here  be  made  to  the  more  important  of  the  ap- 
pearances. 

(a)  Retinitis. — This  occurs  in  certain  general  affections,  more  particu- 
larly in  Bright's  disease,  syphilis,  leukgemia,  and  anasmia.  The  common 
feature  in  all  these  states  is  the  occurrence  of  hsemorrhage  and  the  develop- 
ment of  opacities.  There  may  also  be  a  diffuse  cloudiness  due  to  effusion 
of  serum.  The  hagmorrhages  are  in  the  layer  of  nerve  fibres.  They  vary 
greatly  in  size  and  form,  but  often  follow  the  course  of  vessels.  Wlien 
recent  the  color  is  bright  red,  but  they  gradually  change  and  old  hsemor- 
rhages  are  almost  black.  The  white  spots  are  due  either  to  fibrinous  exudate 
or  to  fatty  degeneration  of  the  retinal  elements,  and  occasionally  to  accumu- 
lation of  leucocytes  or  to  a  localized  sclerosis  of  the  retinal  elements.  The 
more  important  of  the  forms  of  retinitis  to  be  recognized  are: 

ATbuminuric  retinitis,  which  occurs  in  chronic  nephritis,  particularly  in 
the  interstitial  or  contracted  form.  The  percentage  of  cases  affected  is  from 
15  to  25.  There  are  instances  in  which  these  retinal  changes  are  associated 
with  the  granular  kidney  at  a  stage  when  the  amount  of  albumen  may  be 
slight  or  transient;  but  in  all  such  instances  it  will  be  found  that  there 
is  a  marked  arterio-sclerosis.  Gowers  recognizes  a  degenerative  form  (most 
common),  in  which,  with  the  retinal  changes,  there  may  be  scarcely  any 
alteration  in  the  disk;  a  hsemorrhagic  form,  with  many  haemorrhages  and 
but  slight  signs  of  inflammation;  and  an  inflammatory  form,  in  which 
there  is  much  swelling  of  the  retina  and  obscuration  of  the  disk.  It  is  note- 
worthy that  in  some  instances  the  inflammation  of  the  optic  nerve  pre- 
dominates over  the  retinal  changes,  and  one  may  be  in  doubt  for  a  time 
whether  the  condition  is  really  associated  with  the  renal  changes  or  de- 
pendent upon  intracranial  disease. 

Syphilitic  Retinitis. — In  the  acquired  form  this  is  less  common  than 
choroiditis.  In  inherited  syphilis  retinitis  pigmentosa  is  sometimes  met 
with. 

Retinitis  in  Anwrnia. — It  has  long  been  known  that  a  patient  may 
become  blind  after  a  large  haemorrhage,  either  suddenly  or  within  two  or 
three  days,  and  in  one  or  both  eyes.  Occasionally  the  loss  may  be  perma- 
nent and  complete.  In  some  of  these  instances  a  neuro-retinitis  has  been 
found,  probably  sufficient  to  account  for  the  symptoms.  In  the  more 
chronic  anaemias,  particularly  in  the  pernicious  form,  retinitis  is  common, 
as  determined  first  by  Quincke. 

In  malaria  retinitis  or  neuro-retinitis  may  be  present,  as  noted  by 


1040  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Stephen  Mackenzie.  It  is  seen  only  in  the  chronic  cases  with  anaemia,  and 
in  my  experience  is  not  nearly  so  common  proportionately  as  in  pernicious 
anasmia. 

Leukcemic  Retinitis. — In  this  affection  the  retinal  veins  are  large  and 
distended;  there  is  also  a  peculiar  retinitis,  as  described  by  Liebreich.  It 
is  not  very  common.  It  existed  in  only  3  of  10  cases  of  which  I  have  notes 
of  examination  of  the  retina.  There  are  numerous  haemorrhages  and  white 
or  yellow  areas,  which  may  be  large  and  prominent.  In  one  of  my  cases 
the  retina  post  mortem  was  dotted  with  many  small,  opaque,  white  spots, 
looking  like  little  tumors,  the  larger  of  which  had  a  diameter  of  nearly 
2  mm.  In  Case  13  of  my  series  the  leukaemia  was  diagnosed  by  Norris  and 
De  Schweinitz,  at  whose  clinic  the  patient  had  applied  on  account  of  failing 
vision,  from  the  condition  of  the  eye-grounds  alone, 

Eetinitis  is  also  found  occasionally  in  diabetes,  in  purpura,  in  chronic 
lead  poisoning,  and  sometimes  as  an  idiopathic  affection. 

{h)  Functional  Disturbances  of  Vision.— (1)  Toxic  Amaurosis. — This 
occurs  in  uremia  and  may  follow  convulsions  or  come  on  independently. 
The  condition,  as  a  rule,  persists  only  for  a  day  or  two.  This  form  of 
amaurosis  occurs  in  poisoning  by  lead,  alcohol,  and  occasionally  by  quinine. 
It  seems  more  probable  that  the  poisons  act  on  the  centres  and  not  on  the 
retina. 

(3)  Tobacco  Amblyopia. — The  loss  of  sight  is  usually  gradual,  equal  in 
both  eyes,  and  affects  particularly  the  centre  of  the  field  of  vision.  The 
eye-grounds  may  be  normal,  but  occasionally  there  is  congestion  of  the 
disks.  On  testing  the  color  fields  a  central  scotoma  for  red  and  green  is 
found  in  all  cases.  Ultimately,  if  the  use  of  tobacco  is  continued,  organic 
changes  may  develop  with  atrophy  of  the  disk. 

(3)  Hysterical  Amaurosis. — More  frequently  this  is  loss  of  acuteness 
of  vision — amblyopia — but  the  loss  of  sight  in  one  or  both  eyes  may  ap- 
parently be  complete.  The  condition  will  be  mentioned  subsequently  under 
hysteria. 

(4)  Night-blindness — nyctalopia — the  condition  in  which  objects  are 
clearly  seen  during  the  day  or  by  strong  artificial  light,  but  become  invisible 
in  the  shade  or  in  twilight,  and  hemeralopia,  in  which  objects  cannot  be 
clearly  seen  without  distress  in  daylight  or  in  a  strong  artificial  light,  but 
are  readily  seen  in  a  deep  shade  or  in  twilight,  are  functional  anomalies  of 
vision  which  rarely  come  under  the  notice  of  the  physician.  It  may  occur 
in  epidemic  form. 

(5)  Retinal  hypercesthesia  is  sometimes  seen  in  hysterical  women,  but 
is  not  found  frequently  in  actual  retinitis.  I  have  seen  it  once,  however, 
in  albuminuric  retinitis,  and  once,  in  a  marked  degree,  in  a  patient  with 
aortic  insufficiency,  in  whose  retinae  there  were  no  signs  other  than  the 
throbbing  arteries. 

(3)  Lesions  of  the  Optic  Nerve. 

(a)  Optic  Neuritis  (Papillitis;  ChoTced  Dish). — In  the  first  stage  there 
is  congestion  of  the  disk  and  the  edges  are  blurred  and  striated.  In  the 
second  stage,  the  congestion  is  more  marked,  the  swelling  increases,  the 


DISEASES  OP  THE  CEREBRAL  NERVES.  1041 

striation  also  is  more  visible.  The  physiological  cupping  disappears  and 
haemorrhages  are  not  uncommon.  The  arteries  present  little  change,  the 
veins  are  dilated,  and  the  disk  may  swell  greatly.  In  slight  grades  of  in- 
flammation the  swelling  gradually  subsides  and  occasionally  the  nerve  re- 
covers completely.  In  instances  in  which  the  swelling  and  exudate  are 
very  great,  the  subsidence  is  slow,  and  when  it  finally  disappears  there  is 
complete  atrophy  of  the  nerve.  The  retina  not  infrequently  participates 
in, the  inflammation,  which  is  then  a  neuro-retinitis. 

This  condition  is  of  the  greatest  importance  in  diagnosis.  It  may  exist 
in  its  early  stages  without  any  disturbance  of  vision,  and  even  with  exten- 
sive papillitis  the  sight  may  for  a  time  be  good. 

Optic  neuritis  is  seen  occasionally  in  anaemia  and  lead  poisoning,  more 
commonly  in  Bright's  disease  as  neuro-retinitis.  It  occurs  occasionally  as 
a  primary  idiopathic  affection.  The  frequent  connection  with  intracranial 
disease,  particularly  tumor,  makes  its  presence_of  great  value  to  practi- 
tioners. The  nature  of  the  growth  is  without  influence.  In  over  90  per 
cent  of  such  instances  the  papillitis  is  bilateral.  It  is  also  found  in  menin- 
gitis, either  the  tuberculous  or  the  simple  form.  In  meningitis  it  is  easy 
to  see  how  the  inflammation  may  extend  down  the  nerve  sheath.  In  the 
case  of  tumor  it  was  thought  at  first  that  a  choked  disk  resulted  from  in- 
creased pressure  within  the  skull.  It  is  now  more  commonly  regarded, 
however,  as  a  descending  neuritis. 

(i)  Optic  Atrophy. — This  may  be:  (1)  A  primary  affection.  There  is 
an  hereditary  form,  in  which  the  disease  has  developed  in  all  the  males  of 
a  family  shortly  after  puberty.  A  large  number  of  the  cases  of  primary 
atrophy  are  associated  with  spinal  disease,  particularly  locomotor  ataxia. 
Other  causes  which  have  been  assigned  for  the  primary  atrophy  are  cold, 
sexual  excesses,  diabetes,  the  specific  fevers,  alcohol,  and  lead. 

(2)  Secondary  atrophy  results  from  cerebral  diseases,  pressure  on  the 
chiasma  or  on  the  nerves,  or,  most  commonly  of  all,  as  a  sequence  of  pa- 
pillitis. 

The  ophthalmoscopic  appearances  are  different  in  the  cases  of  primary 
and  secondary  atrophy.  In  the  former,  the  disk  has  a  gray  tint,  the  edges 
are  well  defined,  and  the  arteries  look  almost  normal;  whereas  in  the  con- 
secutive atrophy  the  disk  has  a  staring  opaque-white  aspect,  with  irregular 
outlines,  and  the  arteries  are  very  small. 

The  symptom  of  optic  atrophy  is  loss  of  sight,  proportionate  to  the 
damage  in  the  nerve.  The  change  is  in  three  directions:  "  (1)  Diminished 
acuity  of  vision;  (3)  alteration  in  the  field  of  vision;  and  (3)  altered  per- 
ception of  color  "  (Gowers).    The  outlook  in  primary  atrophy  is  bad. 


(3)  Affections  of  the  Chiasma  and  Tract. 

At  the  chiasma  the  optic  nerves  undergo  partial  decussation.  Each 
optic  tract,  as  it  leaves  the  chiasma,  contains  nerve  fibres  which  originate 
in  the  retinae  of  both  eyes.  Thus,  of  the  fibres  of  the  right  tract,  part  have 
come  through  the  chiasma  without  decussating  from  the  temporal  half 
of  the  right  retina,  the  other  and  larger  portion  of  the  fibres  of  the  tract 


1042  DISEASES  OP  THE  NERVOUS  SYSTEM. 

have  decussated  in  the  chiasma,  coming  as  they  do  from  the  left  optic  nerve 
and  the  nasal  half  of  the  retina  on  the  left  side.  The  fibres  which  cross 
are  in  the  middle  portion  of  the  chiasma,  while  the  direct  fibres  are  on  each 
side.  The  following  are  the  most  important  changes  which  ensue  in  lesions 
of  the  tract  and  of  the  chiasma: 

(a)  Unilateral  Affection  of  Tract. — If  on  the  right  side,  this  produces 
loss  of  function  in  the  temporal  half  of  the  retina  on  the  right  side,  and  in 
the  nasal  half  of  the  retina  on  the  left  side,  so  that  there  is  only  half  vision^ 
and  the  patient  is  blind  to  objects  on  the  left  side.  This  is  termed  homony- 
mous hemianopia  or  lateral  hemianopia.  The  fibres  passing  to  the  right 
half  of  each  retina  being  involved,  the  patient  is  blind  to  objects  in  the 
left  half  of  each  visual  field.  The  hemianopia  may  be  partial  and  only  a 
portion  of  .the  half  field  may  be  lost.  The  unaffected  visual  fields  may  have 
the  normal  extent,  but  in  some  instances  there  is  considerable  reduction. 
When  the  left  half  of  one  field  and  the  right  half  of  the  other,  or  vice  versa, 
are  blind,  the  condition  is  known  as  heteronymous  hemianopia. 

ih)  Disease  of  the  Chiasma. — (1)  A  lesion  involves,  as  a  rule,  chiefly 
the  central  portion,  in  which  the  decussating  fibres  pass  which  supply  the 
inner  or  nasal  halves  of  the  retinae,  producing  in  consequence  loss  of  vision 
in  the  outer  half  of  each  field,  or  what  is  known  as  temporal  hemianopia. 

(2)  If  the  lesion  is  more  extensive  it  may  involve  not  only  the  central 
portion,  but  also  the  direct  fibres  on  one  side  of  the  commissure,  in  which 
case  there  would  be  total  blindness  in  one  eye  and  temporal  hemianopia 
in  the  other. 

(3)  Still  more  extensive  disease  is  not  infrequent  from  pressure  of  tu- 
mors in  this  region,  the  whole  chiasma  is  involved,  and  total  blindness 
results.  The  different  stages  in  the  process  may  often  be  traced  in  a  single 
case  from  temporal  hemianopia,  then  complete  blindness  in  one  eye  with 
temporal  hemianopia  in  the  other,  and  finally  complete  blindness. 

(4)  A  limited  lesion  of  the  outer  part  of  the  chiasma  involves  only  the 
direct  fibres  passing  to  the  temporal  halves  of  the  retinge  and  inducing 
blindness  in  the  nasal  field,  or,  as  it  is  called,  nasal  hemianopia.  This,  of 
course,  is  extremely  rare.  Double  nasal  hemianopia  may  occur  as  a  mani- 
festation of  tabes  and  in  tumors  involving  the  outer  fibres  of  each  tract. 

(4)  Affections  of  the  Tract  and  Centres. 

The  optic  tract  crosses  the  crus  (cerebral  peduncle)  to  the  hinder  part 
of  the  optic  thalamus  and  divides  into  two  portions,  one  of  which  (the 
lateral  root)  goes  to  the  pulvinar  of  the  thalamus,  the  lateral  geniculate 
body,  and  to  the  anterior  quadrigeminal  body  (superior  colliculus).  From 
these  parts,  in  which  the  lateral  root  terminates,  fibres  pass  into  the  pos- 
terior part  of  the  internal  capsule  and  enter  the  occipital  lobe,  forming  the 
fibres  of  the  optic  radiation,  which  terminate  in  and  about  the  cuneus,  the 
region  of  the  visual  perceptive  centre.  The  fibres  of  the  meditil  division  of 
the  tract  pass  to  the  medial  geniculate  body  and  to  the  posterior  quadri- 
geminal body.  The  medial  root  contains  the  fibres  of  the  commissura  in- 
ferior of  V.  Gudden,  which  are  believed  to  have  no  connection  with  the 


DISEASES  OF  THE   CEREBRAL  NERVES. 


1043 


'su  ^^ 


Fig.  11. — Diagram  of  visual  paths.  (From  Vialet,  modified.)  OP.  N.,  Optic  nerve. 
OP.  C,  Optic  chiasm.  OP.  T.,  Optic  tract.  OP.  R.,  Optic  radiations.  GEN.,  Genic- 
ulate body.  THO.,  Optic  thalamus.  C.  QU.,  Corpora  quadrigemina.  C.  C,  Corpus 
callosum.  "V.  S.,  Visual  speech  centre.  A.  S.,  Auditory  speech  centre.  M.  S.,  Motor 
speech  centre.  A  lesion  at  1  causes  blindness  of  that  eye ;  at  2,  bi-temporal  hemia- 
nopia ;  at  3,  nasal  hemianopia.  Symmetrical  lesions  at  3  and  3'  would  cause  bi-nasal 
hemianopia;  at  4,  hemianopia  of  both  eyes,  with  hemianopic  pupillary  inaction;  at 
5  and  6,  hemianopia  of  both  eyes,  pupillary  reflexes  normal ;  at  7,  amblyopia,  espe- 
cially of  opposite  eye ;  at  8,  on  left  side,  word-blindness. 


1044  DISEASES   OF   THE  XERVOUS  SYSTEM. 

letinse.  It  is  still  held  by  some  physiologists  that  the  cortical  visual  centre 
is  not  confined  to  the  occipital  lobe  alone^,  but  embraces  the  occipito-angular 
region. 

A  lesion  of  the  fibres  of  the  optic  path  anywhere  between  the  cortical 
centre  and  the  chiasma  will  produce  hemianopia.  The  lesion  may  be  situ- 
ated:: (a)  In  the  optic  tract  itself,  (h)  In  the  region  of  the  thalamus, 
lateral  geniculate  body,  and  the  corpora  quadrigemina,  into  which  the 
larger  part  of  each  tract  enters,  (c)  A  lesion  of  the  fibres  passing  from  the 
centres  just  mentioned  to  the  occipital  lobe.  This  may  be  either  in  the 
hinder  part  of  the  internal  capsule  or  the  white  fibres  of  the  optic  radiation. 
(d)  Lesion  of  the  cuneus.  Bilateral  disease  of  the  cuneus  may  result  in 
total  blindness,  (e)  There  is.  clinical  evidence  to  show  that  lesion  of  the  an- 
gular gyrus  may  be  associated  with  visual  defect,  not  so  often  hemianopia 
as  crossed  amblyopia,  dimness  of  vision  in  the  opposite  eye,  and  great  con- 
traction in  the  field  of  vision.  Lesions  in  tliis  region  are  associated  with 
mind  blindness,  a  condition  in  which  there  is  failure  to  recognize  the  nature 
of  objects. 

The  effects  of  lesions  in  the  optic  nerve  in  different  situations  from  the 
retinal  expansion  to  the  brain  cortex  are  as  follows:  (1)  Of  the  optic  nerve 
— total  blindness  of  the  corresponding  eye;  (2)  of  the  optic  chiasma,  either 
temporal  hemianopia,  if  the  central  part  alone  is  involved,  or  nasal  hemi- 
anopia, if  the  lateral  region  of  each  chiasma  is  involved;  (3)  lesion  of  the 
optic  tract  between  the  chiasma  and  the  lateral  geniculate  body,  pro- 
duces lateral  hemianopia;  (4)  lesion  of  the  central  fibres  of  the  nerve  be- 
tween the  geniculate  bodies  and  the  cerebral  cortex  produces  lateral  hemi- 
anopia; (5)  lesion  of  the  cuneus  causes  lateral  hemianopia;  and  (6)  lesion 
of  the  angular  gyrus  may  be  associated  with  hemianopia,  sometimes  crossed 
amblyopia,  and  the  condition  known  as  mind  blindness.  (See  Fig.  11,  with 
accompanying  explanation.) 

Diagnosis. — The  student  or  practitioner  must  have  a  clear  idea  of 
the  physiology  of  the  nerve  centres  before  he  can  appreciate  the  s}Tnptoms 
or  undertake  the  diagnosis  of  lesions  of  the  optic  nerve.  Having  deter- 
mined the  presence  of  hemianopia,  the  question  arises  as  to  the  situation 
of  the  lesion,  whether  in  the  tract  between  the  chiasma  and  the  geniculate 
bodies  or  in  the  central  portion  of  the  fibres  between  these  bodies  and  the 
visual  centres.  This  can  be  determined  in  some  cases  by  the  test  known 
as  Wernicke's  Tiemiopic  pupillary  inaction.  The  pupil  refiex  depends  on 
the  integrity  of  the  retina  or  receiving  membrane,  on  the  fibres  of  the  op- 
tic nerve  and  tract  which  transmit  the  impulse,  and  the  nerve  centre  at 
the  termination  of  the  optic  tract  which  receives  the  impression  and  trans- 
mits it  to  the  third  nerve  along  which  the  motor  impulses  pass  to  the  iris. 
If  a  bright  light  is  thrown  into  the  eye  and  the  pupil  reacts,  the  integrity 
of  this  reflex  arc  is  demonstrated.  It  is  possible  in  cases  of  lateral  hemi- 
anopia so  to  throw  the  light  into  the  eye  that  it  falls  upon  the  blind  half 
of  the  retina.  If  when  this  is  done  the  pupil  contracts,  the  indication  is 
that  the  reflex  arc  above  referred  to  is  perfect,  by  which  we  mean  that  the 
optic  nerve  fibres  from  the  retinal  expansion  to  the  centre,  the  centre 
itself,  and  the  third  nerve  are  uninvolved.     In  such  a  case  the  conclusion 


DISEASES  OF  THE  CEREBRAL  NERVES.  1045 

would  be  justified  that  the  cause  of  the  hemianopia  was  central;  that  is, 
situated  beyond  the  geniculate  body,  either  in  the  fibres  of  the  optic  radi- 
ation or  in  the  visual  cortical  centres.  If,  on  the  other  hand,  when  the 
light  is  carefully  thrown  on  the  hemiopic  half  of  the  retina,  the  pupil  re- 
mains inactive,  the  conclusion  is  justifiable  that  there  is  interruption  in  the 
path  between  the  retina  and  the  nucleus  of  the  third  nerve,  and  that  the 
hemianopia  is  not  central,  but  dependent  upon  a  lesion  situated  in  the  optic 
tract.  This  test  of  Wernicke's  is  sometimes  difficult  to  obtain.  It  is  best 
performed  as  follows:  "  The  patient  being  in  a  dark  or  nearly  dark  room 
with  the  lamp  or  gas-light  behind  his  head  in  the  usual  position,  I  bid  him 
look  over  to  the  other  side  of  the  room,  so  as  to  exclude  accommodative 
iris  movements  (which  are  not  necessarily  associated  with  the  reflex).  Then 
I  throw  a  faint  light  from  a  plane  mirror  or  from  a  large  concave  mirror, 
held  well  out  of  focus,  upon  the  eye  and  note  the  size  of  the  pupil.  With 
my  other  hand  I  now  throw  a  beam  of  light,  focussed  from  the  lamp  by  an 
ophthalmoscopic  mirror,  directly  into  the  optical  centre  of  the  eye;  then 
laterally  in  various  positions,  and  also  from  above  and  below  the  equator 
of  the  eye,  noting  the  reaction  at  all  angles  of  incidence  of  the  ray  of  light." 
(Seguin.) 

The  significance  of  hemianopia  varies.  There  is  a  functional  hemi- 
anopia associated  with  migraine  and  hysteria.  In  a  considerable  propor- 
tion of  all  cases  there  are  signs  of  organic  brain-disease.  In  a  certain  num- 
ber of  instances  of  slight  lesions  of  the  occipital  lobe  hemiachromatopsia 
has  been  observed.  The  homonymous  halves  of  the  retina  as  far  as  the 
fixation  point  are  dulled,  or  blind  for  colors.  Hemiplegia  is  common,  in 
which  event  the  loss  of  power  and  blindness  are  on  the  same  side.  Thus, 
a  lesion  in  the  left  hemisphere  involving  the  motor  tract  produces  right 
hemiplegia,  and  when  the  fibres  of  the  optic  radiation  are  involved  in  the 
internal  capsule,  there  is  also  lateral  hemianopia,  so  that  objects  in  the  field 
of  vision  to  the  right  are  not  perceived.  Hemianassthesia  is  not  uncommon 
in  such  cases,  owing  to  the  close  association  of  the  sensory  and  visual  tracts 
at'  the  posterior  part  of  the  internal  capsule.  Certain  forms  of  aphasia 
also  occur  in  many  of  the  cases. 

The  optic  aphasia  of  Freund  may  be  mentioned  here.  The  patient  after 
an  apoplectic  attack,  though  able  to  recognize  ordinary  objects  shown  to 
him  is  unable  to  name  them  correctly.  If  he  be  permitted  to  touch  the 
object  he  may  be  able  to  name  it  quickly  and  correctly.  Freund's  optic 
aphasia  differs  from  mind-blindness,  since  in  the  latter  affection  the  objects 
seen  are  not  recognized.  Optic  aphasia,  like  word-blindness,  never  occurs 
alone,  but  is  always  associated  with  hemianopia,  or  mind-blindness,  and 
often  also  with  word-deafness.  In  the  cases  which  have  thus  far  come  to 
autopsy  there  has  always  been  a  lesion  in  the  white  matter  of  the  occipital 
lobe  on  the  left  side. 

Motor  Neeves  of  the  Eyeball. 

Third  Nerve  (Nervus  oculomotorius). — The  nucleus  of  origin  of  this 
nerve  is  situated  in  the  floor  of  the  aqueduct  of  Sylvius;  the  nerve  passes 


1046  DISEASES  OP   THE  NERVOUS  SYSTEM. 

through  the  eras  at  the  side  of  which  it  emerges.  Passing  along  the  wall 
of  the  cavernous  sinus,  it  enters  the  orbit  through  the  sphenoidal  fissure 
and  supplies,  by  its  superior  branch,  the  levator  palpebras  superioris  and 
the  superior  rectus,  and  by  its  inferior  branch  the  internal  and  inferior 
recti  muscles  and  the  inferior  oblique.  Branches  pass  to  the  ciliary  muscle 
and  the  constrictor  of  the  iris.  Lesions  may  affect  the  nucleus  or  the  nerve 
in  its  course  and  cause  either  paralysis  or  spasm. 

Paralysis. — A  nuclear  lesion  is  usually  associated  with  the  disease  of 
the  centres  for  the  other  eye  muscles,  producing  a  condition  of  general  oph- 
thalmoplegia. More  commonly  the  nerve  itself  is  involved  in  its  course, 
either  by  meningitis,  gummata,  or  aneurism,  or  is  attacked  by  a  neuritis,  as 
in  diphtheria  and  locomotor  ataxia.  Complete  paralysis  of  the  third  nerve 
is  accompanied  by  the  following  symptoms: 

Paralysis  of  all  the  muscles,  except  the  superior  oblique  and  external 
rectus,  by  which  the  eye  can  be  moved  outward  and  a  little  downward  and 
inward.  There  is  divergent  strabismus.  There  is  ptosis  or  drooping  of 
the  upper  eyelid,  owing  to  paralysis  of  the  levator  palpebrge.  The  pupil  is 
usually  dilated.  It  does  not  contract  to  light,  and  the  power  of  accom- 
modation is  lost.  The  most  striking  features  of  this  paralysis  are  the 
external  strabismus,  with  diplopia  or  double  vision,  and  the  ptosis.  In 
very  many  cases  the  affection  of  the  third  nerve  is  partial.  Thus  the 
levator  palpebras  and  the  superior  rectus  may  be  involved  together,  or  the 
ciliary  muscles  and  the  iris  may  be  affected  and  the  external  muscles  may 
escape. 

There  is  a  remarkable  form  of  recurring  oculo-motor  paralysis  affect- 
ing chiefly  women,  and  involving  all  the  branches  of  the  nerve.  In  some 
cases  the  attacks  have  come  on  at  intervals  of  a  month;  in  others  a  much 
longer  period  has  elapsed.  The  attacks  may  persist  throughout  life.  They 
are  sometimes  associated  with  pain  in  the  head  and  sometimes  with  mi- 
graine.    Mary  Sherwood  has  collected  from  the  literature  23  cases. 

Ptosis  is  a  common  and  important  symptom  in  nervous  affections.  We 
may  here  briefly  refer  to  the  conditions  under  which  it  may  occur:  (a.)  A 
congenital,  incurable  form,  which  is  frequently  seen;  (h)  the  form  associ- 
ated with  definite  lesion  of  the  third  nerve,  either  in  its  course  or  at  its 
nucleus.  This  may  come  on  with  paralysis  of  the  superior  rectus  alone  or 
with  paralysis  of  the  internal  and  inferior  recti  as  well,  (c)  There  are 
instances  of  complete  or  partial  ptosis  associated  with  cerebral  lesions  with- 
out any  other  branch  of  the  third  nerve  being  paralyzed.  The  exact  po- 
sition of  the  cortical  centre  or  centres  is  as  yet  imknown.  (d)  Hysterical 
ptosis,  which  is  double  and  occurs  with  other  hysterical  symptoms,  (e) 
Pseudo-ptosis,  due  to  affection  of  the  sympathetic  nerve,  is  associated  with 
symptoms  of  vaso-motor  palsy,  such  as  elevation  of  the  temperature  on  the 
affected  side  with  redness  and  oedema  of  the  skin.  Contraction  of  the  pupil 
exists  on  the  same  side  and  the  eyeball  appears  rather  to  have  shrunk  into 
the  orbit.  (/)  In  idiopathic  muscular  atrophy,  when  the  face  muscles  are 
involved,  there  may  be  marked  bilateral  ptosis.  And,  lastly,  in  weak,  deli- 
cate women  there  is  often  to  be  seen  a  transient  ptosis,  particularly  in  the 
morning. 


DISEASES   OF  THE  CEREBRAL  NERVES.  lO^Y 

Among  the  most  important  of  the  symptoms  of  the  third-nerve  paraly- 
sis are  those  which  relate  to  the  ciliary  muscle  and  iris. 

Cycloplegia,  paralysis  of  the  ciliary  muscle,  causes  loss  of  the  power  of 
accommodation.  Distant  vision  is  clear,  but  near  objects  cannot  be  prop- 
erly seen.  In  consequence  the  vision  is  indistinct,  but  can  be  restored  by 
the  use  of  convex  glasses.  This  may  occur  in  one  or  in  both  eyes;  in  the 
latter  case  it  is  usually  associated  with  disease  in  the  nuclei  of  the  nerve. 
Cycloplegia  is  an  early  and  frequent  symptom  in  diphtheritic  paralysis  and 
occurs  also  in  tabes. 

Iriddplegia,  or  paralysis  of  the  iris,  occurs  in  three  forms  (Gowers). 

(a)  Accommodative  iridoplegia,  in  which  the  pupil  does  not  diminish  in 
size  during  the  act  of  accommodation.  To  test  for  this  the  patient  should 
look  first  at  a  distant  and  then  at  a  near  object  in  the  same  line  of  vision. 

(&)  Reflex  Iridoplegia. — The  path  for  the  iris  reflex  is  along  the  optic 
nerve  and  tract  to  its  termination,  then  to  the  nucleus  of  the  third  nerve, 
and  along  the  trunk  of  this  nerve  to  the  ciliary  ganglion,  and  so  through 
the  ciliary  nerves  to  the  eyes.  Each  eye  should  be  tested  separately,  the 
other  one  being  covered.  The  patient  should  look  at  a  distant  object  in  a 
dark  part  of  the  room;  then  a  light  is  brought  suddenly  in  front  of  the 
eye  at  a  distance  of  three  or  four  feet,  so  as  to  avoid  the  effect  of  accommo- 
dation. Loss  of  this  iris  reflex  with  retention  of  the  accommodation  con- 
traction is  known  as  the  Argyll  Eobertson  pupil. 

(c)  Loss  of  the  Shin  Reflex. — If  the  skin  of  the  neck  is  pinched  or 
pricked  the  pupil  dilates  reflexly,  the  afferent  impulses  being  conveyed 
along  the  cervical  sympathetic.  Erb  pointed  out  that  this  skin  reflex  is 
lost  usually  in  association  with  the  reflex  contraction,  but  the  two  are  not 
necessarily  conjoined.  In  iridoplegia  the  pupils  are  often  small,  particu- 
larly in  spinal  disease,  as  in  the  characteristic  small  pupils  of  tabes — spinal 
myosis.     Iridoplegia  may  coexist  with  a  pupil  of  medium  size. 

Inequality  of  the  pupils — anisocoria — is  not  infrequent  in  progressive 
paresis  and  in  tabes.    It  may  also  occur  in  perfectly  healthy  individuals. 

Spasm. — Occasionally  in  meningitis  and  in  hysteria  there  is  spasm  of 
the  muscles  supplied  by  the  third  nerve,  particularly  the  internal  rectus 
and  the  levator  palpebrge.  The  clonic  rhythmical  spasm  of  the  eye  muscles 
is  known  as  nystagmus,  in  which  there  is  usually  a  bilateral,  rhythmical, 
involuntary  movement  of  the  eyeballs.  The  condition  is  met  with  in  many 
congenital  and  acquired  brain  lesions,  in  albinism,  and  sometimes  in  coal- 
miners. 

Fourth  Nerve  {Nervus  trochlearis). — This  supplies  the  superior  oblique 
muscle.  In  its  course  around  the  outer  surface  of  the  crus  and  in  its 
passage  into  the  orbit  it  is  liable  to  be  compressed  by  tumors,  by  aneurism, 
or  in  the  exudation  of  basilar  meningitis.  Its  nucleus  in  the  upper  part 
of  the  fourth  ventricle  may  be  involved  by  tumors  or  undergo  degeneration 
with  the  other  ocular  nuclei.  The  superior  oblique  muscle  acts  in  such  a 
way  as  to  direct  the  eyeball  downward  and  rotates  it  slightly.  The  paralysis 
causes  defective  downward  and  inward  movement,  often  too  slight  to  be 


1048  DISEASES  OF  THE  NERVOUS  SYSTEM. 

noticed.     The  head  is  inclined  somewhat  forward  and  toward  the  sound 
side,  and  there  is  double  vision  when  the  patient  iooks  down. 

Sixth  Nerve  (Nervus  abducens). — This  nerve  emerges  at  the  junction  of 
the  pons  and  medulla,  then,  passing  forward,  it  enters  the  orbit  and  sup- 
plies the  external  rectus  muscle.  It  is  affected  by  meningitis  at  the  base, 
by  gummata  or  other  tumors,  and  sometimes  by  cold.  There  is  internal 
strabismus,  and  the  eye  cannot  be  turned  outward.  Diplopia  occurs  on 
looking  toward  the  paralyzed  side. 

"  When  the  nucleus  is  affected  there  is,  in  addition  to  paralysis  of  the 
external  rectus,  inability  of  the  internal  rectus  of  the  opposite  eye  to  turn  that 
eye  inward.  As  a  consequence  of  this  the  axes  of  the  eyes  are  kept  parallel 
and  both  are  conjugately  deviated  to  the  opposite  side,  away  from  the  side 
of  lesion.  The  reason  of  this  is  that  the  nucleus  of  the  sixth  nerve  sends 
fibres  up  in  the  pons  to  that  part  of  the  nucleus  of  the  opposite  third 
nerve  which  supplies  the  internal  rectus.  We  thus  have  paralysis  of  the 
internal  rectus  without  the  nucleus  of  the  third  nerve  being  involved, 
owing  to  its  receiving  its  nervous  impulses  for  parallel  movement  from 
the  sixth  nucleus  of  the  opposite  side.  As  the  sixth  nucleus  is  in  such 
proximity  to  the  facial  nerve  in  the  substance  of  the  pons,  it  is  frequently 
found  that  the  whole  of  the  face  on  the  same  side  is  paralyzed,  and  gives 
the  electrical  reaction  of  degeneration,  so  that  with  a  lesion  of  the  left 
sixth  nucleus  there  is  conjugate  deviation  of  both  eyes  to  the  right — ^i.  e., 
paralysis  of  the  left  external  and  the  right  internal  rectus,  and  sometimes 
complete  paralysis  of  the  left  side  of  the  face  "  (Beevor). 

General  Features  of  Paralysis  of  the  Motor  Nerves  of  the  Eye. — Gowers 
divides  them  into  five  groups: 

(a)  Limitation  of  Movement. — Thus,  in  paralysis  of  the  external  rectus, 
the  eyeball  cannot  be  moved  outward.  When  the  paralysis  is  incomplete 
the  movement  is  deficient  in  proportion  to  the  degree  of  the  palsy. 

(6)  Strabismus. — The  axes  of  the  eyes  do  not  correspond.  Thus,  pa- 
ralysis of  the  internal  rectus  causes  a  divergent  squint;  of  the  external 
rectus,  a  convergent  squint.  At  first  this  is  only  evident  when  the  eyes  are 
moved  in  the  direction  of  the  action  of  the  weak  muscle,  but  may  become 
constant  by  the  contraction  of  the  opposing  muscle.  The  deviation  of  the 
axis  of  the  affected  eye  from  parallelism  with  the  other  is  called  the  pri-i 
mary  deviation. 

(c)  Secondary  Deviation. — If,  while  the  patient  is  looking  at  an  ob- 
ject, the  sound  eye  is  covered,  so  that  he  fixes  the  object  looked  at  with 
the  affected  eye  only,  the  sound  eye  is  moved  still  further  in  the  same  di- 
rection^e.  g.,  outward — with  paralysis  of  the  opposite  internal  rectus. 
This  is  known  as  secondary  deviation.  It  depends  upon  the  fact  that,  if 
two  muscles  are  acting  together,  when  one  is  weak  and  an  effort  is  made 
to  contract  it,  the  increased  effort — innervation — acts  powerfully  upon  the 
other  muscle,  causing  an  increased  contraction. 

{d)  Erroneous  Projection. — "  We  judge  of  the  relation  of  external  ob- 
jects to  each  other  by  the  relation  of  their  images  on  the  retina;  but  we 
judge  of  their  relation  to  our  own  body  by  the  position  of  the  eyeball 


DISEASES  OF  THE  CEREBRAL  NERVES.  1049 

as  indicated  to  us  by  the  innervation  we  give  to  the  ocular  muscles " 
(Gowers).  With  the  eyes  at  rest  in  the  mid-position,  an  object  at  which 
we  are  looking  is  directly  opposite  our  face.  Turning  the  eyes  to  one 
side,  we  recognize  that  object  in  the  middle  of  the  field  or  to  the  side  of 
this  former  position.  We  estimate  the  degree  by  the  amount  of  movement 
of  the  eyes,  and  when  the  object  moves  and  we  follow  it  we  judge  of  its 
position  by  the  amount  of  movement  of  the  eyeballs.  When  one  ocular 
muscle  is  weak,  the  increased  innervation  gives  the  impression  of  a  greater 
movement  of  the  eye  than  has  really  taken  place.  The  mind,  at  the  same 
time,  receives  the  idea  that  the  object  is  further  on  one  side  than  it  really 
is,  and  in  an  attempt  to  touch  it  the  finger  may  go  beyond  it.  As  the 
equilibrium  of  the  body  is  in  a  large  part  maintained  by  a  knowledge  of 
the  relation  of  external  objects  to  it  obtained  by  the  action  of  the  eye  mus- 
cles, this  erroneous  projection  resulting  from  paralysis  disturbs  the  har- 
mony of  these  visual  impressions  and  may  lead  to  giddiness — ocular  vertigo. 
(e)  Double  Vision. — This  is  one  of  the  most  disturbing  features  of 
paralysis  of  the  eye  muscles.  The  visual  axes  do  not  correspond,  so  that 
there  is  a  double  image — diplopia.  That  seen  by  the  sound  eye  is  termed 
the  true  image;  that  by  the  paralyzed  eye,  the  false.  In  simple  or  homon- 
ymous diplopia  the  false  image  is  "  on  the  same  side  of  the  other  as  the  eye 
by  which  it  is  seen."  In  crossed  diplopia  it  is  on  the  other  side.  In  con- 
vergent squint  the  diplopia  is  simple;  in  divergent  it  is  crossed. 

Opiltlialmoplegia. — Under  this  term  is  described  a  chronic  progressive 
paralysis  of  the  ocular  muscles.  Two  forms  are  recognized — ophthalmo- 
plegia externa  and  ophthalmoplegia  interna.  The  conditions  may  occur 
separately  or  together  and  are  described  by  Gowers  under  nuclear  ocular 
palsy. 

Ophthalmoplegia  externa. — The  condition  is  one  of  more  or  less  com- 
plete palsy  of  the  external  muscles  of  the  eyeball,  due  usually  to  a  slow 
degeneration  in  the  nuclei  of  the  nerves,  but  sometimes  to  pressure  of 
tumors  or  to  basilar  meningitis.  It  is  often,  but  not  necessarily,  associated 
with  ophthalmoplegia  interna.  Siemerling,  in  a  monograph  on  the  sub- 
ject, states  that  63  cases  are  on  record.  In  only  11  of  these  could  syphilis 
be  positively  determined.  The  levator  muscles  of  the  eyelids  and  the 
superior  recti  are  first  involved,  and  gradually  the  other  muscles,  so  that 
the  eyeballs  are  fixed  and  the  eyelids  droop.  There  is  sometimes  slight 
protrusion  of  the  eyeballs.  The  disease  is  essentially  chronic  and  may  last 
for  many  years.  It  is  found  particularly  in  association  with  general  paraly- 
sis, locomotor  ataxia,  and  in  progressive  muscular  atrophy.  Mental  dis- 
orders were  present  in  11  of  the  62  cases.  With  it  may  be  associated 
atrophy  of  the  optic  nerve  and  affections  of  other  cerebral  nerves.  Occa- 
sionally, as  noted  by  Bristowe,  it  may  be  functional. 

Ophthalmoplegia  interna. — Jonathan  Hutchinson  applied  this  term  to 
a  progressive  paralysis  of  the  internal  ocular  muscles,  causing  loss  of  pupil- 
lary action  and  the  power  of  accommodation.  When  the  internal  and  ex- 
ternal muscles  are  involved  the  afl'ection  is  known  as  total  ophthalmoplegia, 
and  in  a  majority  of  the  cases  the  two  conditions  are  associated.  In  some 
instances  the  internal  form  may  depend  upon  disease  of  the  ciliary  ganglion. 


1050  DISEASES  OF  THE  NERVOUS  SYSTEM. 

"While,  as  a  rule,  ophthalmoplegia  is  a  chronic  process,  there  is  an  acute 
form  associated  with  hsemorrhagic  softening  of  the  nuclei  of  the  ocular 
muscles.  There  is  usually  marked  cerebral  disturbance.  It  was  to  this 
form  that  Wernicke  gave  the  name  poho-encephalitis  superior. 

Treatment  of  Ocular  Palsies. — It  is  important  to  ascertain,  if 
possible,  the  cause.  The  forms  associated  with  locomotor  ataxia  are  ob- 
stinate, and  resist  treatment.  Occasionally,  however,  a  palsy,  complete  or 
partial,  may  pass  away  spontaneously.  The  group  of  cases  associated  with 
chronic  degenerative  changes,  as  in  progressive  paresis  and  bulbar  paraly- 
sis, is  little  affected  by  treatment.  On  the  other  hand,  in  syphihtic  cases, 
mercury  and  iodide  of  potassium  are  indicated  and  are  often  beneficial. 
Arsenic  and  strychnia,  the  latter  hypodermically,  may  be  employed.  In 
any  case  in  which  the  onset  is  acute,  with  pain,  hot  fomentations  and  coun- 
ter-irritation or  leeches  applied  to  the  temple  give  relief.  The  direct  treat- 
ment by  electricity  has  been  extensively  employed,  but  probably  without 
any  special  effect.  The  diplopia  may  be  relieved  by  the  use  of  prisms,  or 
it  may  be  necessary  to  cover  the  affected  eye  with  an  opaque  glass. 

Fifth  ISTerye  (Nervus  trigeminus). 

Paralysis  may  result  from:  (a)  Disease  of  the  pons,  particularly  haem- 
orrhage or  patches  of  sclerosis.  (&)  Injury  or  disease  at  the  base  of  the 
brain.  Fracture  rarely  involves  the  nerve;  on  the  other  hand,  meningitis, 
acute  or  chronic,  and  caries  of  the  bone  are  not  uncommon  causes,  (c) 
The  branches  may  be  affected  as  they  pass  out — the  first  division  by  tumors 
pressing  on  the  cavernous  sinus  or  by  aneurism;  the  second  and  third 
divisions  by  growths  which  invade  the  spheno-masillary  fossa,  (d)  Pri- 
mary neuritis,  which  is  rare. 

Symptoms. — (a)  Sensory  Portion. — Disease  of  the  fifth  nerve  may 
cause  loss  of  sensation  in  the  parts  supplied,  including  the  half  of  the  face, 
the  corresponding  side  of  the  head,  the  conjunctiva,  the  mucosa  of  the  lips, 
tongue,  hard  and  soft  palate,  and  of  the  nose  of  the  same  side.  The 
ansesthesia  may  be  preceded  by  tingling  or  pain.  The  muscles  of  the  face 
are  also  insensible  and  the  movements  may  be  slower.  The  sense  of  smell 
is  interfered  with.  There  is  disturbance  of  the  sense  of  taste.  There 
are,  in  addition,  trophic  changes;  the  salivary,  lachrymal,  and  buccal  secre- 
tions may  be  lessened,  abrasions  of  the  mucous  membranes  heal  slowly, 
and  the  teeth  may  become  loose.  The  eye  inflames,  the  cornea  become 
cloudy  and  may  ulcerate.  It  was  formerly  held  that  these  symptoms  only 
occurred  when  the  Gasserian  ganglion  was  affected,  but  of  late  years  this 
has  been  completely  removed  for  obstinate  neuralgia  without  producing 
any  trophic  disturbance.  This  apparent  contradiction  is  not  yet  explained. 
Herpes  may  develop  in  the  region  supplied  by  the  nerve,  usually  the  upper 
branch,  and  is  associated  with  much  pain,  which  may  be  peculiarly  endur- 
ing, lasting  for  months  or  years  (Gowers).  In  herpes  zoster  with  the  neu- 
ritis there  may  be  slight  enlargement  of  the  cervical  glands. 

(b)  Motor  Portion. — The  inability  to  use  the  muscles  of  mastication  on 
the  affected  side  is  the  distinguishing  feature  of  paralysis  of  this  portion  of 


DISEASES  OP  THE  CEREBRAL   NERVES.  1051 

the  nerve.  It  is  recognized  by  placing  the  finger  on  the  masseter  and  tem- 
poral muscles,  and,  when  the  patient  closes  the  jaw,  the  feebleness  of  their 
contraction  is  noted.  If  paralyzed,  the  external  pterygoid  cannot  move 
the  jaw  toward  the  unaffected  side;  and  when  depressed,  the  jaw  deviates 
to  the  paralyzed  side.  The  motor  paralysis  of  the  fifth  nerve  is  almost  in- 
variably a  result  of  involvement  of  the  nerve  after  it  has  left  the  nucleus. 
Cases,  however,  have  been  associated  with  cortical  lesions.  Hirt  concludes, 
from  his  case,  that  the  cortical  motor  centre  for  the  trigeminus  is  in  the 
neighborhood  of  the  lower  third  of  the  anterior  central  convolution. 

Spasm  of  the  Muscles  of  Mastication. — Trismus,  the  masticatory  spasm 
of  Komberg,  may  be  tonic  or  clonic,  and  is  either  an  associated  phenome- 
non in  general  convulsions  or,  more  larely,  an  independent  affection.  In 
the  tonic  form  the  jaws  are  kept  close  together — lock-jaw — or  can  be  sepa- 
rated only  for  a  short  space.  The  muscles  of  mastication  can  be  seen  in 
contraction  and  felt  to  be  hard;  the  spasm  is  often  painful.  This  tonic 
contraction  is  an  early  symptom  in  tetanus,  and  is  sometimes  seen  in  tetany. 
A  form  of  this  tonic  spasm  occurs  in  hysteria.  Occasionally  trismus 
follows  exposure  to  cold,  and  is  said  to  be  due  to  reflex  irritation  from 
the  teeth,  the  mouth,  or  caries  of  the  jaw.  It  may  also  be  a  symptom 
of  organic  disease  due  to  irritation  near  the  motor  nucleus  of  the  fifth 
nerve. 

Clonic  spasm  of  the  muscles  supplied  by  the  fifth  occurs  in  the  form  of 
rapidly  repeated  contractions,  as  in  "  chattering  teeth."  This  is  rare  apart 
from  general  conditions,  though  cases  are  on  record,  usually  in  women  late 
in  life,  in  whom  this  isolated  clonic  spasm  of  the  muscles  of  the  jaw  has 
been  found.  In  another  form  of  clonic  spasm  sometimes  seen  in  chorea, 
there  are  forcible  single  contractions.  Gowers  mentions  an  instance  of  its 
occurrence  as  an  isolated  affection. 

(c)  Gustatory. — Loss  of  the  sense  of  taste  in  the  anterior  two  thirds  of 
the  tongue,  as  a  rule,  follows  paralysis  of  the  fifth  nerve.  The  gustatory 
fibres  of  the  lingual  branch  of  the  fifth  pass  with  the  chorda  tympani  to 
the  seventh  nerve,  which  they  are  believed  to  leave  by  the  petrosal  nerve, 
and  to  again  reach  the  fifth  through  Meckel's  ganglion.  Disease  of  the 
fifth  nerve  is,  however,  not  always  associated  with  loss  of  taste,  in  which 
case  either  the  taste  fibres  escape,  or  the  disease  is  within  the  pons  where 
these  fibres  are  separate  from  those  of  sensation.  It  may  be  that  the 
nervus  intermedius  of  Wrisberg  carries  the  taste  fibres. 

The  diagnosis  of  disease  of  the  trifacial  nerve  is  rarely  difficult.  It 
must  be  remembered  that  the  preliminary  pain  and  hypersesthesia  are 
sometimes  mistaken  for  ordinary  neuralgia.  The  loss  of  sensation  and  the 
palsy  of  the  muscles  of  mastication  are  readily  determined. 

Treatment. — When  the  pain  is  severe  morphia  may  be  required  and 
local  applications  are  useful.  If  there  is  a  suspicion  of  syphilis,  appropri- 
ate treatment  should  be  given.    Faradization  is  sometimes  beneficial. 

Facial  Nerve. 

Paralysis  {Bell's  Palsy). — The  facial  or  seventh  may  be  paralyzed  by 
(1)  lesions  of  the  cortex — supranuclear  palsy;  (2)  lesions  of  the  nucleus 


1052  DISEASES  OP  THE  NERVOUS  SYSTEM. 

itself;  or  (3)  involvement  of  the  nerve  trunk  in  its  tortuous  course  within 
the  pons  and  through  the  wall  of  the  skull. 

1.  Supranuclear  paralysis,  due  to  lesion  of  the  cortex  or  of  the  facial 
fibres  in  the  corona  radiata  or  internal  capsule,  is,  as  a  rule,  associated 
with  hemiplegia.  It  may  be  caused  by  tumors,  abscess,  chronic  inflamma- 
tion, or  softening  in  the  cortex  or  in  the  region  of  the  internal  capsule.  It 
is  distinguished  from  the  peripheral  form  by  well-marked  characters — the 
persistence  of  the  normal  electrical  excitability  of  both  nerves  and  muscles 
and  the  absence  of  involvement  of  the  upper  branches  of  the  nerve,  so  that 
the  orbicularis  palpebrarum,  frontalis,  and  corrugator  muscles  are  spared. 
In  some  cases  the  mouth  can  be  pursed  by  the  action  of  the  orbicularis 
oris.  In  rare  instances  these  muscles  are  paralyzed.  In  this  form  the  vol- 
untary movements  are  more  impaired  than  the  emotional.  Isolated  paral- 
ysis— monoplegia  facialis — due  to  involvement  of  the  cortex  or  of  the 
fibres  in  their  path  to  the  nucleus,  is  uncommon.  In  the  great  majority 
of  cases  supranuclear  facial  paralysis  is  part  of  a  hemiplegia.  Paralysis 
is  on  the  same  side  as  that  of  the  arm  and  leg  because  the  facial  muscles 
bear  precisely  the  same  relation  to  the  cortex  as  the  spinal  muscles.  The 
nuclei  of  origin  on  either  side  of  the  middle  line  in  the  medulla  are  united 
by  decussating  fibres  with  the  cortical  centre  on  the  opposite  side  (see  Fig. 
10).  A  few  fibres  reach  the  nucleus  from  the  cerebral  cortex  of  the  same 
side  (Melius,  Hoclie),  and  this  uncrossed  path  may  innervate  the  upper 
facial  muscles  (Bruce). 

2.  The  nuclear  paralysis  caused  by  lesions  of  the  nerve  centres  in  the 
medulla  is  not  common  alone;  but  is  seen  occasionally  in  tumors,  chronic 
softening,  and  hsemorrhage.  We  have  had  one  instance  of  its  involvement  in 
anterior  polio-myelitis.  In  diphtheria  this  centre  may  also  be  involved. 
The  symptoms  are  practically  similar  to  those  of  an  affection  of  the  nerve 
fibre  itself — infranuclear  paralysis. 

3.  Involvement  of  the  Nerve  T runic. — Paralysis  may  result  from: 

(a)  Involvement  of  the  nerve  as  it  passes  through  the  pons — that  is, 
between  its  nucleus  in  the  floor  of  the  fourth  ventricle  and  the  point  of 
emergence  in  the  postero-lateral  aspect  of  the  pons.  The  specially  inter- 
esting feature  in  connection  with  involvement  of  this  part  is  the  production 
of  what  is  called  alternating  or  crossed  paralysis,  the  face  being  involved  on 
the  same  side  as  the  lesion,  and  the  arm  and  leg  on  the  opposite  side,  since 
the  motor  path  is  involved  above  the  point  of  decussation  in  the  medulla 
(Fig.  10).  This  occurs  only  when  the  lesion  is  in  the  lower  section  of  the 
pons.  A  lesion  in  the  upper  half  of  the  pons  involves  the  fibres  not  of  the 
outgoing  nerve  on  the  same  side,  but  of  the  fibres  from  the  hemispheres 
before  they  have  crossed  to  the  nucleus  of  the  opposite  side.  In  this  case 
there  would  of  course  be,  as  in  hemiplegia,  paralysis  of  the  face  and  limbs 
on  the  side  opposite  to  the  lesion.  The  palsy,  too,  would  resemble  the  cere- 
bral form,  involving  only  the  lower  fibres  of  the  facial  nerve. 

(&)  The  nerve  may  be  involved  at  its  point  of  emergence  by  tumors, 
gummata,  meningitis,  or  occasionally  may  be  injured  in  fracture  of  the 
base. 

(c)  In  passing  through  the  Fallopian  canal  the  nerve  may  be  involved 
in  disease  of  the  ear,  particularly  by  caries  of  the  bone  in  otitis  media. 


DISEASES  OP  THE  CEREBRAL  NERVES.  1053 

This  is  a  common  cause  in  children.     I  have  seen  two  instances  follow  otitis 
in  puerperal  fever. 

(d)  As  the  nerve  emerges  from  the  styloid  foramen  it  is  exposed  to 
injuries  and  blows  which  not  infrequently  cause  paralysis.  The  fibres  may 
be  cut  in  the  removal  of  tumors  in  this  region,  or  the  paralysis  may  be 
caused  by  pressure  of  the  forceps  in  an  instrumental  delivery. 

"    (e)  Exposure  to  cold  is  the  most  common  cause  of  facial  paralysis,  in- 
ducing a  neuritis  of  the  nerve  within  the  Fallopian  canal. 

(/)  Syphilis  is  not  an  infrequent  cause,  and  the  paralysis  may  develop 
early  with  the  secondary  symptoms. 

(g)  It  may  develop  with  herpes. 

Facial  diplegia  is  a  rare  condition  occasionally  found  in  affections  at 
the  base  of  the  brain,  lesions  in  the  pons,  simultaneous  involvement  of  the 
nerves  in  ear  disease,  and  in  diphtheritic  paralysis.  Disease  of  the  nuclei 
or  symmetrical  involvement  of  the  cortex  might  also  produce  it.  It  may 
occur  as  a  congenital  affection.  H.  M.  Thomas  has  described  two  cases  in 
one  family. 

Symptoms.' — In  the  peripheral  facial  paralysis  all  the  branches  of 
the  nerve  are  involved.  The  face  on  the  affected  side  is  immobile  and  can 
neither  be  moved  at  will  nor  participate  in  any  emotional  movements.  The 
skin  is  smooth  and  the  wrinkles  are  effaced,  a  point  particularly  notice- 
able on  the  forehead  of  elderly  persons.  The  eye  cannot  be  closed,  the 
lower  lid  droops,  and  the  eye  waters.  On  the  affected  side  the  angle  of 
the  mouth  is  lowered,  and  in  drinking  the  lips  are  not  kept  in  close  apposi- 
tion to  the  glass,  so  that  the  liquid  is  apt  to  run  out.  In  smiling  or  laugh- 
ing the  contrast  is  most  striking,  as  the  affected  side  does  not  move,  which 
gives  a  curious  unequal  appearance  to  the  two  sides  of  the  face.  The  eye 
cannot  be  closed  nor  can  the  forehead  be  wrinkled.  In  long-standing 
cases,  when  the  reaction  of  degeneration  is  present,  if  the  patient  tries  to 
close  the  eyes  while  looking  fixedly  at  an  object  the  lids  on  the  sound  side 
close  firmly,  but  on  the  paralyzed  side  there  is  only  a  narrowing  of  the 
palpebral  orifice,  and  the  eye  is  turned  upward  and  outward  by  the  inferior 
oblique.  On  asking  the  patient  to  show  his  upper  teeth,  the  angle  of  the 
mouth  is  not  raised.  In  all  these  movements  the  face  is  drawn  to  the  sound 
side  by  the  action  of  the  muscles.  Speaking  may  be  slightly  interfered 
with,  owing  to  the  imperfection  in  the  formation  of  the  labial  sounds. 
Whistling  cannot  be  performed.  In  chewing  the  food,  owing  to  the  paraly- 
sis of  the  buccinator,  particles  collect  on  the  affected  side.  The  paralysis 
of  the  nasal  muscles  is  seen  on  asking  the  patient  to  sniff.  Owing  to  the 
fact  that  the  lips  are  drawn  to  the  sound  side,  the  tongue,  when  protruded, 
looks  as  if  it  were  pushed  to  the  paralyzed  side;  but  on  taking  its  position 
from  the  incisor  teeth,  it  will  be  found  to  be  in  the  middle  line.  The  reflex 
movements  are  lost  in  this  peripheral  form.  It  is  usually  stated  that  the 
palate  is  paralyzed  on  the  same  side  and  that  the  uvula  deviates.  Both 
Gowers  and  Hughlings  Jackson  deny  the  existence  of  this  involvement  in 
the  great  majority  of  cases,  and  Horsley  and  Beevor  have  shown  that  these 
parts  are  innervated  by  the  accessory  nerve  to  the  vagus. 

When  the  nerve  is  involved  within  the  canal  between  the  genu  and  the 


1054:  DISEASES  OP  THE  NERVOUS  SYSTEM. 

origin  of  tlie  chorda  tympani,  the  sense  of  taste  may  be  lost  in  the  anterior 
part  of  the  tongue  on  the  affected  side,  owing  probably  to  injury  to  the 
nervus  intermedins  of  Wrisberg.  When  the  nerve  is  damaged  outside  the 
skull  the  sense  of  taste  is  unaffected.  Hearing  is  often  impaired  in  facial 
paralysis,  most  commonly  by  preceding  ear-disease.  The  paralysis  of  the 
stapedius  muscle  may  lead  to  increased  sensitiveness  to  musical  notes. 
Herpes  is  sometimes  associated  with  facial  paralysis.  Pain  is  not  common, 
but  there  may  be  neuralgia  about  the  ear.  The  face  on  the  affected  side 
may  be  swollen. 

The  electrical  reactions,  which  are  those  of  a  peripheral  palsy,  have  con- 
siderable importance  from  a  prognostic  standpoint.  Erb's  rules  are  as 
follows:  If  there  is  no  change,  either  faradic  or  galvanic,  the  prognosis 
is  good  and  recovery  takes  place  in  from  fourteen  to  twenty  days.  If  the 
faradic  and  galvanic  excitability  of  the  nerve  is  only  lessened  and  that  of 
the  muscle  increased  to  the  galvanic  current  and  the  contraction  formula 
altered  (the  contraction  sluggish  AnOCC),  the  outlook  is  relatively  good 
and  recovery  will  probably  take  place  in  from  four  to  six  weeks;  occasion- 
ally in  from  eight  to  ten.  When  the  reaction  of  degeneration  is  present — 
that  is,  if  the  faradic  and  galvanic  excitability  of  the  nerves  and  the  faradic 
excitability  of  the  muscles  are  lost  and  the  galvanic  excitability  of  the 
muscle  is  quantitatively  increased  and  qualitatively  changed,  and  if  the 
mechanical  excitability  is  altered — the  prognosis  is  relatively  unfavorable 
and  the  recovery  may  not  occur  for  two,  six,  eight,  or  even  fifteen  months. 

The  course  of  facial  paralysis  is  usually  favorable.  The  onset  in  the 
form  following  cold  is  very  rapid,  developing  perhaps  within  twenty-four 
hours,  but  rarely  is  the  paralysis  permanent.  Eecurring  attacks  have  been 
described;  Sinkler  mentions  five.  On  the  other  hand,  in  the  paralysis  from 
injury,  as  by  a  blow  on  the  mastoid  process,  the  condition  may  remain. 
When  permanent,  the  muscles  are  entirely  toneless.  In  some  instances  con- 
tracture develops  as  the  voluntary  power  returns,  and  the  natural  folds 
and  the  wrinkles  on  the  affected  side  may  be  deepened,  so  that  on  looking 
at  the  face  one  at  first  may  have  the  impression  that  the  affected  side  is 
the  sound  one.  This  is  corrected  at  once  on  asking  the  patient  to  smile, 
when  it  is  seen  which  side  of  the  face  has  the  most  active  movement.  Are- 
tseus  noted  the  difficulty  sometimes  experienced  in  determining  which  side 
was  affected  until  the  patient  spoke  or  laughed. 

The  diagnosis  of  facial  paralysis  is  usually  easy.  The  distinction  be- 
tween the  peripheral  and  central  form  is  based  on  facts  already  mentioned. 

Treatment. — In  the  cases  which  result  from  cold  and  are  probably 
due  to  neuritis  within  the  bony  canal,  hot  applications  first  should  be  made; 
subsequently  the  thermo-cautery  may  be  used  lightly  at  intervals  of  a 
day  or  two  over  the  mastoid  process,  or  small  blisters  applied.  If  the 
ear  is  diseased,  free  discharge  for  the  secretion  should  be  obtained.  The 
continuous  current  may  be  employed  to  keep  up  the  nutrition  of  the  mus- 
cles. The  positive  pole  should  be  placed  behind  the  ear,  the  negative  one 
along  the  zygomatic  and  other  muscles.  The  application  can  be  made  daily 
for  a  quarter  of  an  hour  and  the  patient  can  readily  be  taught  to  make  it 
himself  before  the  looking-glass.    Massage  of  the  muscles  of  the  face  is  also 


DISEASES  OF  THE  CEREBRAL  NERVES.  1055 

useful.    A  course  of  iodide  of  potassium  may  be  given  even  when  there  is 
no  indication  of  syphilis. 

In  some  of  the  traumatic  cases  the  possibility  of  surgical  interference 
may  be  considered.  In  a  patient  with  chronic  otitis  media  of  twenty-three 
years'  duration  and  secondary  mastoid  disease  Bloodgood  operated  in  May, 
1896.  Complete  facial  paralysis  followed.  Eight  weeks  later  the  facial 
nerve  was  exposed  in  its  canal  and  found  to  be  almost  completely  severed. 
The  ends  were  brought  together  and  the  wound  allowed  to  fill  with  blood- 
clot,  which  organized.  Four  months  later  the  patient  had  improved,  and 
one  year  and  six  months  from  the  operation  the  power  had  returned  to  all 
the  muscles  except  the  occipito-frontalis  and  the  depressor  of  the  lower  lip. 
The  response  to  galvanic  and  faradic  currents  was  normal. 

Spasm. — The  spasm  may  be  limited  to  a  few  or  involve  all  the  muscles 
innervated  by  the  facial  nerve  and  may  be  unilateral  or  bilateral.  ^ 

It  is  known  also  by  the  name  of  mimic  spasm  or  of  convulsive  tic.  Sev- 
eral different  affections  are  usually  considered  under  the  name  of  facial 
or  mimic  spasm,  but  we  shall  here  speak  only  of  the  simple  spasm  of  the 
facial  muscles,  either  primary  or  following  paralysis,  and  shall  not  in- 
clude the  cases  of  habit  spasm  in  children,  or  the  tic  co7ivulsif  of  the 
French. 

Gowers  recognizes  two  classes — one  in  which  there  is  an  organic  lesion, 
and  an  idiopathic  form.  It  is  thought  to  be  due  also  to  reflex  causes,  such 
as  the  irritation  from  carious  teeth  or  the  presence  of  intestinal  worms. 
The  disease  usually  occurs  in  adults,  whereas  the  habit  spasm  and  the  tic 
convuhif  of  the  French,  often  confounded  with  it,  are  most  common  in 
children.  True  mimic  spasm  occasionally  comes  on  in  childhood  and  per- 
sists. In  the  case  of  a  school-mate,  the  affection  was  marked  as  early  as 
the  eleventh  or  twelfth  year  and  still  continues.  When  the  result  of  or- 
ganic disease,  there  has  usually  been  a  lesion  of  the  centre  in  the  cortex,  as 
in  the  case  reported  by  Berkley,  or  pressure  on  the  nerve  at  the  base  of 
the  brain  by  aneurism  or  tumor. 

Symptoms. — The  spasm  may  involve  only  the  muscles  around  the 
eye — blepharospasm — in  which  case  there  is  constant,  rapid,  quick  action 
of  the  orbicularis  palpebrarum,  which,  in  association  with  photophobia, 
may  be  tonic  in  character.  More  commonly  the  spasm  affects  the  lateral 
facial  muscles  with  those  of  the  eye,  and  there  is  constant  twitching  of  the 
side  of  the  face  with  partial  closure  of  the  eye.  The  frontalis  is  rarely  in- 
volved. In  aggravated  cases  the  depressors  of  the  angle  of  the  moutli,  the 
levator  menti,  and  the  platysma  myoides  are  affected.  This  spasm  is  con- 
fined to  one  side  of  the  face  in  a  majority  of  cases,  though  it  may  extend 
and  become  bilateral.  It  is  increased  by  emotional  causes  and  by  voluntary 
movements  of  the  face.  As  a  rule,  it  is  painless,  but  there  may  be  tender 
points  over  the  course  of  the  fifth  nerve,  particularly  the  supraorbital 
branch.  Tonic  spasm  of  the  facial  muscle  may  follow  paralysis,  and  is  said 
to  result  occasionally  from  cold. 

The  outlook  in  facial  spasm  is  always  dubious.  A  majority  of  the  cases 
persist  for  years  and  are  incurable. 


1056  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — Sources  of  irritation  should  be  looked  for  and  removed. 
Wlien  a  painful  spot  is  present  over  the  fifth  nerve,  blistering  or  the  appli- 
cation of  the  thermo-cautery  may  relieve  it.  Hypodermic  injections  of 
strychnia  may  be  tried,  but  are  of  doubtful  benefit.  Weir  Mitchell  recom- 
mends the  freezing  of  the  cheek  for  a  few  minutes  daily  or  every  second 
day  with  the  sj)ray,  and  this,  in  some  instances,  is  beneficial.  Often  the  re- 
lief is  transient;  the  cases  return,  and  at  every  clinic  may  be  seen  half  a 
dozen  or  more  of  such  patients  who  have  run  the  gamut  of  all  measures 
without  material  improvement.  Operative  interference  may  be  resorted  to 
in  severe  cases,  although  not  much  can  be  expected  of  it. 

Auditory  IsTeeve. 

The  eighth,  known  also  as  portio  mollis  of  the  seventh  pair,  passes  from 
the  ear  through  the  internal  auditory  meatus,  and  in  reality  consists  of  two 
separate  nerves — the  cochlear  and  vestibular  roots.  These  two  roots  have 
entirely  different  functions,  and  may  therefore  be  best  considered  separately. 
The  cochlear  nerve  is  the  one  connected  with  the  organ  of  Corti,  and  is  con- 
cerned in  hearing.  The  vestibular  nerve  is  connected  with  the  vestibule 
and  semicircular  canals,  and  has  to  do  with  the  maintenance  of  equilibrium. 

The  Cochlear  Nerve.  * 

The  cortical  centre  for  hearing  is  in  the  temporo-sphenoidal  lobe.  Pri- 
mary disease  of  the  auditory  nerve  in  its  centre  or  intracranial  course  is 
uncommon.  More  frequently  the  terminal  branches  are  affected  within  the 
labyrinth. 

(a)  Affection  of  the  Cortical  Centre. — In  the  monkey,  experiments  indi- 
cate that  the  superior  temporal  gyrus  represents  the  centre  for  hearing.  In 
man  the  cases  of  disease  indicate  that  it  has  the  same  situation,  as  destruction 
of  this  gyrus  on  the  left  side  results  in  word-deafness,  which  may  be  defined 
as  an  inability  to  understand  the  meaning  of  words,  though  they  may  still 
be  heard  as  sounds.  The  central  auditory  path  extending  to  the  cortical 
centre  from  the  terminal  nuclei  of  the  cochlear  nerve  may  be  involved  and 
produce  deafness.  This  may  result  from  involvement  of  the  lateral  lemnis- 
cus from  the  presence  of  a  tumor  in  the  corpora  quadrigemina,  especially 
if  it  involve  the  posterior  quadrigeminal  bodies,  from  a  lesion  of  the  internal 
geniculate  body,  or  it  may  be  associated  with  a  lesion  of  the  internal  cap- 
sule. 

(&)  Lesions  of  the  nerve  at  the  base  of  the  brain  may  result  from  the 
pressure  of  tumors,  meningitis  (particularly  the  cerebro-spinal  form),  hgem- 
orrhage,  or  traumatism.  A  primary  degeneration  of  the  nerve  may  occur 
in  locomotor  ataxia.  Primary  disease  of  the  terminal  nuclei  of  the  cochlear 
nerve  (nucleus  nervi  cochlearis  dorsalis  and  nucleus  nervi  cochlearis  ven- 
tralis)  is  rare.  By  far  the  most  interesting  form  results  from  epidemic 
cerebro-spinal  meningitis,  in  which  the  nerve  is  frequently  involved,  caus- 
ing permanent  deafness.  In  young  children  the  condition  results  in  deaf- 
mutism. 


DISEASES   OF   THE  CEREBRAL  NERVES.  Iu57 

(c)  In  a  majority  of  the  cases  associated  with  auditory-nerve  symptoms 
the  lesion  is  in  the  internal  ear,  either  primary  or  the  result  of  extension 
of  disease  of  the  middle  ear.  Two  groups  of  symptoms  may  be  produced — 
hyperassthesia  and  irritation  and  diminished  function  or  nervous  deafness. 

(1)  llypercestliesia  and  Irritatioti. — This  may  be  due  to  altered  func- 
tion of  the  centre  as  well  as  of  the  nerve  ending.  True  hyperesthesia — 
hyperacusis — is  a  condition  in  which  sounds,  sometimes  even  those  inaudi- 
ble to  other  persons,  are  heard  with  great  intensity.  It  occurs  in  hysteria 
and  occasionally  in  cerebral  disease.  As  already  mentioned,  in  paralysis 
of  the  stapedius  low  notes  may  be  heard  with  intensity.  In  dysesthesia, 
or  dysacusis,  ordinary  sounds  cause  an  unpleasant  sensation,  as  commonly 
happens  in  connection  with  headache,  when  ordinary  noises  are  badly 
borne. 

Tinnitus  aurium  is  a  term  employed  to  designate  certain  subjective 
sensations  of  ringing,  roaring,  ticking,  and  whirring  noises  in  the  ear.  It  is 
a  very  common  and  often  a  distressing  symptom.  It  is  associated  with  many 
forms  of  ear-disease  and  may  result  from  pressure  of  wax  on  the  drum.  It 
is  rare  in  organic  disease  of  the  central  connections  of  the  nerve.  Sudden 
intense  stimulation  of  the  nerve  may  cause  it.  A  form  not  uncommonly 
met  with  in  medical  practice  is  that  in  which  the  patient  hears  a  continual 
Iruit  in  the  ear,  and  the  noise  has  a  systolic  intensification,  usually  on  one 
side.  I  have  twice  been  consulted  by  physicians  for  this  condition  under 
the  belief  that  they  had  an  internal  aneurism.  A  systolic  murmur  may  be 
heard  occasionally  on  auscultation.  It  occurs  in  conditions  of  anaemia  and 
neurasthenia.  Subjective  noises  in  the  ear  may  precede  an  epileptic  seizure 
and  are  sometimes  present  in  migraine.  In  whatever  form  tinnitus  exists, 
though  slight  and  often  regarded  as  trivial,  it  occasions  great  annoyance 
and  often  mental  distress,  and  has  even  driven  patients  to  suicide. 

The  diagnosis  is  readily  made;  but  it  is  often  extremely  difficult  to  de- 
termine upon  what  condition  the  tinnitus  depends.  The  relief  of  con- 
stitutional states,  such  as  anaemia,  neurasthenia,  or  gout,  may  result  in 
cure.  A  careful  local  examination  of  the  ear  should  always  be  made.  One 
of  the  most  worrying  forms  is  the  constant  clicking,  sometimes  audible 
many  feet  away  from  the  patient,  and  due  probably  to  clonic  spasm  of  the 
muscles  connected  with  the  Eustachian  tube  or  of  the  levator  palati.  The 
condition  may  persist  for  years  unchanged,  and  then  disappear  suddenly. 
The  pulsating  forms  of  tinnitus,  in  which  the  sound  is  like  that  of  a  sys- 
tolic hruif,  are  almost  invariably  subjective,  and  it  is  very  rare  to  hear  any- 
thing with  the  stethoscope.  It  is  to  be  remembered  that  in  children  there 
is  a  systolic  brain  murmur,  best  heard  over  the  ear,  and  in  some  instances 
appreciable  in  the  adult. 

(2)  Diminislied  Function  or  Nervous  Deafness. — In  testing  for  nervous 
deafness,  if  the  tnning-fork  cannot  be  heard  when  placed  near  tlie  meatus, 
but  the  vibrations  are  audible  by  placing  the  foot  of  the  tuning-fork  against 
the  temporal  bone,  the  conclusion  may  be  drawn  that  the  deafness  is  not 
due  to  involvement  of  the  nerve.  The  vibrations  are  conveyed  tlirough 
the  temporal  bone  to  the  cochlea  and  vestibule.  The  watch  may  be  used 
for  the  same  purpose,  and  if  the  meatus  is  closed  and  the  watch  is  heard 

66 


1058  DISEASES  OF  THE  NERVOUS  SYSTEM. 

better  in  contact  with  the  mastoid  process  than  when  opposite  the  open 
meatus,  the  deafness  is  probably  not  nervous.  Disturbance  of  the  function 
of  the  auditory  nerve  is  not  a  very  frequent  symptom  in  brain-disease,  but 
in  all  cases  the  function  of  the  nerve  should  be  carefully  tested. 

The  Vestibular  Nerve. 

The  most  frequent  symptoms  met  with  in  association  with  disease  of  the 
vestibular  nerve  and  its  central  connections  are  vertigo,  nystagmus,  and 
loss  of  coordination  of  the  muscles  of  the  head,  neck,  and  eyes. 

Auditory  Vertigo— Meniere's  Disease. — In  1861  Meniere,  a  French  phy- 
sician, described  an  affection  characterized  by  noises  in  the  ear,  vertigo 
(which  might  be  associated  with  loss  of  consciousness),  vomiting,  and,  in 
many  cases,  progressive  loss  of  hearing.  The  following  grouping  of  the 
cases  has  been  made  by  Parkes  Weber:  (1)  The  apoplectic  form,  due  to 
haemorrhage  into  the  labyrinth,  as  in  leukaemia,  followed,  as  a  rule,  by 
complete  deafness  in  one  or  both  ears.  (2)  The  cases  associated  with  pro- 
gressive inflammatory  disease  of  the  labyrinth.  (3)  Associated  with  organic 
changes  in  the  auditory  nerves,  as  in  tumors,  sometimes  in  tabes,  and  in 
cases  of  aural  vertigo  associated  with  facial  paralysis  on  one  side.  (4) 
Cases  in  which  a  paroxysm  of  epilepsy  is  preceded  by  an  auditory  aura. 
(5)  The  moderate  attacks  which  are  associated  with  the  various  middle- 
ear  affections,  with  wax  in  the  meatus,  with  violent  syringing  of  the  ears, 
etc.,  all  of  which  are  probably  due  to  increase  in  the  intra-labyrinthine 
pressure.  Meniere's  symptoms  may  occasionally  be  due  to  temporary  ex- 
cessive increase  in  the  perilymph,  possibly  of  angioneurotic  character. 

Symptoms. — The  attack  usually  sets  in  suddenly  with  a  buzzing  noise 
in  the  ears  and  the  patient  feels  as  if  he  was  reeling  or  staggering.  He 
may  feel  himself  to  be  reeling,  or  the  objects  about  him  may  seem  to  be 
turning,  or  the  phenomena  may  be  combined.  The  attack  is  often  so 
abrupt  that  the  patient  falls,  though,  as  a  rule,  he  has  time  to  steady  him- 
self by  grasping  some  neighboring  object.  There  may  be  slight  but  tran- 
sient loss  of  consciousness.  In  a  few  minutes,  or  even  less,  the  vertigo 
passes  oif  and  the  patient  becomes  pale  and  nauseated,  a  clammy  sweat 
breaks  out  on  the  face,  and  vomiting  may  follow. 

The  tinnitus  is  described  as  either  a  roaring  or  a  throbbing  sound. 
Ocular  symptoms  may  be  present;  thus,  jerking  of  the  eyeballs  or  nystag- 
mus may  develop  during  the  attack,  or  diplopia. 

Labyrinthine  vertigo  is  paroxysmal,  coming  on  at  irregular  intervals, 
sometimes  of  weeks  or  months;  or  several  attacks  may  occur  in  a  day. 

The  disturbances  of  equilibrium,  including  the  vertigo,  are  dependent 
upon  a  disturbance  of  the  functions  of  the  vestibular  nerve  or  of  the  organs 
with  which  this  nerve  is  connected,  either  in  its  peripheral  distribution  or 
by  means  of  its  central  connection.  The  auditory  symptoms  often  accom- 
panying it  are  doubtless  always  due  to  involvement  of  the  cochlear  nerve 
or  its  peripheral  or  central  connections. 

Diagnosis. — The  combination  of  tinnitus  with  giddiness,  with  or 
without  gastric  disturbance,  is  sufficient  to  establish  a  diagnosis.  There 
are  other  forms  of  vertigo  from  which  it  must  be  distino-uished.    The  form 


DISEASES  OF  THE  CEREBRAL  NERVES.  10^9 

known  as  gastric  vertigo,  which  is  associated  with  dyspepsia  and  occurs 
most  commonly  in  persons  of  middle  age,  is,  as  a  rule,  readily  distinguished 
by  the  absence  of  tinnitus  or  evidences  of  disturbance  in  the  function  of 
the  auditory  nerve.  This  variety  of  vertigo  is  much  less  common  than 
Trousseau's  description  would  lead  us  to  believe.  It  is  important  to  note 
the  close  connection  of  vertigo  with  ocular  defects. 

The  cardio-vascular  vertigo,  one  of  the  most  common  forms,  occurs  in 
cases  of  valvular  disease,  particularly  aortic  insufficiency,  and  as  frequently 
in  arterio-sclerosis. 

Endemic  Paralytic  Vertigo. — In  parts  of  Switzerland  and  France  there 
is  a  remarkable  form  of  vertigo  described  by  Grerlier,  which  is  characterized 
by  attacks  of  paretic  weakness  of  the  extremities,  falling  of  the  eyelids, 
remarkable  depression,  but  with  retention  of  consciousness.  It  occurs  also 
in  northern  Japan,  where  Miura  says  it  develops  paroxysmally  among  the 
farm  laborers  of  both  sexes  and  all  ages.     It  is  known  there  as  hubisagari. 

Aural  vertigo  must  be  carefully  distinguished  from  attacks  of  petit  mat, 
or,  indeed,  of  definite  epilepsy.  It  is  rare  in  petit  mal  to  have  noises  in  the 
ear  or  actual  giddiness,  but  in  the  aura  preceding  an  epileptic  attack  the 
patient  may  feel  giddy.  Giddiness  and  transient  loss  of  consciousness  may 
be  associated  with  organic  disease  of  the  brain,  more  particularly  with 
tumor.  Vomiting  also  may  be  present.  A  careful  investigation  of  the 
symptoms  will  usually  lead  to  a  correct  diagnosis. 

The  outlook  in  Meniere's  disease  is  uncertain.  While  many  cases  re- 
cover completely,  in  others  deafness  results  and  the  attacks  recur  at  shorter 
intervals.  In  aggravated  eases  the  patient  constantly  suffers  from  vertigo 
and  may  even  be  confined  to  his  bed. 

Treatment. — Bromide  of  potassium,  in  20-grain  doses  three  times  a 
day,  is  sometimes  beneficial.  If  there  is  a  history  of  syphilis,  the  iodide 
should  be  administered.  The  salicylates  are  recommended,  and  Charcot 
advises  quinine  to  cinchonism.  In  cases  in  which  there  is  increase  in  the 
arterial  tension,  nitroglycerin  may  be  given,  at  first  in  very  small  doses,  but 
increasing  gradually.  It  is  not  specially  valuable  in  Meniere's  disease,  but 
in  the  cases  of  giddiness  in  middle-aged  men  and  women  associated  with 
arterio-sclerosis  it  sometimes  acts  very  satisfactorily.  Correction  of  errors 
of  refraction  is  sometimes  followed  by  prompt  relief  of  the  vertigo. 

Glosso-pharyngeal  Nerve  (Nervus  glossopharyngeus). 

The  ninth  nerve  contains  both  motor  and  sensory  fibres  and  is  also  a 
nerve  of  the  special  sense  of  taste  to  the  tongue.  It  supplies,  by  its  motor 
branches,  the  stylo-pharyngeus  and  the  middle  constrictor  of  the  pharynx. 
The  sensory  fibres  are  distributed  to  the  upper  part  of  the  pharynx. 

Symptoms. — Of  nuclear  disturbance  we  know  very  little.  The 
pharyngeal  symptoms  of  bull)ar  paralysis  are  probably  associated  with  in- 
volvement of  the  nuclei  of  this  nerve.  Lesion  of  the  nerve  trunk  itself  is 
rare,  hut  it  may  be  compressed  by  tumors  or  involved  in  meningitis.  Dis- 
turbance of  the  sense  of  taste  may  result  from  loss  of  function  of  this  nerve, 
in  which  case  it  is  chiefly  in  the  posterior  part  of  the  tongue  and  soft  pal- 


1060  DISEASES  OP  THE  NERVOUS  SYSTEM. 

ate.  Gowers,  however,  states  that  there  is  no  ease  on  record  in  which  loss 
of  taste  in  these  regions  has  been  produced  by  disease  of  the  roots  of  the 
giosso-i^haryngeal;  wliereas,  on  the  other  hand,  disease  of  the  root 
of  the  fifth  nerve  may  cause  loss  of  taste  on  the  back  as  well  as  the  front 
of  the  tongue,  as  if  the  taste  fibres  of  the  glosso-pharyngeal  came  from  the 
fifth. 

The  general  disturbances  of  the  sense  of  taste  may  here  be  briefly  referred 
to.  Loss  of  the  sense  of  taste — ageusia — ^may  be  caused  by  disturbance  of 
the  peripheral  end  organs,  as  in  affections  of  the  mucosa  of  the  tongue. 
This  is  very  common  in  the  dry  tongue  of  fever  or  the  furred  tongue  of 
dyspepsia,  under  which  circumstances,  as  the  saying  is,  everything  tastes 
alike.  Strong  irritants  too,  such  as  pepper,  tobacco,  or  vinegar,  may  dull 
or  diminish  the  sense  of  taste.  Complete  loss  may  be  due  to  involvement 
of  the  nerves  either  in  their  course  or  in  the  centres.  Disturbance  in  the 
sense  of  taste  is  most  commonly  seen  in  involvement  of  the  fifth  nerve, 
and  it  may  be  that  this  nerve  alone  subserves  the  function.  Perversion  of 
the  sense  of  taste — parageusis — is  rarely  found,  except  as  an  hysterical 
manifestation  and  in  the  insane.  Increased  sensitiveness  is  still  more  rare. 
There  are  occasional  subjective  sensations  of  taste,  occurring  as  an  aura 
in  epilepsy  or  as  part  of  the  hallucinations  in  the  insane. 

To  test  the  sense  of  taste  the  patient's  eyes  should  be  closed  and  small 
quantities  of  various  substances  applied.  The  sensation  should  be  per- 
ceived before  the  tongue  is  withdrawn.  The  following  are  the  most  suitable 
tests:  For  bitter,  quinine;  for  sweetness,  a  strong  solution  of  sugar  or  sac- 
charin; for  acidity,  vinegar;  and  for  the  saline  test,  common  salt.  One 
of  the  most  important  tests  is  the  feeble  galvanic  current,  which  gives  the 
well-known  metallic  taste. 

Pneumogasteic  ISTerve  {Nervus  vagus). 

The  tenth  nerve  has  an  important  and  extensive  distribution,  supply- 
ing the  pharynx,  larynx,  lungs,  heart,  oesophagus,  and  stomach.  The  nerve 
may  be  involved  at  its  nucleus  along  with  the  spinal  accessory  and  the  hypo- 
glossal, forming  what  is  known  as  bulbar  paralysis.  It  may  be  compressed 
by  tumors  or  aneurism,  or  in  the  exudation  of  meningitis,  simple  or  syphi- 
litic. In  its  course  in  the  neck  the  trunk  may  be  involved  by  tumors  or 
in  wounds.  It  has  been  tied  in  ligature  of  the  carotid,  and  has  been  cut 
in  the  removal  of  deep-seated  tumors.  The  trunk  may  be  attacked  by 
neuritis. 

The  affections  of  the  vagus  are  best  considered  in  connection  with  the 
distribution  of  the  separate  nerves. 

(«)  Pharyngeal  Branches. — In  combination  with  the  glosso-pharyngeal 
the  branches  from  the  vagus  form  the  pharyngeal  plexus,  from  which  the 
muscles  and  mucosa  of  the  pharynx  are  supplied.  In  paralysis  due  to 
involvement  of  this  either  in  the  nuclei,  as  in  bulbar  paralysis,  or  in  the 
course  of  the  nerve,  as  in  diphtheritic  neuritis,  there  is  difficulty  in  swal- 
lowing and  the  food  is  not  passed  on  into  the  oesophagus.  If  the  nerve  on 
one  side  only  is  involved,  the  deglutition  is  not  much  impaired.     In  these 


DISEASES   OF   THE   CEREBEAL  NERVES.  1061 

cases  the  particles  of  food  frequently  pass  into  the  larynx^  and,  when  the 
soft  palate  is  involved,  into  the  posterior  nares. 

Spasm  of  the  pharynx  is  always  a  functional  disorder,  usually  occur- 
ring in  hysterical  and  nervous  people.  Gowers  mentions  a  case  of  a  gentle- 
man who  could  not  eat  unless  alone,  on  account  of  the  inability  to  swallow 
in  the  presence  of  others  from  spasm  of  the  pharynx.  This  spasm  is  a  well- 
marked  feature  in  hydrophobia,  and  I  have  seen  it  in  a  case  of  pseudo- 
hydrophobia. 

(b)  Laryngeal  Branches. — The  superior  laryngeal  nerve  supplies  the 
mucous  membrane  of  the  larynx  above  the  cords  and  the  crico-thyroid  mus- 
cle. The  inferior  or  recurrent  laryngeal  curves  around  the  arch  of  the 
aorta  on  the  left  side  and  the  subclavian  artery  on  the  right,  passes  along 
the  trachea  and  supplies  the  mucosa  below  the  cords  and  all  the  muscles  of 
the  larynx  except  the  crico-thyroid  and  the  epiglottidean.  Experiments  have 
shown  that  these  motor  nerves  of  the  pneumogastric  are  all  derived  from 
the  spinal  accessory.  The  remarkable  course  of  the  recurrent  laryngeal 
nerves  renders  them  liable  to  pressure  by  tumors  within  the  thorax,  par- 
ticularly by  aneurism.  The  following  are  the  most  important  forms  of 
paralysis: 

(1)  Bilateral  Paralysis  of  the  Aiductors.— In  this  condition,  the  pos- 
terior crico-arytenoids  are  involved  and  the  glottis  is  not  opened  during 
inspiration.  The  cords  may  be  close  together  in  the  position  of  phonation, 
and  during  inspiration  may  be  brought  even  nearer  together  by  the  pressure 
of  air,  so  that  there  is  only  a  narrow  chink  through  which  the  air  whistles 
with  a  noisy  stridor.  This  dangerous  form  of  laryngeal  paralysis  occurs 
occasionally  as  a  result  of  cold,  or  may  follow  a  laryngeal  catarrh.  The 
posterior  muscles  have  been  found  degenerated  when  the  others  were 
healthy.  The  condition  may  be  produced  by  pressure  upon  both  vagi,  or 
upon  both  recurrent  nerves.  As  a  central  affection  it  occurs  in  tabes  and 
bulbar  paralysis,  but  may  be  seen  also  in  hysteria.  The  characteristic  symp- 
toms are  inspiratory  stridor  with  unimpaired  phonation.  Possibly,  as 
Gowers  suggests,  many  cases  of  so-called  hysterical  spasm  of  the  glottis  are 
in  reality  abductor  paralysis. 

(2)  Unilateral  Ahdudor  Paralysis. — This  frequently  results  from  the 
pressure  of  tumors  or  involvement  of  one  recurrent  nerve.  Aneurism  is 
by  far  the  most  common  cause,  though  on  the  right  side  the  nerve  may  be 
involved  in  thickening  of  the  pleura.  The  symptoms  are  hoarseness  or 
roughness  of  the  voice,  such  as  is  so  common  in  aneurism.  Dyspnoea  is  not 
often  present.  The  cord  on  the  affected  side  does  not  move  in  inspiration. 
Subsequently  the  adductors  may  also  become  involved,  in  which  case  the 
phonation  is  still  more  impaired. 

(3)  Adductor  Paralysis. — This  results  from  involvement  of  the  lateral 
crico-arytenoid  and  the  arytenoid  muscle  itself.  It  is  common  in  hysteria, 
particularly  of  women,  and  causes  the  hysterical  aphonia,  which  may  come 
on  suddenly.  It  may  result  from  catarrh  of  the  larynx  or  from  overuse  of 
the  voice.  In  laryngoscopic  examination  it  is  seen,  on  attempt  at  phonation, 
that  there  is  no  power  to  bring  the  cords  together.  In  this  connection  the 
following  table  from  Gowers'  work  will  be  found  valuable  to  tlie  student: 


1062 


DISEASES  OF   THE  NERVOUS  SYSTEM. 


Symptoms. 

No  voice ;  no  cough ; 
stridor  only  on  deep  in- 
spiration. 

Voice  low  pitched 
and  hoarse  ;  no  cough ; 
stridor  absent  or  slight 
on  deep  breathing. 


Voice  little  changed ; 
cough  normal;-  inspira- 
tion difficult  and  long, 
with  loud  stridor. 

Symptoms  incon- 
clusive ;  little  affection 
of  voice  or  cough. 

No  voice ;  perfect 
cough;  no  stridor  or 
dyspnoea. 


SlG]S"S. 

Both  cords  moder- 
ately abducted  and  mo- 
tionless. 

One  cord  moder- 
ately abducted  and  mo- 
tionless, the  other  mov- 
ing freely,  and  even 
beyond  the  middle  line 
in  phonation. 

Both  cords  near  to- 
gether, and  dui'ing  in- 
spiration not  separated, 
but  even  drawn  nearer 
together. 

One  cord  near  the 
middle  line  not  moving 
during  inspiration,  the 
other  normal. 

Cords  normal  in  po- 
sition and  moving  nor- 
mally in  respiration, 
but  not  brought  to- 
gether on  an  attempt 
at  phonation. 


Lesiok. 
Total  bilateral  palsy. 


Total  unilateral  palsy. 


Total  abductor  palsy. 


Unilateral 
palsy. 


abductor 


Adductor  palsy. 


Spasm  of  the  Muscles  of  the  Larynx. — In  this  the  adductor  muscles  are 
involved.  It  is. not  an  uncommon  affection  in  children,  and  has  already 
been  referred  to  as  laryngismus  stridulus.  Paroxysmal  attacks  of  laryngeal 
spasm  are  rare  in  the  adult,  but  cases  are  described  in  which  the  patient, 
usually  a  young  girl,  wakes  at  night  in  an  attack  of  intense  dyspnoea,  which 
may  persist  long  enough  to  produce  cyanosis.  Liveing  states  that  they  may 
replace  attacks  of  migraine.  They  occur  in  a  characteristic  form  in  loco- 
motor ataxia,  forming  the  so-called  laryngeal  crises.  There  is  a  condition 
known  as  spastic  aphonia,  in  which,  when  the  patient  attempts  to  speak, 
phonation  is  completely  prevented  by  a  spasm. 

Disturbance  of  the  sensory  nerves  of  the  larynx  is  rare. 

Ancestjiesia  may  occur  in  bulbar  paralysis  and  in  diphtheritic  neuritis — 
a  serious  condition,  as  portions  of  food  may  enter  the  windpipe.  It  is 
usually  associated  with  dysphagia  and  is  sometimes  present  in  hysteria. 
Hypergesthesia  of  the  larynx  is  rare. 

(c)  Cardiac  Branches. — The  cardiac  plexus  is  formed  by  the  union  of 
branches  of  the  vagi  and  of  the  sympathetic  nerves.  The  vagus  fibres  sub- 
serve motor,  sensory,  and  probably  trophic  functions. 

(1)  Motor. — The  fibres  which  inhibit,  control,  and  regulate  the  cardiac 
action  pass  in  the  vagi.  Irritation  may  produce  slowing  of  the  action.  Czer- 
mak  could  slow  or  even  arrest  the  heart's  action  for  a  few  beats  by  pressing 
a  small  tumor  in  his  neck  against  one  pneumogastric  nerve,  and  it  is  said 


DISEASES  OF  THE  CEREBRAL  NERVES.  1063 

that  the  same  can  he  produced  by  forcible  bilateral  pressure  on  the  carotid 
canal.  There  are  instances  in  which  persons  appear  to  have  had  volun- 
tary control  over  the  action  of  the  heart.  Cheyne  mentions  the  case  of 
Colonel  Townshend,  "  who  could  die  or  expire  when  he  pleased,  and  yet 
by  an  effort  or  somehow  come  to  life  again,  which  it  seems  he  had  some- 
times tried  before  he  had  sent  for  us."  Eetardation  of  the  heart's  action 
has  also  followed  accidental  ligature  of  one  vagus.  Irritation  at  the  nuclei 
may  also  be  accompanied  with  a  neurosis  of  this  nerve.  On  the  other  hand, 
when  there  is  complete  paralysis  of  the  vagi,  the  inhibitory  action  may  be 
abolished  and  the  acceleratory  influences  have  full  sway.  The  heart's 
action  is  then  greatly  increased.  This  is  seen  in  some  instances  of  diph- 
theritic neuritis  and  in  involvement  of  the  nerve  by  tumors,  or  its  accidental 
removal  or  ligature.  Complete  loss  of  function  of  one  vagus  may,  however, 
not  be  followed  by  any  symptoms. 

(2)  Sensory  symptoms  on  the  part  of  the  cardiac  branches  are  very 
varied.  Normally,  the  heart's  action  proceeds  regularly  without  the  par- 
ticipation of  consciousness,  but  the  unpleasant  feelings  and  sensations  of 
palpitation  and  pain  are  conveyed  to  the  brain  through  this  nerve.  How 
far  the  fibres  of  the  pneumogastric  are  involved  in  angina  it  is  impossible 
to  say.  The  various  disturbances  of  sensation  are  described  under  the  car- 
diac neuroses. 

{d)  Pulmonary  Branches. — We  know  very  little  of  the  pulmonary 
branches  of  the  vagi.  The  motor  fibres  are  stated  to  control  the  action  of 
the  bronchial  muscles,  and  it  has  long  been  held  that  asthma  may  be  a  neu- 
rosis of  these  fibres.  The  various  alterations  in  the  respiratory  rhythm  are 
probably  due  more  to  changes  in  the  centre  than  in  the  nerves  themselves. 

{e)  Gastric  and  (Esophageal  Branches. — The  muscular  movements  of 
these  parts  are  presided  over  by  the  vagi  and  vomiting  is  induced  through 
them,  usually  reflexly,  but  also  by  direct  irritation,  as  in  meningitis.  Spasm 
of  the  oesophagus  generally  occurs  with  other  nervous  phenomena.  Gas- 
tralgia  may  sometimes  be  due  to  cramp  of  the  stomach,  but  is  more  com- 
monly a  sensory  disturbance  of  this  nerve,  due  to  direct  irritation  of  the 
peripheral  ends,  or  is  a  neuralgia  of  the  terminal  fibres.  Hunger  is  said 
to  be  a  sensation  aroused  by  the  pneumogastric,  and  some  forms  of  nervous 
dyspepsia  probably  depend  upon  disturbed  function  of  this  nerve.  The 
severe  gastric  crises  which  occur  in  locomotor  ataxia  are  due  to  central 
irritation  of  the  nuclei.  Some  describe  exophthalmic  goitre  under  lesions 
of  the  vagi. 

Spinal  Accessory  Nerve  (Nervus  accessorius). 

Paralysis. — The  smaller  or  internal  part  of  this  nerve  joins  the  vagus 
and  is  distributed  through  it  to  the  laryngeal  muscles.  The  larger  external 
part  is  distributed  to  the  sterno-mastoid  and  trapezius  muscles. 

The  nuclei  of  the  nerve,  particularly  of  the  accessory  part,  may  be  in- 
volved in  bulbar  paralysis.  The  nuclei  of  the  external  portion,  situated 
as  they  are  in  the  cervical  cord,  may  be  attacked  in  progressive  degenera- 
tion of  the  motor  nuclei  of  the  cord.  The  nerve  mny  be  involved  in  the 
exudation  of  meningitis,  or  be  compressed  by  tumors,  or  in  caries.     The 


1064  DISEASES  OF  THE  NERVOUS  SYSTEM. 

symptoms  of  paralysis  of  the  accessory  portion  which  joins  the  vagus  have 
already  been  given  in  the  account  of  the  palsy  of  the  laryngeal  branches 
of  the  pneumogastric.  Disease  or  compression  of  the  external  portion  is 
followed  by  paralysis  of  the  sterno-mastoid  and  of  the  trapezius  on  the 
same  side.  In  paralysis  of  one  sterno-mastoid,  the  patient  rotates  the  head 
with  difficulty  to  the  opposite  side,  but  there  is  no  torticollis,  though  in 
some  cases  the  head  is  held  obliquely.  As  the  trapezius  is  supplied  in  part 
from  the  cervical  nerves,  it  is  not  completely  paralyzed,  but  the  portion 
which  passes  from  the  occipital  bone  to  the  acromion  is  functionless.  The 
paralysis  of  the  muscle  is  well  seen  when  the  patient  draws  a  deep  breath 
or  shrugs  the  shoulders.  The  middle  portion  of  the  trapezius  is  also  weak- 
ened, the  shoulder  droops  a  little,  and  the  angle  of  the  scapula  is  rotated 
inward  by  the  action  of  the  rhomboids  and  the  levator  anguli  scapulae. 
Elevation  of  the  arm  is  impaired,  for  the  trapezius  does  not  fix  the  scapula 
as  a  point  from  which  the  deltoid  can  work. 

In  progressive  muscular  atrophy  we  sometimes  see  bilateral  paralysis 
of  these  muscles.  Thus,  if  the  sterno-mastoids  are  affected,  the  head  tends 
to  fall  back;  when  the  trapezii  are  involved,  it  falls  forward,  a  characteristic 
attitude  of  the  head  in  many  cases  of  progressive  muscular  atrophy.  Gowers 
suggests  that  lesions  of  the  accessory  in  difficult  labor  may  account  for  those 
cases  in  which  during  the  first  year  of  life  the  child  has  great  difficulty  in 
holding  up  the  head.  In  children  this  drooping  of  the  head  is  an  impor- 
tant symptom  in  cervical  meningitis,  the  result  of  caries. 

The  treatment  of  the  condition  depends  much  upon  the  cause.  In  the 
central  nuclear  atrophy  but  little  can  be  done.  In  paralysis  from  pressure 
the  symptoms  may  gradually  be  relieved.  The  paralyzed  muscles  should 
be  stimulated  by  electricity  and  massage. 

Accessory  Spasm. — {Torticollis;  Wryneck.) — The  forms  of  spasm  af- 
fecting the  cervical  muscles  are  best  considered  here,  as  the  inuscles  sup- 
plied by  the  accessory  are  chiefly,  though  not  solely,  responsible  for  the 
condition.    The  following  forms  may  be  described  in  this  section: 

(a)  Congenital  Torticollis. — This  condition,  also  known  as  fixed  torti- 
collis, depends  upon  the  shortening  and  atrophy  of  the  sterno-mastoid  on 
one  side.  It  occurs  in  children  and  may  not  be  noticed  for  several  years 
on  account  of  the  shortness  of  the  neck,  the  parents  often  alleging  that  it 
has  only  recently  come  on.  It  affects  the  right  side  almost  exclusively.  A 
remarkable  circumstance  in  connection  with  it  is  the  existence  of  facial 
asymmetry  noted  by  Wilks,  which  appears  to  be  an  essential  part  of  this 
congenital  form.  It  occurred  in  6  cases  reported  by  Golding-Bird.  In 
congenital  wryneck  the  sterno-mastoid  is  shortened,  hard  and  firm,  and  in 
a  condition  of  more  or  less  advanced  atrophy.  This  must  be  distinguished 
from  the  local  thickening  in  the  sterno-mastoid  due  to  rupture,  which  may 
occur  at  the  time  of  birth  and  produce  an  induration  or  muscle  callus. 
Although  the  sterno-mastoid  is  almost  always  affected,  there  are  rare  cases 
in  which  the  fibrous  atrophy  affects  the  trapezius.  This  form  of  wryneck 
in  itself  is  unimportant,  since  it  is  readily  relieved  by  tenotomy,  but 
Golding-Bird  states  that  the  facial  asymmetry  persists,  or  indeed  may,  as 
shown  by  photographs  in  my  case,  become  more  evident.     With  reference 


DISEASES   OF   THE   CEREBRAL  NERVES.  1065 

to  the  pathology  of  the  affection,  Golding-Bird  conchicles  that  the  facial 
asymmetry  and  the  torticollis  are  integral  parts  of  one  affection  which  has 
a  central  origin  and  is  the  counterpart  in  the  head  and  neck  of  infantile 
paralysis  with  talipes  in  the  foot. 

{!))  Spasmodic  Wrynecl-. — Two  varieties  of  this  spasm  occur,  the  tonic 
and  the  clonic,  which  may  alternate  in  the  same  case;  or,  as  is  most  com- 
mon, they  are  separate  and  remain  so  from  the  outset.  The  disease  is 
most  frequent  in  adults  and,  according  to  Gowers,  more  common  in  females. 
In  this  country  it  is  certainly  more  frequent  in  males.  Of  the  8  or  10  cases 
which  came  under  my  observation  in  Montreal  and  Philadelphia,  all  were 
males.  In  females  it  may  be  an  hysterical  manifestation.  There  may  be 
a  marked  neurotic  family  history,  but  it  is  usually  impossible  to  fix  upon 
any  definite  etiological  factor.  Some  cases  have  followed  cold;  others 
a  blow. 

The  symptoms  are  well  defined.  In  the  tonic  form  the  contracted 
sterno-mastoid  draws  the  occiput  toward  the  shoulder  of  the  affected  side; 
the  chin  is  raised,  and  the  face  rotated  to  the  other  shoulder.  The  sterno- 
mastoid  may  be  affected  alone  or  in  association  with  the  trapezius.  When 
the  latter  is  implicated  the  head  is  depressed  still  more  toward  the  same 
side.  In  long-standing  cases  these  muscles  are  prominent  and  very  rigid. 
There  may  be  some  curvature  of  the  spine,  the  convexity  of  which  is  toward 
the  sound  side.  The  cases  in  which  the  spasm  is  clonic  are  much  more 
distressing  and  serious.  The  spasm  is  rarely  limited  to  a  single  muscle. 
The  sterno-mastoid  is  almost  always  involved  and  rotates  the  head  so  as  to 
approximate  the  mastoid  process  to  the  inner  end  of  the  clavicle,  turning 
the  face  to  the  opposite  side  and  raising  the  chin.  When  with  this  the 
trapezius  is  affected,  the  depression  of  the  head  toward  the  same  side  is 
more  marked.  The  head  is  drawn  somewhat  backward;  the  shoulder,  too, 
is  raised  by  its  action.  According  to  Gowers,  the  splenius  is  associated 
with  the  sterno-mastoid  about  half  as  frequently  as  the  trapezius.  Its  action 
is  to  incline  the  head  and  rotate  it  slightly  toward  the  same  side.  Other 
muscles  may  be  involved,  such  as  the  scalenus  and  platysma  myoides;  and 
in  rare  cases  the  head  may  be  rotated  by  the  deep  cervical  muscles,  the 
rectus  and  obliquus.  There  are  cases  in  which  the  spasm  is  bilateral,  caus- 
ing a  backward  movement — the  retro-collic  spasm.  This  may  be  either 
tonic  or  clonic,  and  in  extreme  cases  the  face  is  horizontal  and  looks  upward. 

These  clonic  contractions  may  come  on  without  warning,  or  be  pre- 
ceded for  a  time  by  irregular  pains  or  stiffness  of  the  neck.  The  jerking 
movements  recur  every  few  moments,  and  it  is  impossible  to  keep  the  head 
still  for  more  than  a  minute  or  two.  In  time  the  muscles  undergo  hyper- 
trophy and  may  be  distinctly  larger  on  one  side  than  the  other.  In  some 
cases  the  pain  is  considerable;  in  others  there  is  simply  g,  feeling  of  fatigue. 
The  spasms  cease  during  sleep.  Emotion,  excitement,  and  fatigue  increase 
them.  The  spasm  may  extend  from  the  muscles  of  the  neck  and  involve 
those  of  the  face  or  of  the  arms. 

The  disease  varies  much  in  its  course.  Cases  occasionally  get  well,  but 
the  great  majority  of  tliem  persist,  and,  even  if  temporarily  relieved,  the 
disease  frequently  recurs.    The  affection  is  usually  regarded  as  a  functional 


1066  DISEASES  OF   THE  NERVOUS   SYSTEM. 

neurosis,  but  it  is  possibly  due  to  disturbance  of  the  cortical  centres  presid- 
ing over  the  muscles. 

Treatment. — Temporary  relief  is  sometimes  obtained;  a  permanent 
cure  is  exceptional.  Various  drugs  have  been  used,  but  rarely  with  benefit. 
Occasionally,  large  doses  of  bromide  will  lessen  the  intensity  of  the  spasm. 
Morphia,  subcutaneously,  has  been  successful  in  some  reported  cases,  but 
there  is  the  great  danger  of  establishing  the  morphia  habit.  Galvanism 
may  be  tried.  Counter-irritation  is  probably  useless.  Fixation  of  the  head 
mechanically  can  rarely  be  borne  by  the  patient.  These  obstinate  cases  fall 
ultimately  into  the  hands  of  the  surgeon,  and  the  operations  of  stretching, 
division,  and  excision  of  the  accessory  nerve  and  division  of  the  muscles 
have  been  tried.  The  last  does  not  check  the  spasm,  and  may  aggravate 
the  symptoms.  Temporary  relief  niay  follow,  but,  as  a  rule,  the  condition 
returns.  Eisien  Eussell  thinks  that  resection  of  the  posterior  branches  of 
the  upper  cervical  nerves  is  most  likely  to  give  relief,  and  this  has  been 
done  by  Keen  and  others. 

(c)  The  nodding  spasm  of  children  may  here  be  mentioned  as  involving 
chiefly  the  muscles  innervated  by  the  accessory  nerve.  It  may  be  a  simple 
trick,  a  form  of  habit  spasm,  or  a  phenomenon  of  epilepsy  (E.  nutans),  in 
which  case  it  is  associated  with  transient  loss  of  consciousness.  A  similar 
nodding  spasm  may  occur  in  older  children.  In  women  it  sometimes  occurs 
as  an  hysterical  manifestation,  commonly  as  part  of  the  so-called  salaam 
convulsion. 

Hypoglossal  Keeve. 

This  is  the  motor  nerve  of  the  tongue  and  for  most  of  the  muscles  at- 
tached to  the  hyoid  bone.  Its  cortical  centre  is  probably  the  lower  part  of 
the  anterior  central  gyrus. 

Paralysis. — (1)  Cortical  Lesion. — The  tongue  is  often  involved  in  hemi- 
plegia, and  the  paralysis  may  result  from  a  lesion  of  the  cortex  itself,  or  of 
the  fibres  as  they  pass  to  the  medulla.  It  does  not  occur  alone  and  is 
considered  with  hemiplegia.  There  is  this  difference,  however,  between 
the  cortical  and  other  forms,  that  the  muscles  on  both  sides  of  the  tongue 
may  be  more  or  less  affected  but  do  not  waste,  nor  are  their  electrical  re- 
actions disturbed. 

(2)  Nuclear  and  infra-yiuclear  lesions  of  the  hypoglossal  result  from 
slow  progressive  degeneration,  as  in  bulbar  paralysis  or  in  locomotor  ataxia; 
occasionally  there  is  acute  softening  from  obstruction  of  the  vessels. 
The  nuclei  of  both  nerves  are  usually  affected  together,  but  may  be  attacked 
separately.  Trauma  and  lead  poisoning  have  also  been  assigned  as  causes. 
The  fibres  may  be  damaged  by  a  tumor,  and  at  the  base  by  meningitis; 
or  the  nerve  is  sometimes  involved  in  the  condylar  foramen  by  disease  of  the 
skull.  It  may  be  involved  in  its  course  in  a  scar,  as  in  Birkett's  case,  or 
compressed  by  a  tumor  in  the  parotid  region,  as  in  a  case  at  present  under 
my  care.  As  a  result,  there  is  loss  of  function  in  the  nerve  fibres  and  the 
tongue  undergoes  atrophy  on  the  affected  side.  It  is  protruded  toward  the 
paralyzed  side  and  may  show  fibrillary  twitching. 

The  symptoms  of  involvement  of  one  hypoglossal,  either  at  its  centre 


DISEASES   OF  THE  SPINAL  NERVES.  1067 

or  in  its  course,  are  those  of  unilateral  paralysis  and  atrophy  of  the  tongue. 
When  protruded,  it  is  pushed  toward  the  affected  side,  and  there  are  fibril- 
lary twitchings.  The  atrophy  is  usually  marked  and  the  mucous  membrane 
on  the  affected  side  is  thrown  into  folds.  Articulation  is  not  much  im- 
paired in  the  unilateral  affection.  There  is  a  remarkable  triad  of  symptoms, 
to  which  Hughlings  Jackson  first  called  attention — unilateral  hemi-atrophy 
of  the  tongue,  loss  of  power  in  the  palate  muscle,  with  paralysis  of  the 
larynx  on  the  same  side.  When  the  disease  is  bilateral,  the  tongue  lies 
almost  motionless  in  the  floor  of  the  mouth;  it  is  atrophied,  and  can- 
not be  protruded.  Speech  and  mastication  are  extremely  difficult  and 
deglutition  may  be  impaired.  If  the  seat  of  the  disease  is  above  the 
nuclei,  there  may  be  little  or  no  wasting.  The  condition  is  seen  in 
progressive  bulbar  paralysis  and  occasionally  in  progressive  muscular 
atrophy. 

The  diagnosis  is  readily  made  and  the  situation  of  the  lesion  can  usu- 
ally be  determined,  since  when  supra-nuclear  there  is  associated  hemi- 
plegia and  no  wasting  of  the  muscles  of  the  tongue.  Nuclear  disease  is 
only  occasionally  unilateral;  most  commonly  bilateral  and  part  of  a  bulbar 
paralysis.  It  should  be  borne  in  mind  that  the  fibres  of  the  hypoglossal 
may  be  involved  within  the  medulla  after  leaving  their  nuclei.  In  such 
a  case  there  may  be  paralysis  of  the  tongue  on  one  side  and  paralysis  of 
the  limbs  on  the  opposite  side,  and  the  tongue,  when  protruded,  is  pushed 
toward  the  sound  side. 

Spasm. — This  rare  affection  may  be  unilateral  or  bilateral.  It  is  most 
frequently  a  part  of  some  other  convulsive  disorder,  such  as  epilepsy, 
chorea,  or  spasm  of  the  facial  muscles.  In  some  cases  of  stuttering,  spasm 
of  the  tongue  precedes  the  explosive  utterance  of  the  words.  It  may  occur 
in  hysteria,  and  is  said  to  follow  reflex  irritation  in  the  fifth  nerve.  The 
most  remarkable  cases  are  those  of  paroxysmal  clonic  spasm,  in  which  the 
tongue  is  rapidly  thrust  in  and  out,  as  many  as  forty  or  fifty  times  a  minute. 
In  the  case  reported  by  Gowers  the  attacks  occurred  during  sleep  and  con- 
tinued for  a  year  and  a  half.  The  spasm  is  usually  bilateral.  Wendt  has 
reported  a  case  in  which  it  was  unilateral.     The  prognosis  is  usually  good. 


IV.    DISEASES    OF   THE    SPINAL    NERVES. 

Cervical  Plexus. 

(1)  Occipito-cervical  Neuralgia.— This  involves  the  nerve  territory  sup- 
plied by  the  second,  the  occipitalis  major  and  minor,  and  the  auricularis 
magnus  nerves.  The  pains  are  chiefly  in  the  back  of  the  head  and  neck 
and  in  the  ear.  The  condition  may  follow  cold  and  is  sometimes  associated 
with  stiffness  of  the  neck  or  torticollis.  Unless  connected  with  it  there 
exists  disease  of  the  bones  or  due  to  pressure  of  tumors,  the  outlook  is  usu- 
ally good.  There  are  tender  points  midway  between  the  mastoid  process 
and  the  spine  and  just  above  tlie  parietal  eminence,  and  between  the  sterno- 
mastoid  and  the  trapezius.  The  affection  may  be  due  to  direct  pressure,  in 
persous  who  carry  very  heavy  loads  on  the  neck. 


1068  DISEASES  OF   THE  NERVOUS  SYSTEM. 

(2)  Affections  of  the  Phrenic  Nerve. — Paralysis  may  follow  a  lesion  in 
the  anterior  horns  at  the  level  of  the  third  and  fourth  cervical  nerves,  or 
may  be  due  to  compression  of  the  nerve  by  tumors  or  aneurism.  More 
rarely  paralysis  results  from  neuritis. 

It  may  be  part  of  a  diphtheritic  or  lead  palsy  and  is  usually  bilateral. 
When  the  diaphragm  is  paralyzed  respiration  is  carried  on  by  the  inter- 
costal and  accessory  muscles.  When  the  patient  is  quiet  and  at  rest  little 
may  be  noticed,  but  the  abdomen  retracts  in  inspiration  and  is  forced  out 
in  expiration.  On  exertion  or  even  on  attempting  to  move  there  may  be 
dyspnoea.  If  the  paralysis  sets  in  suddenly  there  may  be  dyspnoea  and 
lividity,  which  is  usually  temporary  (W.  Pasteur).  Intercurrent  attacks  of 
bronchitis  seriously  aggravate  the  condition.  Difficulty  in  coughing,  owing 
to  the  impossibility  of  drawing  a  full  breath,  adds  greatly  to  the  danger 
of  this  complication,  as  the  mucus  accumulates  in  the  tubes. 

When  the  phrenic  nerve  is  paralyzed  on  one  side  the  paralysis  may  be 
scarcely  noticeable,  but  careful  inspection  shows  that  the  descent  of  the 
diaphragm  is  much  less  on  the  affected  side. 

The  diagnosis  of  paralysis  is  not  always  easy,  particularly  in  women, 
who  habitually  use  this  muscle  less  than  men,  and  in  whom  the  diaphrag- 
matic breathing  is  less  conspicuous.  Immobility  of  the  diaphragm  is  not 
uncommon,  particularly  in  diaphragmatic  pleurisy,  in  large  effusions,  and 
in  extensive  emphysema.  The  muscle  itself  may  be  degenerated  and  its 
power  impaired. 

Owing  to  the  lessened  action  of  the  diaphragm,  there  is  a  tendency  to 
accumulation  of  blood  at  the  bases  of  the  lungs,  and  there  may  be  im- 
paired resonance  and  signs  of  oedema.  As  a  rule,  however,  the  paralysis  is 
not  confined  to  this  muscle,  but  is  part  of  a  general  neuritis  or  an  anterior 
polio-myelitis,  and  there  are  other  symptoms  of  value  in  determining  its 
presence.  The  outlook  is  usually  serious.  Pasteur  states  that  of  15  cases 
following  diphtheria,  only  8  recovered.  The  treatment  is  that  of  the  neuri- 
tis or  polio-myelitis  with  which  it  is  associated. 

Hiccough. — Here  may,  perhaps,  best  be  considered  this  remarkable  symp- 
tom, caused  by  intermittent,  sudden  contraction  of  the  diaphragm.  The 
mechanism,  however,  is  complex,  and  while  the  afferent  impressions  to  the 
respiratory  centre  may  be  peripheral  or  central,  the  efferent  are  distributed 
through  the  phrenic  nerve  to  the  diaphragm,  causing  the  intermittent 
spasm,  and  through  the  laryngeal  branches  of  the  vagus  to  the  glottis,  caus- 
ing sudden  closure  as  the  air  is  rapidly  inspired. 

Obstinate  hiccough  is  one  of  the  most  distressing  of  all  symptoms,  and 
may  tax  to  the  uttermost  the  resources  of  the  physician.  W.  Langford 
Symes  in  a  recent  study  groups  the  cases  into : 

(a)  Inflammatory,  seen  particularly  in  affections  of  the  abdominal  vis- 
cera, gastritis,  peritonitis,  hernia,  internal  strangulation,  appendicitis,  sup- 
purative pancreatitis,  and  in  the  severe  forms  of  typhoid  fever. 

(&)  Irritative,  as  in  the  direct  stimulus  of  the  diaphragm  in  the  swal- 
lowing of  very  hot  substances,  local  disease  of  the  oesophagus  near  the 
diaphragm,  and  in  many  conditions  of  gastric  and  intestinal  disorder,  more 
particularly  those  associated  with  flatus. 


DISEASES   OP   THE  SPINAL  NERVES.  1069 

(c)  Specific,  or,  perhajjs  more  properly,  idiopatldc,  in  which  no  evident 
causes  are  present.  In  these  cases  there  is  usually  some  constitutional  taint, 
as  gout,  diabetes,  or  chronic  Bright's  disease.  I  have  seen  several  instances 
of  obstinate  hiccough  in  the  later  stages  of  chronic  interstitial  nephritis. 

{d)  Neurotic,  cases  in  which  the  primary  cause  is  in  the  nervous  system; 
hysteria,  epilepsy,  shock,  or  cerebral  tumors.  Of  these  cases  the  hysterical 
are,  perhaps,  the  most  obstinate. 

The  treatment  is  often  very  unsatisfactory.  Sometimes  in  the  milder 
forms  a  sudden  reflex  irritation  will  check  it  at  once.  Eeaders  of  Plato's 
Symposium  will  remember  that  the  physician  Eryximachus  recommended 
to  Aristophanes,  who  had  hiccough  from  eating  too  much,  either  to  hold 
his  breath  (which  for  trivial  forms  of  hiccough  is  very  satisfactory)  or  to 
gargle  with  a  little  water;  but  if  it  still  continued,  "  tickle  your  nose  with 
something  and  sneeze;  and  if  you  sneeze  once  or  twice  even  the  most  vio- 
lent hiccough  is  sure  to  go."  The  attack  must  have  been  of  some  severity, 
as  it  is  stated  subsequently  that  the  hiccough  did  not  disappear  until  Aris- 
tophanes had  resorted  to  the  sneezing. 

Ice,  a  teaspoonful  of  salt  and  lemon-juice,  or  salt  and  vinegar,  or  a  tea- 
spoonful  of  raw  spirits  may  be  tried.  When  the  hiccough  is  due  to  gas- 
tric irritation,  lavage  is  sometimes  promptly  curative.  I  saw  a  case 
of  a  week's  duration  cured  by  a  hypodermic  injection  of  gr.  ^  of  apomor- 
phia.  In  obstinate  cases  the  various  antispasmodics  have  been  used  in  suc- 
cession. Pilocarpine  has  been  recommended.  The  ether  spray  on  the  epi- 
gastrium may  be  promptly  curative.  Hypodermics  of  morphia,  inhalations 
of  chloroform,  the  use  of  nitrite  of  amyl  and  of  nitroglycerin,  have  been 
beneficial  in  some  cases.  Galvanism  over  the  phrenic  nerve,  or  pressure 
on  the  nerves,  applied  between  the  heads  of  the  sterno-cleido-mastoid  mus- 
cles may  be  used.  Strong  retraction  of  the  tongue  may  give  immediate 
relief. 

Beachial  Plexus. 

(1)  Combined  Paralysis. — The  plexus  may  be  involved  in  the  supra- 
clavicular region  by  compression  of  the  nerve  trunks  as  they  leave  the  spine, 
or  by  tumors  and  other  morbid  processes  in  the  neck.  Below  the  clavicle 
lesions  are  more  common  and  result  from  injuries  following  dislocation 
or  fracture,  sometimes  from  neuritis.  The  most  common  cause  of  lesion  of 
the  brachial  plexus  is  luxation  of  the  humerus,  particularly  the  subcoracoid 
form.  If  the  dislocation  is  quickly  reduced  the  symptoms  are  quite  tran- 
sient, and  disappear  in  a  few  days.  In  severe  cases  all  the  branches  of  the 
plexus,  or  only  one  or  two,  may  be  involved.  The  most  serious  cases  are 
those  in  which  the  dislocation  is  undetected  or  unreduced  for  some  time, 
when  the  prolonged  pressure  on  the  nerves  may  cause  complete  and  perma- 
nent paralysis  of  the  arm.  The  muscles  waste,  the  reaction  of  degeneration 
is  present,  and  trophic  changes  in  the  skin  are  apt  to  occur.  The  medico- 
legal bearings  of  these  cases  are  important,  and  may  be  thus  briefly  sum- 
marized: Direct  injury,  as  by  a  fall  or  blow  on  the  shoulder,  resulting  in 
great  bniising  of  the  nerves  without  dislocation,  is  occasionally  followed  1)y 
complete  paralysis  of  the  arm.    A  dislocation  may  be  set  immediately  and 


1070  DISEASES  OF   THE  NERVOUS  SYSTEM. 

yet  the  lesion  of  the  brachial  plexus  may  be  such  as  to  cause  permanent 
paralysis  of  the  nerves.  The  dislocation  may  be  reduced  and  the  joint  in 
subsequent  movements  slips  out  again.  It  has  happened  that  by  the  time 
the  surgeon  sees  the  patient  again,  the  damage  has  become  irreparable. 

Injuries  and  blows  on  the  neck  may  cause  partial  paralysis  of  the  arm, 
involving  the  deltoid,  supraspinatus,  infraspinatus,  biceps,  brachialis  an- 
ticus,  and  the  supinator.  The  injury  may  occur  to  the  child  during  de- 
livery. 

A  primary  neuritis  of  the  brachial  plexus  is  rare.  More  commonly  the 
process  is  an  ascending  neuritis  from  a  lesion  of  a  peripheral  branch,  involv- 
ing first  the  radial  or  ulnar  nerves,  and  spreading  upward  to  the  plexus, 
producing  gradually  complete  loss  of  power  in  the  arm. 

(2)  Lesions  of  Individual  Nerves  of  tlie  Plexus. — (a)  Long  Thoracic 
Nerve  (Serratus  Palsy.) — This  occurs  chiefly  in  men.  The  nerve  is  injured 
in  the  posterior  triangle  of  the  neck,  usually  by  direct  pressure  in  the  carry- 
ing of  loads;  cold  may  cause  neuritis.  It  may  be  involved  also  in  pro- 
gressive muscular  atrophy  and  in  polio-myelitis  anterior.  When  paralyzed 
the  scapula  on  the  affected  side  looks  winged,  which  results  from  the  pro- 
jection of  the  angle  and  posterior  border.  This  is  particularly  noticeable 
when  the  arm  is  moved  forward,  when  the  serratus  no  longer  holds  the 
scapula  against  the  thorax.  It  is  a  well-defined  and  readily  recognized 
form  of  paralysis.  The  onset  is  associated  with,  sometimes  preceded  by, 
neuralgic  pains.  The  course  is  dubious,  and  many  months  may  elapse 
before  there  is  any  improvement. 

(5)  Circumflex  Nerve. — This  siipplies  the  deltoid  and  the  teres  minor. 
The  nerve  is  apt  to  be  involved  in  injuries,  in  dislocations,  bruising  by  a 
crutch,  or  sometimes  by  extension  of  infiammation  from  the  joint.  Occa- 
sionally the  paralysis  arises  from  a  pressure  neuritis  during  an  illness.  As 
a  consequence  of  loss  of  power  in  the  deltoid,  the  arm  cannot  be  raised. 
The  wasting  is  usually  marked  and  changes  the  shape  of  the  shoulder. 
Sensation  may  also  be  impaired  in  the  skin  over  the  muscle.  The  joint 
may  be  relaxed  and  there  may  be  a  distinct  space  between  the  head  of  the 
humerus  and  the  acromion.  In  other  instances  the  ligaments  are  thick- 
ened, and  a  condition  not  unlike  ankylosis  may  be  produced,  but  which  is 
readily  distinguished  on  moving  the  arm. 

(c)  Musculo-spiral  Paralysis;  Radial  Paralysis. — This  is  one  of  the 
most  common  of  peripheral  palsies,  and  results  from  the  exposed  position 
of  the  musculo-spiral  nerve.  It  is  often  bruised  in  the  use  of  the  crutch, 
by  injuries  of  the  arm,  blows,  or  fractures.  It  is  frequently  injured  when 
a  person  falls  asleep  with  the  arm  over  the  back  of  a  chair,  or  by  pressure 
of  the  body  upon  the  arm  when  a  person  is  sleeping  on  a  bench  or  on  the 
ground.  It  may  be  paralyzed  by  sudden  violent  contraction  of  the  triceps. 
It  is  sometimes  involved  in  a  neuritis  from  cold,  but  this  is  uncommon  in 
comparison  with  other  causes.  In  the  subcutaneous  injection  of  ether  the 
nerve  may  be  accidentally  struck  and  temporarily  paralyzed.  The  paraly- 
sis of  lead  poisoning  is  the  result  of  involvement  of  certain  branches  of 
this  nerve. 

A  lesion  when  high  up  involves  the  triceps,  the  brachialis  anticus,  and 


DISEASES   OP  THE  SPINAL   NERVES.  1071 

the  supinator  longus,  as  well  as  the  extensors  of  the  wrist  and  fingers. 
Naturally,  in  lesions  just  above  the  elbow  the  arm  muscles  and  the  supinator 
longus  are  spared.  The  most  characteristic  feature  of  the  paralysis  is  the 
wrist-drop  and  the  inability  to  extend  the  first  phalanges  of  the  fingers  and 
thumb.  In  the  pressure  palsies  the  supinators  are  usually  involved  and 
the  movements  of  supination  cannot  be  accomplished.  The  sensations  may 
be  impaired,  or  there  may  be  marked  tingling,  but  the  loss  of  sensation  is 
rarely  so  pronounced  as  that  of  motion. 

The  affection  is  readily  recognized,  but  it  is  sometimes  difficult  to  say 
upon  what  it  depends.  The  sleep  and  pressure  palsies  are,  as  a  rule,  uni- 
lateral and  involve  the  supinator  longus.  The  paralysis  from  lead  is  bi- 
lateral and  the  supinators  are  unaffected.  Bilateral  wrist-drop  is  a  very 
common  symptom  in  many  forms  of  multiple  neuritis,  particularly  the 
alcoholic;  but  the  mode  of  onset  and  the  involvement  of  the  legs  and  arms 
are  features  which  make  the  diagnosis  easy.  The  duration  and  course 
of  the  musculo-spiral  paralyses  are  very  variable.  The  pressure  palsies  may 
disappear  in  a  few  days.  Recovery  is  the  rule,  even  when  the  affection  lasts 
for  many  weeks.  The  electrical  examination  is  of  importance  in  the  prog- 
nosis, and  the  rules  laid  down  under  paralysis  of  the  facial  nerve  hold  good 
here. 

The  treatment  is  that  of  neuritis. 

(d)  Ulnar  Nerve. — The  motor  branches  supply  the  ulnar  halves  of  the 
deep  flexor  of  the  fingers,  the  muscles  of  the  little  finger,  the  interossei, 
the  adductor  and  the  inner  head  of  the  short  flexor  of  the  thumb,  and  the 
ulnar  flexor  of  the  wrist.  The  sensory  branches  supply  the  ulnar  side  of 
the  hand — two  and  a  half  fingers  on  the  back,  and  one  and  a  half  fingers 
on  the  front.  Paralysis  may  result  from  pressure,  usually  at  the  elbow- 
joint,  although  the  nerve  is  here  protected.  Possibly  the  neuritis  in  the 
ulnar  nerve  in  some  cases  of  acute  illness  may  be  due  to  this  cause.  Gowers 
mentions  the  case  of  a  lady  who  twice  had  ulnar  neuritis  after  confinement. 
Owing  to  paralysis  of  the  ulnar  flexor  of  the  wrist,  the  hand  moves  toAvard 
the  radial  side;  adduction  of  the  thumb  is  impossible;  the  first  phalanges 
cannot  be  flexed,  and  the  others  cannot  be  extended.  In  long-standing 
cases  the  first  phalanges  are  overextended  and  the  others  strongly  flexed, 
producing  the  claw-hand;  but  this  is  not  so  marked  as  in  the  progressive 
muscular  atrophy.  The  loss  of  sensation  coiTesponds  to  the  sensory  dis- 
tribution just  mentioned. 

(e)  Median  Nerve. — This  supplies  the  flexors  of  the  fingers  except  the 
ulnar  half  of  the  deep  flexors,  the  abductor  and  the  flexors  of  the  thumb, 
the  two  radial  lumbricales,  the  pronators,  and  the  radial  flexor  of  the  wrist. 
The  sensory  fibres  supply  the  radial  side  of  the  palm  and  the  front  of  the 
thumb,  the  first  two  fingers  and  half  the  third  finger,  and  the  dorsal  sur- 
faces of  the  same  three  fingers. 

This  nerve  is  seldom  involved  alone.  Paralysis  results  from  injury  and 
occasionally  from  neuritis.  The  signs  are  inability  to  pronate  the  forearm 
beyond  the  mid-position.  The  wrist  can  only  be  flexed  toward  the  ulnar 
side;  the  thumb  cannot  be  opposed  to  the  tips  of  fingers.  The  second 
phalanges  cannot  be  flexed  on  the  first;  the  distal  phalanges  of  the  first 


IQI^  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  second  fingers  cannot  be  flexed;  but  in  the  third  and  fourth  fingers 
this  action  can  be  performed  by  the  ulnar  half  of  the  flexor  profundus.  The 
loss  of  sensation  is  in  the  region  corresponding  to  the  sensory  distribution 
already  mentioned.  The  wasting  of  the  thumb  muscles,  which  is  usually 
marked  in  this  paralysis,  gives  to  it  a  characteristic  appearance. 

Lumbar  and  Sacral  Plexuses. 

The  lumbar  plexus  is  sometimes  involved  in  growths  of  the  lymph- 
glands,  in  psoas  abscess,  and  in  disease  of  the  bones  of  the  vertebra.  Of 
its  branches  the  oMurator  nerve  is  occasionally  injured  during  parturition. 
When  paralyzed  the  power  is  lost  over  the  adductors  of  the  thigh  and  one 
leg  cannot  be  crossed  over  the  other.  Outward  rotation  is  also  disturbed. 
The  anterior  crural  nerve  is  sometimes  involved  in  wounds  or  in  disloca- 
tion of  the  hip-joint,  less  commonly  during  parturition,  and  sometimes 
by  disease  of  the  bones  and  in  psoas  abscess.  The  special  symptoms  of  affec- 
tion of  this  nerve  are  paralysis  of  the  extensors  of  the  knee  with  wasting 
of  the  muscles,  anesthesia  of  the  antero-lateral  parts  of  the  thigh  and  of  the 
inner  side  of  the  leg  to  the  big  toe.  This  nerve  is  sometimes  involved  early 
in  growths  about  the  spine,  and  there  may  be  pain  in  its  area  of  distribu- 
tion. Loss  of  the  power  of  abducting  the  thigh  results  from  paralysis  of 
the  gluteal  nerve,  which  is  distributed  to  the  gluteus,  medius,  and  minimus 
muscles. 

The  sacral  plexus  is  frequently  involved  in  tumors  and  inflammations 
within  the  pelvis  and  may  be  injured  during  parturition.  Keuritis  is  com- 
mon, usually  an  extension  from  the  sciatic  nerve. 

Of  the  branches,  the  sciatic  nerve,  when  injured  at  or  near  the  notch, 
causes  paralysis  of  the  flexors  of  the  legs  and  the  muscles  below  the  knee, 
but  injury  below  the  middle  of  the  thigh  involves  only  the  latter  muscles. 
There  is  also  anesthesia  of  the  outer  half  of  the  leg,  the  sole,  and  the  greater 
portion  of  the  dorsum  of  the  foot.  Wasting  of  the  muscles  frequently  fol- 
lows, and  there  may  be  trophic  disturbances.  In  paralysis  of  one  sciatic 
the  leg  is  flxed  at  the  knee  by  the  action  of  the  quadriceps  extensor  and  the 
patient  is  able  to  walk. 

Paralysis  of  the  small  sciatic  nerve  is  rarely  seen.  The  gluteus  maximus 
is  involved  and  there  may  be  difficulty  in  rising  from  a  seat.  There  is  a 
strip  of  angesthesia  along  the  back  of  the  middle  third  of  the  thigh. 

External  Popliteal  Nerve. — Paralysis  involves  the  peronsei,  the  long  ex- 
tensor of  the  toes,  tibialis  anticus,  and  the  extensor  brevis  digitonim.  The 
ankle  cannot  be  flexed,  resulting  in  a  condition  known  as  foot-drop,  and 
as  the  toes  cannot  be  raised  the  whole  leg  must  be  lifted,  producing  the 
characteristic  steppage  gait  seen  in  so  many  forms  of  peripheral  neuritis. 
In  long-standing  cases  the  foot  is  permanently  extended  and  there  is  Avasting 
of  the  anterior  tibial  and  peroneal  muscles.  The  loss  of  sensation  is  in  the 
outer  half  of  the  front  of  the  leg  and  on  the  dorsum  of  the  foot. 

Internal^  Popliteal  Nerve. — When  paralyzed,  plantar  flexion  of  the  foot 
and  flexion  of  the  toes  are  impossible.  The  foot  cannot  be  adducted,  nor 
can  the  patient  rise  on  tiptoe.     In  long-standing  cases  talipes  calcaneus 


DISEASES  OF  THE  SPINAL  NERVES.  1073 

follows  and  the  toes  assume  a  claw-like  position  from  secondary  contracture, 
due  to  overextension  of  the  proximal  and  flexion  of  the  second  and  third 
phalanges. 

Sciatica. 

This  is,  as  a  rule,  a  neuritis  either  of  the  sciatic  nerve  or  of  its  cords 
of  origin.     It  may  in  some  instances  be  a  functional  neurosis  or  neuralgia. 

It  occurs  most  commonly  in  adult  males.  A  history  of  rheumatism  or 
of  gout  is  present  in  many  cases.  Exposure  to  cold,  particularly  after 
heavy  muscular  exertion,  or  a  severe  wetting  are  not  uncommon  causes. 
Within  the  pelvis  the  nerves  may  be  compressed  by  large  ovarian  or  uterine 
tumors,  by  lymphadenomata,  by  the  foetal  head  during  labor;  occasion- 
ally lesions  of  the  hip-joint  induce  a  secondary  sciatica.  The  condition 
of  the  nerve  has  been  examined  in  a  few  cases,  and  it  has  often  been  seen 
in  the  operation  of  stretching.  It  is,  as  a  rule,  swollen,  reddened,  and  in  a 
condition  of  interstitial  neuritis.  The  afl:ection  may  be  most  intense  at  the 
sciatic  notch  or  in  the  nerve  about  the  middle  of  the  thigh. 

Of  the  symptoms,  p^tin  is  the  most  constant  and  troublesome.  The 
onset  may  be  severe,  with  slight  pyrexia,  but,  as  a  rule,  it  is  gradual,  and 
for  a  time  there  is  only  slight  pain  in  the  back  of  the  thigh,  particularly 
in  certain  positions  or  after  exertion.  Soon  the  pain  becomes  more  intense, 
and  instead  of  being  limited  to  the  upper  portion  of  the  nerve,  extends 
down  the  thigh,  reaching  the  foot  and  radiating  over  the  entire  distribu- 
tion of  the  nerve.  The  patient  can  often  point  out  the  most  sensitive  spots, 
usually  at  the  notch  or  in  the  middle  of  the  thigh;  and  on  pressure  these 
are  exquisitely  painful.  The  pain  is  described  as  gnawing  or  burning,  and 
is  usually  constant,  but  in  some  instances  is  paroxysmal,  and  often  worse 
at  night.  On  walking  it  may  be  very  great;  the  knee  is  bent  and  the  pa- 
tient treads  on  the  toes,  so  as  to  relieve  the  tension  on  the  nerve.  In  pro- 
tracted cases  there  may  be  much  wasting  of  the  muscles,  but  the  reaction  of 
degeneration  can  seldom  be  obtained.  In  these  chronic  cases  cramp  may 
occur  and  fibrillar  contractions.  Herpes  may  develop,  but  this  is  unusual. 
In  rare  instances  the  neuritis  ascends  and  involves  the  spinal  cord. 

The  duration  and  course  are  extremely  variable.  As  a  rule  it  is  an  ob- 
stinate affectioii,  lasting  for  months,  or  even,  with  slight  remissions,  for 
years.  Eelapses  are  not  uncommon,  and  the  disease  may  be  relieved  in  one 
nerve  only  to  appear  in  the  other.  In  the  severer  forms  the  patient  is  bed- 
ridden, and  such  cases  prove  among  the  most  distressing  and  trying  which 
the  physician  is  called  upon  to  treat. 

In  the  diagnosis  it  is  important,  in  the  first  place,  to  determine  whether 
the  disease  is  primary,  or  secondary  to  some  affection  of  the  pelvis  or  of 
the  spinal  cord.  A  careful  rectal  examination  should  be  made,  and,  in 
women,  pelvic  tumor  should  be  excluded.  Lumbago  may  b6  confounded 
with  it.  Affections  of  tbe  hip-joint  are  easily  distinguished  by  the  absence 
of  tendermess  in  the  course  of  the  nerve  and  the  sense  of  pain  on  movement 
of  the  hip-joint  or  on  pressure  in  the  region  of  the  trochanter.  There  are 
instances  of  sacro-iliac  disease  in  which  the  patient  complains  of  pain  in 
the  upper  part  of  the  thigh,  which  may  sometimes  radiate;  but  careful 
67 


lQ'^4i  DISEASES  OF   THE  NERVOUS  SYSTEM. 

examination  vill  readily  distinguish  between  the  affections.  Pressure  on 
the  nerve  trunks  of  the  cauda  equina,  as  a  rule,  causes  bilateral  pain  and 
disturbances  of  sensation,  and,  as  double  sciatica  is  rare,  these  circumstances 
always  suggest  lesion  of  the  nerve  roots.  Between  the  severe  lightning 
pains  of  tabes  and  sciatica  the  differences  are  usually  well  defined. 

Treatment. — The  pelvic  organs  should  be  carefully  and  systematically 
examined.  Constitutional  conditions,  such  as  rheumatism  and  gout,  should 
receive  appropriate  treatment.  In  a  few  eases  with  pronounced  rheumatic 
history,  which  come  on  acutely  with  fever,  the  salicylates  seem  to  do  good. 
In  other  instances  they  are  quite  useless.  If  there  is  a  suspicion  of  syphilis, 
the  iodide  of  potassium  should  be  employed,  and  in  gouty  cases  salines. 

Eest  in  bed  with  fixation  of  the  limb  by  means  of  a  long  splint  is  a 
most  valuable  method  of  treatment  in  many  cases,  one  upon  which  Weir 
Mitchell  has  specially  insisted.  I  have  known  it  to  relieve,  and  in  some 
instances  to  cure,  obstinate  and  protracted  cases  which  had  resisted  all 
other  treatment.  Hydrotherapy  is  sometimes  satisfactory,  particularly  the 
warm  baths  or  the  mud  baths.  Many  cases  are  relieved  by  a  prolonged 
residence  at  one  of  the  thermal  springs. 

Antipyrin,  antifebrin,  and  quinine,  are  of  doubtful  benefit. 

Local  applications  are  more  beneficial.  The  hot  iron  or  the  thermo- 
cautery or  blisters  relieve  the  pain  temporarily.  Deep  injections  into  the 
nerves  give  great  relief  and  may  be  necessary  for  the  pain.  It  is  best  to  use 
cocaine  at  first,  in  doses  of  from  an  eighth  to  a  quarter  of  a  grain.  If  the 
pain  is  u.nbearable  morphia  may  be  used,  but  it  is  a  dangerous  remedy  in 
sciatica  and  should  be  withheld  as  long  as  possible.  The  disease  is  so  pro- 
tracted, so  liable  to  relapse,  and  the  patient's  morale  so  undermined  by 
the  constant  worry  and  the  sleepless  nights,  that  the  danger  of  contracting 
the  morphia  habit  is  very  great.  On  no  consideration  should  the  patient 
be  permitted  to  use  the  hypodermic  needle  himself.  It  is  remarkable  how 
promptly,  in  some  cases,  the  injection  of  distilled  water  into  the  nerve  will 
relieve  the  pain.  Acupuncture  may  also  be  tried;  the'  needles  should  be 
thrust  deeply  into  the  most  painful  spot  for  a  distance  of  about  2  inches, 
and  left  for  from  fifteen  to  twenty  minutes.  The  injection  of  chloroform 
into  the  nerve  has  also  been  recommended. 

Electricity  is  an  uncertain  remedy.  Sometimes  it  gives  prompt  relief; 
in  other  cases  it  may  be  used  for  weeks  without  the  slightest  benefit.  It 
is  most  serviceable  in  the  chronic  cases  in  which  there  is  wasting  of  the 
legs,  and  should  be  combined  with  massage.  The  galvanic  current  should 
be  used;  a  flat  electrode  should  be  placed  over  the  sciatic  notch,  and  a 
smaller  one  used  along  the  course  of  the  nerve  and  its  branches.  In  very 
obstinate  cases  nerve-stretching  may  be  employed.  It  is  sometimes  success- 
ful; but  in  other  instances  the  condition  recurs  and  is  as  bad  as  ever. 


ACUTE  DELIRIUM.  1075 

YII   GEKEEAL  AND  FUl^CTIONAL  DISEASES. 

I.    ACUTE   DELIRIUM   {BelVs  Mania). 

Definition. — Acute  delirium  running  a  rapidly  fatal  course,  with 
slight  fever,  and  in  which  post  mortem  no  lesions  are  found  sufficient  to 
account  for  the  disease. 

Cases  are  reported  by  many  old  writers  under  the  term  brain  fever  or 
phrenitis.  Bell,  at  the  time  Superintendent  of  the  McLean  Asylum,  de- 
scribed it  *  accurately  under  the  designation,  "  a  form  of  disease  resembling 
some  advanced  stages  of  mania  and  fever." 

The  disease  may  set  in  abruptly  or  be  preceded  by  a  period  of  irrita- 
bility, restlessness,  and  insomnia.  The  mental  symptoms  develop  with 
rapidity  and  may  quickly  reach  a  grade  of  the  most  intense  frenzy.  There 
are  the  wildest  hallucinations  and  outbreaks  of  great  violence.  The  pa- 
tient talks  incessantly,  but  incoherently  and  unintelligibly.  No  sleep  is 
obtained,  and  at  last,  worn  out  with  the  intensity  of  the  muscular  move- 
ments, the  patient  becomes  utterly  prostrated  and  assumes  the  sitting  or 
recumbent  posture.  There  may  sometimes  be  definite  salaam  movements, 
and  in  a  case  which  I  saw  at  Westphal's  clinic  the  patient  incessantly  made 
motions  as  if  working  a  pump  handle.  After  a  period  of  intense  bodily 
excitement,  lasting  for  from  twenty-four  to  thirty-six  hours  or  longer,  the 
patient  can  be  examined,  and  presents  the  conditions  which  Bell  described 
as  typho-mania.  The  temperature  ranges  from  102°  to  104°,  or  even 
higher.  The  tongue  is  dry,  the  pulse  rapid  and  feeble;  sometimes  there 
are  seen  on  the  skin  bullae  and  pustules,  and  frequently  sores  from 
abrasion  and  self-inflicted  injuries.  Toward  the  close  or,  according  to 
Spitzka,  even  during  the  development  of  the  disease  there  may  be  lucid 
intervals.  There  may  be  petechia  on  the  skin,  and  often  there  is  marked 
congestion  of  the  face  and  extremities.  The  duration  of  the  disease  is 
variable.  Very  acute  cases  may  terminate  within  a  week;  others  persist 
for  two  or  even  three  weeks.  The  course  of  the  disease  is  almost  uniformly 
fatal.  The  anatomical  condition  is  practically  negative,  or  at  any  rate 
presents  nothing  distinctive.  There  is  great  venous  engorgement  of  the 
vessels  of  the  meninges  and  of  the  gray  cortex.  In  two  cases  in  which  I 
made  a  careful  microscopical  examination  of  the  gray  matter  there  were 
perivascular  exudation  and  leucocytes  in  the  lymph  sheaths  and  pcri- 
gangliar  spaces.  In  the  inspection  of  fatal  cases  of  acute  delirium  care- 
ful examination  should  be  made  of  the  lungs  and  ileum.  It  should  be 
borne  in  mind  that  in  a  majority  of  the  cases  dying  in  this  manner, 
there  is  engorgement  of  the  bases  of  the  lungs  or  even  deglutition  pii  r.- 
monia. 

The  nature  of  the  disease  is  quite  unknown.  Some  of  the  cases  sug- 
gest acute  infection,  Spitzka  thinks  that  it  is  due  to  an  autochthonoi:r. 
nerve  poison. 

*  American  Journal  of  Insanity,  1849. 


IQ^Q  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Diagnosis. — There  are  several  diseases  which  may  present  identical 
symptoms.  As  Bell  remarks  in  his  paper,  the  first  glance  in  many  cases 
suggests  typhoid  fever,  particularl}'  when  the  patient  is  seen  after  the  vio- 
lence of  the  mania  has  subsided.  He  gives  two  instances  of  this  which  were 
admitted  from  a  general  hospital.  Enlargement  of  the  spleen,  the  occur- 
rence of  spots,  and  the  history  give  clews  for  the  separation  of  the  cases; 
but  there  are  instances  in  which  it  is  at  first  impossible  to  decide.  More- 
over, typhoid  fever  may  set  in  with  the  most  intense  delirium.  The  exist- 
ence of  fever  is  the  most  deceptive  s}Tnptom,  and  its  combination  with 
delirium  and  dry  tongue  so  commonly  means  typhoid  fever  that  it  is  very 
difficult  to  avoid  error. 

Acute  pneumonia  may  come  on  with  violent  maniacal  delirium  and  the 
pulmonary  symptoms  may  be  entirely  masked. 

Occasionally  acute  ursemia  sets  in  suddenly  with  intense  mania,  and 
finally  subsides  into  a  fatal  coma.  The  condition  of  the  urine  and  the  ab- 
sence of  fever  would  be  important  diagnostic  features. 

The  character  of  the  delirium  is  quite  different  from  that  of  mania  a 
potu.  It  may  be  extremely  difficult  to  differentiate  acute  delirium  from 
certain  cases  of  cortical  meningitis  occurring  in  connection  with  pneu- 
monia, ulcerative  endocarditis  or  tuberculosis,  or  due  to  extension  from 
disease  of  the  ear.  This  sets  in  more  frequently  with  a  chill,  and  there 
may  be  convulsions. 

Treatment. — Even  though  bodily  prostration  is  apt  to  come  on  early 
and  be  profound,  in  the  case  of  a  robust  man  free  venesection  might 
be  tried.  I  have  been  criticised  for  this  advice,  but  repeat  it.  It  is 
not  at  all  improbable  that  some  of  the  many  cases  of  mania  in  which 
Benjamin  Eush  let  blood  with  such  benefit  belonged  to  this  class  of  affec- 
tions. Considering  its  remarkable  calming  influence  in  febrile  delirium, 
the  cold  bath  or  the  cold  pack  should  be  employed.  Morphia  and  chloro- 
form may  be  administered  and  hyoscine  and  the  bromides  may  be 
tried.  Krafft-Ebing  states  that  Solivetti  has  obtained  good  results  by 
the  use  of  ergotin.  Unfortunatel}^,  as  as3dum  reports  show,  the  disease 
is  almost  uniformly  fatal. 


II.    PARALYSIS    AGITANS 

(Parkinson's  Disease;  Shaking  Palsy). 

Definition. — A  chronic  affection  of  the  nervous  system,  characterized 
by  muscular  weakness,  tremors,  and  rigidity. 

Etiology. — Men  are  more  frequently  affected  than  women.  It  rarely 
occurs  under  forty,  but  instances  have  been  reported  in  which  the  disease 
began  about  the  twentieth  year.  It  is  by  no  means  an  uncommon  affec- 
tion. Direct  heredity  is  rare,  but  the  patients  often  belong  to  families  in 
which  there  are  other  nervous  affections.  Among  exciting  causes  may  be 
mentioned  exposure  to  cold  and  wet,  and  business  worries  and  anxieties. 
In  some  instances  the  disease  has  followed  directly  upon  severe  mental  shock 
or  trauma.     Cases  have  been  described  after  the  specific  fevers.     Malaria 


PARALYSIS  AGITANS.  1077 

is  believed  by  some  to  be  an  important  factor,  but  of  this  there  is  no  satis- 
factory evidence. 

Morbid  Anatomy. — No  constant  lesions  have  been  found.  The 
similarity  between  certain  of  the  features  of  Parkinson's  disease  and  those 
of  old  age  suggest  that  the  affection  may  depend  upon  a  premature  senil- 
ity of  certain  regions  of  the  brain.  Our  organs  do  not  age  uniformly,  but 
in  some,  owing  to  hereditary  disposition,  the  process  may  be  more  rapid 
than  in  others.  "  Parkinson's  disease  has  no  characteristic  lesions,  but  on 
the  other  hand  it  is  not  a  neurosis.  It  has  for  an  anatomical  basis  the 
lesions  of  cerebro-spinal  senility,  and  w^hich  only  differ  from  those  of  true 
senility  in  their  early  onset  and  greater  intensity "  (Dubief).  The  im- 
portant changes  are  doubtless  in  the  cerebral  cortex. 

Symptoms. — The  disease  begins  gradually,  usually  in  one  or  other 
hand,  and  the  tremor  may  be  either  constant  or  intermittent.  With  this 
may  be  associated  weakness  or  stiffness.  At  first  these  symptoms  may  be 
present  only  after  exertion.  Although  the  onset  is  slow  and  gradual  in 
nearly  all  cases,  there  are  instances  in  which  it  sets  in  abruptly  after  fright 
or  trauma.  When  well  established  the  disease  is  very  characteristic,  and 
the  diagnosis  can  be  made  at  a  glance.  The  four  prominent  symptoms 
are  tremor,  weakness,  rigidity,  and  the  attitude. 

Tremor. — This  may  be  in  the  four  extremities  or  .confined  to  hands  or 
feet;  the  head  is  not  so  commonly  affected.  The  tremor  is  usually  marked 
in  the  hands,  and  the  thumb  and  forefinger  display  the  motion  made  in  the 
act  of  rolling  a  pill.  At  the  wrist  there  are  movements  of  pronation  and 
supination,  and,  though  less  marked,  of  flexion  and  extension.  The  upper- 
arm  muscles  are  rarely  involved.  In  the  legs  the  movement  is  most  eviclent 
at  the  ankle-joint,  and  less  in  the  toes  than  in  the  fingers.  Shaking  of  the 
head  is  less  frequent,  but  does  occur,  and  is  usually  vertical,  not  rotatory. 
The  rate  of  oscillation  is  about  five  per  second.  Any  emotion  exaggerates 
the  movement.  The  attempt  at  a  voluntary  movement  may  check  the 
tremor  (the  patient  may  be  able  to  thread  a  needle),  but  it  returns  with 
increased  intensity.  The  tremors  cease,  as  a  rule,  during  sleep,  but  persist 
when  the  muscles  are  at  repose.  The  writing  of  the  patient  is  tremulous 
and  zigzag. 

Weakness. — Loss  of  power  is  present  in  all  cases,  and  may  occur  even 
before  the  tremor,  but  is  not  very  striking,  as  tested  by  the  dynamometer, 
until  the  late  stages.  The  weakness  is  greatest  where  the  tremor  is  most 
developed.  The  movements,  too,  are  remarkably  slow.  There  is  rarely 
complete  loss  of  power. 

Rigidity  may  early  Ije  expressed  in  a  slowness  and  stiffness  in  the  vol- 
untary movements,  which  are  performed  with  some  effort  and  difficulty, 
and  all  the  actions  of  the  patient  are  deliberate.  This  rigidity  is  in  all  the 
muscles,  and  leads  ultimately  to  the  characteristic 

Attitude  and  Gait. — The  head  is  bent  forward,  the  back  is  bowed,  and 
the  arms  are  held  away  from  the  body  and  are  somewhat  flexed  at  the 
elbow-joints.  The  face  is  expressionless,  and  the  movements  of  the  lips 
are  slow.  The  eyebrows  are  elevated,  and  the  w^hole  expression  is  immobile 
or  mask-like,  the  so-called  Parkinson's  mask.     The  voice,  as  pointed  out 


3^078  DISEASES  OP  THE  NERVOUS  SYSTEM. 

by  Buzzard;,  is  apt  to  be  shrill  and  piping,  and  there  is  often  a  hesitancy  in 
beginning  a  sentence;  then  the  words  are  uttered  with  rapidity,  as  if  the 
patient  was  in  a  hurry.  This  is  sometimes  in  striking  contrast  to  the  scan- 
ning speech  of  insular  sclerosis.  The  fingers  are  flexed  and  in  the  position 
assumed  when  the  hand  is  at  rest;  in  the  late  stages  they  cannot  be  ex- 
tended. Occasionally  there  is  overextension  of  the  terminal  phalanges. 
The  hand  is  usually  turned  toward  the  ulnar  side  and  the  attitude  some- 
what resembles  that  of  advanced  cases  of  rheumatoid  arthritis.  In  the 
late  stages  there  are  contractures  at  the  elbows,  knees,  and  ankles.  The 
movements  of  the  patient  are  characterized  by  great  deliberation.  He  rises 
from  the  chair  slowly  in  the  stooping  attitude,  with  the  head  projecting 
forward.  In  attempting  to  walk  the  steps  are  short  and  hurried,  and,  as 
Trousseau  remarks,  he  appears  to  be  running  after  his  centre  of  gravity. 
This  is  termed  festination  or  propulsion,  in  contradistinction  to  a  peculiar 
gait  observed  when  the  patient  is  pulled  backward,  when  he  makes  a  num- 
ber of  steps  and  would  fall  over  if  not  prevented — retropulsion. 

The  reflexes  are  normal  in  most  cases,  but  in  a  few  they  are  exaggerated. 

Of  sensory  disturbances  Charcot  has  noted  abnormal  alterations  in  the 
temperature  sense.  The  patient  may  complain  of  subjective  sensations  of 
heat,  either  general  or  local — a  phenomenon  which  may  be  present  on  one 
side  only  and  associated  with  an  actual  increase  of  the  surface  temperature, 
as  much  as  6°  F.  (Gowers).  In  other  instances,  patients  complain  of  cold. 
Localized  sweating  may  be  present.  The  skin,  especially  of  the  forehead, 
may  be  thickened.    The  mental  condition  rarely  shows  any  change. 

Variations  in  the  Symptoms. — The  tremor  may  be  absent,  but  the  rigid- 
ity, weakness,  and  attitude  are  sufficient  to  make  the  diagnosis.  The  dis- 
ease may  be  hemiplegic  in  character,  invohdng  only  one  side  or  even  one 
limb.    Usually  these  are  but  stages  of  the  disease. 

Diagnosis.' — In  well-developed  cases  the  disease  is  recognized  at  a 
glance.  The  attitude,  gait,  stiffness,  and  mask-like  expression  are  points 
of  as  much  importance  as  the  oscillations,  and  usually  serve  to  separate 
the  cases  from  senile  and  other  forms  of  tremor.  Disseminated  sclerosis 
develops  earlier,  and  is  characterized  by  the  nystagmus,  and  the  scanning 
speech,  and  does  not  present  the  attitude  so  constant  in  paralysis  agitans. 
Yet  Schultze  and  Sachs  have  reported  cases  in  which  the  signs  of  multiple 
sclerosis  have  been  associated  with  those  of  paralysis.  The  hemiplegic 
form  might  be  confounded  with  post-hemiplegic  tremor,  but  the  history, 
the  mode  of  onset,  and  the  greatly  increased  reflexes  would  be  sufficient  to 
distinguish  the  two.  The  Parkinsonian  face  is  of  great  importance  in  the 
diagnosis  of  the  obscure  and  anomalous  forms. 

The  disease  is  incurable.  Periods  of  improvement  may  occur,  but  the 
tendency  is  for  the  affection  to  proceed  progressively  downward.  It  is  a 
slow,  degenerative  process  and  the  cases  last  for  years. 

Treatment.. — There  is  no  method  which  can  be  recommended  as  satis- 
factory in  any  respect.  Arsenic,  opium,  and  hyoscyamine  may  be  tried,  but 
the  friends  of  the  patient  should  be  told  frankly  that  the  disease  is  incur- 
able, and  that  nothing  can  be  done  except  to  attend  to  the  physical  com- 
forts of  the  patient.  Eegulated  and  systematized  exercises  should  be  car- 
ried out. 


ACUTE  CHOREA.  1079 

Other  Foems  of  Teemoe. 

(a)  Simple  Tremor. — This  is  occasionally  found  in  persons  in  whom  it 
is  impossible  to  assign  any  cause.  It  may  be  transient  or  persist  for  an 
indefinite  time.  It  is  often  extremely  slight,  and  is  aggravated  by  all  causes 
which  lower  the  vitality. 

{b)  Hereditary  Tremor. — C.  L.  Dana  has  reported  remarkable  cases  of 
hereditary  tremor.  It  occurred  in  all  the  members  of  one  family,  and  be- 
ginning in  infancy  continued  without  producing  any  serious  changes. 

(c)  Senile  Tremor. — With  advancing  age  tremulousness  during  muscular 
movements  is  extremely  common,  but  is  rarely  seen  under  seventy.  It  is 
always  a  fine  tremor,  which  begins  in  the  hands  and  often  extends  to  the 
muscles  of  the  neck,  causing  slight  movement  of  the  head. 

{d)  Toxic  tremor  is  seen  chiefly  as  an  effect  of  tobacco,  alcohol,  lead,  or 
mercury;  more  rarely  in  arsenical  or  opium  poisoning.  In  elderly  men 
who  smoke  much  it  may  be  entirely  due  to  the  tobacco.  One  of  the  com- 
monest forms  of  this  is  the  alcoholic  tremor,  which  occurs  only  on  move- 
ment and  has  considerable  range.  Lead  tremor  is  considered  under  lead 
poisoning,  of  which  it  constitutes  a  very  important  symptom. 

(e)  Hysterical  tremor,  which  usually  occurs  under  circumstances  which 
make  the  diagnosis  easy,  will  be  considered  in  the  section  on  hysteria. 


III.    ACUTE    CHOREA 

{Sydenham's  Chorea  ;  St.  Vitus' s  Dance). 

Definition.' — A  disease  chiefly  affecting  children,  characterized  by 
irregular,  involuntary  contraction  of  the  muscles,  a  variable  amount  of 
psychical  disturbance,  and  a  remarkable  liability  to  acute-  endocarditis. 

We  shall  speak  here  only  of  Sydenham's  chorea.  Senile  chorea,  chronic 
chorea,  the  prehemiplegic  and  post  hemiplegic  forms,  and  rhythmic  chorea 
are  totally  different  affections. 

Etiology. — Sex. — Of  554  cases  which  I  have  analyzed  from  the  Phila- 
delphia Infirmary  for  Diseases  of  the  Nervous  System,  71  per  cent  were  in 
females  and  29  per  cent  in  males.  After  puberty  the  percentage  in  females 
increases. 

Age. — The  disease  is  most  common  between  the  ages  of  five  and  fifteen. 
Of  522  cases,  380  occurred  in  this  period.  It  is  more  common  in  the  lower 
classes,  and  is  rare'  among  the  negroes  and  native  races  of  this  continent. 
Morris  J.  Lewis  has  shown  that  the  cases  are  most  numerous  when  the 
mean  relative  humidity  is  excessive  and  the  barometric  pressure  low. 

Rheumatism. — A  causal  relationship  between  rheumatism  and  chorea 
has  been  claimed  by  many  since  the  time  of  Bright.  The  English  and 
French  writers  maintain  the  closeness  of  this  connection;  on  the  other 
hand,  German  authors,  as  a  rule,  regard  the  connection  as  by  no  means  very 
close.  Of  554  cases  which  I  have  analyzed,  in  15.5  per  cent  there  was  a 
history  of  rheumatism  in  the  family.  In  88  cases,  15.8  per  cent,  there 
was  a  history  of  articular  swelling,  acute  or  subacute.     In  33  cases  there 


1080 


blSBASES  OF  THE  NERVOUS  SYSTEM. 


were  pains,  sometimes  described  as  rheumatic,  in  various  parts,  but  not 
associated  with  joint  trouble.  If  we  regard  all  such  cases  as  rheumatic  and 
add  them  to  those  with  manifest  articular  trouble,  the  percentage  is  raised 
to  nearly  21. 

We  find  two  groups  of  cases  in  which  acute  arthritis  is  present  in 
chorea.  In  one,  the  arthritis  antedates  by  some  months  or  years  the  onset 
of  the  chorea,  and  does  not  recur  before  or  during  the  attack.  In  the 
other  group,  the  chorea  sets  in  with  or  follows  immediately  upon  the  acute 
arthritis.  In  some  instances  it  is  impossible  to  decide  whether  the  joint 
symptoms  or  the  movements  have  appeared  first.  It  is  difficult  to  differ- 
entiate the  cases  of  irregular  pains  without  definite  joint  affection.  It  is 
probable  that  many  of  them  are  rheumatic,  and  yet  I  think  it  would  be  a 
mistake  to  regard  as  such  all  cases  in  children  in  which  there  are  complaints 
of  vague  pains  in  the  bones  or  muscles — so-called  growing  pains.  It  should 
never  be  forgotten,  however,  that  a  slight  articular  swelling  may  be  the 
sole  manifestation  of  rheumatism  in  a  child — so  slight,  indeed,  that  the 
disease  may  be  entirely  overlooked. 

Heart-disease. — Endocarditis  is  believed  by  some  writers  to  be  the  cause 
of  the  disease.  The  particles  of  fibrin  and  vegetations  from  the  valves 
pass  as  emboli  to  the  cerebral  vessels.  On  this  view,  which  we  shall  discuss 
later,  chorea  is  the  result  of  an  embolic  process  occurring  in  the  course  of 
a  rheumatic  endocarditis. 

Infectious  Diseases. — Scarlet  fever  with  arthritic  manifestations  may 
be  a  direct  antecedent.  Sturges  states  that  a  history  of  previous  whooping- 
cough  occurs  more  frequently  in  choreic  than  in  other  children,  but  I  find 
no  evidence  of  this  in  the  Infirmary  records.  With  the  exception  of  rheu- 
matic fever,  there  is  no  intimate  relationship  between  chorea  and  the  acute 
diseases  incident  to  childhood.  It  may  be  noted  in  contrast  to  this  that 
the  so-called  canine  chorea  is  a  common  sequel  of  distemper.  Chorea  has 
been  known  to  develop  in  the  course  of  an  acute  pysemia,  and  to  follow 
gonorrhoea  and  puerperal  fever. 

Ancemia  is  less  often  an  antecedent  than  a  sequence  of  chorea,  and 
though  cases  develop  in  children  who  are  anaemic  and  in  poor  health,  this 
is  by  no  means  the  rule.     Chorea  may  develop  in  chlorotic  girls  at  puberty. 

Pregnancy. — A  choreic  patient  may  become  pregnant;  more  frequently 
the  disease  occurs  during  pregnancy;  sometimes  it  develops  post  partum. 
Buist,  of  Dundee  (Trans.  Edin.  Obs.  Soc,  1895),  has  tabulated  carefully 
the  recorded  cases  to  that  date.  Of  226  cases,  in  6  the  chorea  preceded 
the  pregnancy;  in  105  it  occurred  during  the  pregnancy;  in  31  in  recur- 
rent pregnancies;  45  cases  terminated  fatally,  and  in  16  cases  the  chorea 
developed  post  partum.  The  alleged  frequency  in  illegitimate  primiparse  is 
not  borne  out  by  his  figures.  Beginning  in  the  first  three  months  were 
108  cases,  in  the  second  three  months  70  cases,  in  the  last  three  months 
25  cases.  The  disease  is  often  severe,  and  maniacal  symptoms  may  de- 
velop. 

A  tendency  to  the  disease  is  found  in  certain  families.  In  80  cases 
there  was  a  history  of  attacks  of  chorea  in  other  members.  In  one  instance 
both  mother  and  grandmother  had  been  affected.     High-strung,  excitab^e,^ 


ACUTE  CHOREA.  1081 

nervous  children  are  especially  liable  to  the  disease.  Fright  is  considered 
a  frequent  cause,  but  in  a  large  majority  of  the  cases  no  close  connection 
exists  between  the  fright  and  the  onset  of  the  disease.  Occasionally  the 
attack  sets  in  at  once.  Mental  worry,  trouble,  a  sudden  grief,  or  a  scold- 
ing may  apparently  be  the  exciting  cause.  The  strain  of  education,  par- 
ticularly in  girls  during  the  third  hemidecade,  is  a  most  important  factor 
in  the  etiology  of  the  disease.  Bright,  intelligent,  active-minded  girls 
from  ten  to  fourteen,  ambitious  .to  do  well  at  school,  often  stimulated  in 
their  efforts  by  teachers  and  parents,  form  a  large  contingent  of  the  cases 
of  chorea  in  hospital  and  private  practice.  Sturges  has  called  special  at- 
tention to  this  school-made  chorea  as  one  serious  evil  in  our  modern  method 
of  forced  education.  Imitation,  which  is  mentioned  as  an  exciting  cause, 
is  extremely  rare,  and  does  not  appear  to  have  influenced  the  onset  in  a 
single  case  in  the  Infirmary  records. 

The  disease  may  rapidly  follow  an  injury  or  a  slight  surgical  operation. 
Keflex  irritation  was  believed  to  play  an  important  role  in  the  disease, 
particularly  the  presence  of  worms  or  genital  irritation;  but  I  have  met  with 
no  instance  in  which  the  disease  could  be  attributed  to  either  of  these 
causes.  Local  spasm,  particularly  of  the  face — the  habit  chorea  of  Mitchell 
— may  be  associated  with  irritation  in  the  nostrils  and  adenoid  growths  in 
the  vault  of  the  pharynx,  as  pointed  out  by  Jacobi. 

It  has  been  claimed  by  Stevens  that  ocular  defects  lie  at  the  basis  of 
many  cases  of  chorea,  and  that  with  the  correction  of  these  the  irregular 
movements  disappear.  The  investigations  of  De  Schweinitz  show  that 
ocular  defects  do  not  occur  in  greater  proportion  in  choreic  than  in  other 
children.  A  majority  of  the  cases  in  which  operation  has  been  followed  by 
relief  have  been  instances  of  tic,  local  or  general. 

Morbid  Anatomy  and  Pathology. — No  constant  lesions  have 
been  found  in  the  nervous  system  in  acute  chorea.  Vascular  changes, 
such  as  hyaline  transformation,  exudation  of  leucocytes,  minute  hgemor- 
rhages,  and  thrombosis  of  the  smaller  arteries,  have  been  described. 

Embolism  of  the  smaller  cerebral  vessels  has  been  found,  and  there  are 
on  record  7  cases  of  embolism  of  the  central  artery  of  the  retina  (H.  M. 
Thomas,  1901),  Based  on  the  presence  of  emboli,  Kirkes  and  others  have 
supported  what  is  known  as  the  embolic  theory  of  the  disease.  Endocar- 
ditis is  by  far  the  most  frequent  lesion  in  Sydenham's  chorea.  With  no 
disease,  not  excepting  rheumatism,  is  it  so  constantly  associated.  I  have 
collected  from  the  literature  (to  July,  1894)  the  records  of  73  autopsies; 
there  were  G2  with  endocarditis.*  The  endocarditis  is  usually  of  the  sim- 
ple variety,  but  the  ulcerative  form  has  occasionally  been  described. 

We  are  still  far  from  a  solution  of  all  the  problems  connected  with 
chorea.  Unfortunately,  the  word  has  been  used  to  cover  a  series  of  totally 
diverse  disorders  of  movement,  so  that  there  are  still  excellent  observers 
who  hold  that  chorea  is  only  a  symptom,  and  is  not  to  be  regarded  as  an 
etiological  unit.  The  chorea  of  childhood,  the  disease  which  Sydenham 
described^  presents,  however,  characteristics  so  unmistakable  that  it  must 


*  Osier,  Chorea  and  Choreiform  Affections,  1894. 


IQ^2  DISEASES  OF  THE  NERVOUS  SYSTEM. 

be  regarded  as  a  definite,  substantive  affection.  We  cannot  discuss  fully, 
but  only  indicate  briefly,  certain  of  the  theories  which  have  been  advanced 
with  regard  to  it.  The  most  generally  accepted  view  is  that  it  is  a  func- 
tional train  disorder  affecting  the  nerve-centres  controlling  the  motor  ap- 
paratus, an  instability  of  the  nerve-cells,  brought  about,  one  supposes  by 
hypersemia,  another  by  ansemia,  a  third  by  psychical  influences,  a  fourth 
bv  irritation,  centric  or  peripheric.  Of  the  actual  nature  of  this  derange- 
ment we  know  nothing,  nor,  indeed,  whether  the  changes  are  primary  and 
the  result  of  a  faulty  action  of  the  cortical  cells  or  whether  the  impulses 
are  secondarily  disturbed  in  their  course  down  the  motor  path.  The  pre- 
dominance of  the  disease  in  females,  and  its  onset  at  a  time  when  the 
education  of  the  brain  is  rapidly  developing,  are  etiological  facts  which 
Sturges  has  urged  in  favor  of  the  view  that  chorea  is  an  expression  of 
functional  instability  of  the  nerve-centres. 

The  embolic  theory  originally  advanced  by  Kirkes  has  a  solid  basis  of 
fact,  bu.t  it  is  not  comprehensive  enough,  as  all  of  the  cases  cannot  be 
brought  within  its  limits.  There  are  instances  without  endocarditis  and 
without,  so  far  as  can  be  ascertained,  plugging  of  cerebral  vessels;  and 
there  are  also  cases  with  extensive  endocarditis  in  which  the  histological 
examination  of  the  brain,  so  far  as  embolism  is  concerned,  was  negative. 
In  favor  of  the  embolic  view  is  the  experimental  production  in  animals  of 
chorea  by  Eosenthal,  and  later  by  Money,  by  injecting  fine  particles  into 
the  carotids. 

Lately,  as  indeed  might  be  expected,  chorea  has  been  regarded  as  an 
infectious  disease.  JSTothing  definite  has  yet  been  determined.  In  favor  of 
this  view  it  has  been  urged,  as  it  is  impossible  to  refer  the  chorea  to  endo- 
carditis or  the  endocarditis  in  all  cases  to  rheumatism,  that  both  have  their 
origin  in  a  common  cause,  some  infectious  agent,  which  is  capable  also, 
in  persons  predisposed,  of  exciting  articular  disease.  Cases  have  been  re- 
ported in  scarlet  fever  with  arthritic  manifestations,  in  puerperal  fever,  and 
rheumatism,  also  after  gonorrhoea,  and  such  facts  are  suggestive  at  least 
of  the  association  of  the  disease  with  infective  processes.  Possibl}^  as  has 
been  suggested  by  some  writers,  the  paralytic  conditions  associated  with 
chorea  may  be  analogous  to  those  which  occur  in  typhoid  and  certain  of 
the  infectious  diseases.  On  the  other  hand,  there  are  conditions  extremely 
difficult  to  harmonize  with  this  view.  The  prominent  psychical  element 
is  certainly  one  of  the  most  serious  objections,  since  there  can  be  no  doubt 
that  ordinary  chorea  may  rapidly  follow  a  fright  or  a  sudden  emotion. 

Symptoms.^ — Three  groups  of  cases  may  be  recognized — the  mild, 
severe,  and  maniacal  chorea. 

Mild  Chorea. — In  this  the  affection  of  the  muscles  is  slight,  the  speech 
is  not  seriously  disturbed,  and  the  general  health  not  impaired.  Premoni- 
tory symptoms  are  shown  in  restlessness  and  inability  to  sit  still,  a  condi- 
tion well  characterized  by  the  term  "  fidgets."  There  are  emotional  dis- 
turbances, such  as  crying  spells,  or  sometimes  night-terrors.  There  may 
be  pains  in  the  limbs  and  headache.  Digestive  disturbances  and  anaemia 
may  be  present.  A  change  in  the  temperament  is  frequently  noticed,  and 
a  docile,  quiet  child  may  become  cross  and  irritable.     After  these  symp- 


ACUTE  CHOREA.  1083 

toms  have  persisted  for  a  week  or  more  the  characteristic  invotuntary 
movements  begin,  and  are  often  first  noticed  at  the  table,  when  the  child 
spills  a  tumbler  of  water  or  upsets  a  plate.  There  may  be  only  awkwardness 
or  slight  incoordination  of  voluntary  movements,  or  constant  irregular 
clonic  spasms.  The  jerky,  irregular  character  of  the  movements  differen- 
tiates them  from  almost  every  other  disorder  of  motion.  In  the  mild  cases 
only  one  hand,  or  the  hand  and  face,  are  affected,  and  it  may  not  spread 
to  the  other  side. 

In  the  second  grade,  the  severe  form,  the  movements  become  general 
and  the  patient  may  be  unable  to  get  about  or  to  feed  or  undress  herself, 
owing  to  the  constant,  irregular,  clonic  contractions  of  the  various  muscle 
groups.  The  speech  is  also  affected,  and  for  days  the  child  may  not  be 
able  to  talk.  Often  with  the  onset  of  the  severer  symptoms  there  is  loss 
of  power  on  one  side  or  in  the  limb  most  affected. 

The  third  and  most  extreme  form,  the  so-called  maniacal  chorea,  or 
chorea  insaniens,  is  truly  a  terrible  disease,  and  may  develop  out  of  the 
ordinary  form.  These  cases  are  more  common  in  adult  women  and  may 
develop  during  pregnancy. 

Chorea  begins,  as  a  rule,  in  the  hands  and  arms,  then  involves  the  face, 
and  subsequently  the  legs.  The  movements  may  be  confined  to  one  side 
— hemichorea.  The  attack  begins  oftenest  on  the  right  side,  though  oc- 
casionally it  is  general  from  the  outset.  One  arm  and  the  opposite  leg 
may  be  involved.  In  nearly  one  fourth  of  the  cases  speech  is  affected; 
this  may  amount  only  to  an  embarrassment  or  hesitancy,  but  in  other  in- 
stances it  becomes  an  incoherent  jumble.  In  very  severe  cases  the  child 
will  make  no  attempt  to  speak.  The  inability  is  in  articulation  rather  than 
in  phonation.  Paroxysms  of  panting  and  of  hard  expiration  may  occur, 
or  odd  sounds  may  be  produced.  As  a  rule  the  movements  cease  during 
sleep. 

A  prominent  symptom  is  muscular  weakness,  usually  no  more  than  a 
condition  of  paresis.  The  loss  of  power  is  slight,  but  the  weakness  may 
be  shown  by  an  enfeebled  grip  or  by  a  dragging  of  the  leg  or  limping.  In 
his  original  account  Sydenham  refers  to  the  "  unsteady  movements  of  one 
of  the  legs,  which  the  patient  drags."  There  may  be  extreme  paresis  with 
but  few  movements — the  paralytic  chorea  of  Todd.  Occasionally  a  local 
paralysis  or  weakness  remains  after  the  attack. 

It  is  doubtful  whether  choreic  spasms  extend  to  the  muscles  of  organic 
life.  The  rapid  action  and  disturbed  rhythm  of  the  heart  present  nothing 
peculiar  to  the  disease,  and  there  is  no  support  for  the  view  that  irregular 
contractions  occur  in  the  papillary  muscles. 

Heart  Symptoms. — Neurotic. — As  so  many  of  the  subjects  of  chorea  are 
nervous  girls,  it  is  not  surprising  that  a  common  symptom  is  a  rapidly  acting 
heart.  Irregularity,  however,  is  not  so  special  a  feature  in  chorea  as  ra- 
pidity.    The  patients  seldom  complain  of  pain  about  the  heart. 

Hcemic  Murmurs.— W\th  anaemia  and  debility,  not  uncommon  assoc- 
ciates  of  chorea  in  tbe  third  or  fourth  week,  we  find  a  corresponding 
cardiac  condition.  The  impulse  is  diffuse,  perhaps  wavy  in  thin  children. 
The  carotids  throb  visibly,  and  in  the  recumbent  posture  there  may  be 


1084  DISEASES   OF  THE  NERVOUS  SYSTEM. 

pulsation  in  the  cervical  veins.  On  anseultation  a  systolic  murmur  is 
heard  at  the  base,  perhaps,  too,  at  the  apex,  soft  and  blowing  in  quality. 

Endocarditis. — As  in  rheumatism,  so  in  chorea,  acute  valvulitis  rarely 
gives  evidence  of  its  presence  by  symptoms.  It  must  be  sought,  and  clin- 
ical experience  has  shown  that  it  is  usually  associated  with  murmurs  at 
one  or  other  of  the  cardiac  orifices. 

For  the  guidance  of  the  practitioner  the  following  statements  may  be 
made: 

(1)  In  thin,  nervous  children  a  systolic  murmur  of  soft  quality  is  ex- 
tremely common  at  the  base,  with  accentuation  of  the  second  sound,  par- 
ticularly at  the  second  left  costal  cartilage,  and  is  probably  of  no  moment. 

(2)  A  systolic  murmur  of  maximum  intensity  at  the  apex,  and  heard 
also  along  the  left  sternal  margin,  is  not  uncommon  in  ansemic,  en- 
feebled states,  and  does  not  necessarily  indicate  either  endocarditis  or  insuf- 
ficiency. 

(3)  A  murmur  of  maximum  intensity  at  apex,  with  rough  quality,  and 
transmitted  to  axilla  or  angle  of  scapula,  indicates  an  organic  lesion  of 
the  mitral  valve,  and  is  usually  associated  with  signs  of  enlargement  of  the 
heart. 

(4)  When  in  doubt  it  is  much  safer  to  trust  to  the  evidence  of  eye 
and  hand  than  to  that  of  the  ear.  If  the  apex  beat  is  in  the  normal  posi- 
tion, and  the  area  of  dulness  not  increased  vertically  or  to  the  right  of  the 
sternum,  there  is  probably  no  serious  valvular  disease. 

(5)  The  endocarditis  of  chorea  is  almost  invariably  of  the  simple  or 
warty  form,  and  in  itself  is  not  dangerous;  but  it  is  apt  to  lead  to  those 
sclerotic  changes  in  the  valve  which  produce  incompetency.  Of  140  pa- 
tients examined  more  than  two  years  after  the  attack,*  I  found  the  heart 
normal  in  51;  in  17  there  was  functional  disturbance,  and  73  presented 
signs  of  organic  heart-disease. 

(6)  Pericarditis  is  an  occasional  complication  of  chorea,  usually  in  cases 
with  well-marked  rheumatism. 

Sensory  Disturbances. — Pain  in  the  affected  limbs  is  not  common.  Oc- 
casionally there  is  soreness  on  pressure.  There  are  cases,  usually  of  hemi- 
chorea,  in  which  pain  in  the  limbs  is  a  marked  symptom.  Weir  Mitchell 
has  spoken  of  these  as  painful  choreas.  Tender  points  along  the  lines  of 
emergence  of  the  spinal  nerves  or  along  the  course  of  the  nerves  of  the 
limbs  are  rare. 

Psychical  disturbances  are  common,  though  in  a  majority  of  the  cases 
slight  in  degree.  Irritability  of  temper,  marked  wilfulness,  and  emotional 
outbreaks  may  indicate  a  complete  change  in  the  character  of  the  child. 
There  is  deficiency  in  the  powers  of  concentration,  the  memory  is  en- 
feebled, and  the  aptitude  for  study  is  lost.  Earely  there  is  progressive 
impairment  of  the  intellect  with  termination  in  actual  dementia.  Acute 
melancholia  has  been  described  (Edes).  Hallucinations  of  sight  and  hear- 
ing may  occur.  Patients  may  behave  in  an  odd  and  strange  manner  and 
do  all  sorts  of  meaningless  acts.     By  far  the  most  serious  manifestation  of 

*  Monograph  on  Chorea,  1804. 


ACUTE  CHOREA.  1085 

this  character  is  the  maniacal  delirium,  occasionally  associated  with  the 
very  severe  cases — chorea  insaniens.  Usually  the  motor  disturbance  in 
these  cases  is  aggravated,  hut  it  has  been  overlooked  and  patients  have 
been  sent  to  an  asylum. 

The  psychical  element  in  chorea  is  apt  to  be  neglected  by  the  practi- 
tioner. It  is  always  a  good  plan  to  tell  the  parents  that  it  is  not  the 
muscles  alone  of  the  child  which  are  affected,  but  that  the  general  irrita- 
bility and  change  of  disposition,  so  often  found,  really  form  part  of  the 
disease. 

The  condition  of  the  reflexes  in  chorea  is  usually  normal.  Trophic 
lesions  rarely  occur  in  chorea  unless,  as  some  writers  have  done,  we  regard 
the  joint  troubles  as  arthropathies  occurring  in  the  course  of  a  cerebro- 
spinal disease. 

Fever  is  not,  as  a  rule,  present  in  chorea  unless  complications  exist. 
There  may  be  the  most  intense  and  violent  movements  without  any  rise 
of  temperature.  I  have  seen  instances,  however,  in  which  without  appar- 
ently any  visceral  or  articular  disturbances  there  was  slight  daily  fever. 
H.  A.  Hare  states  that  in  monochorea  the  temperature  on  the  affected 
side  may  be  elevated;  but  this  is  not  an  invariable  rule.  Fever  is  found 
with  an  acute  arthritis,  when  there  is  marked  endocarditis  or  pericarditis, 
though  the  former  may  certainly  occur  with  little  if  any  rise  in  tempera- 
ture, and  in  the  cases  of  maniacal  chorea,  in  which  the  fever  may  range 
from  103°  to  104°. 

Cutaneous  Affectiofis. — The  pigmentation,  which  is  not  uncommon,  is 
due  to  the  arsenic.  Herpes  zoster  occasionally  occurs.  Certain  skin  erup- 
tions, usually  regarded  as  rheumatic  in  character,  are  not  uncommon. 
Erythema  nodosum  has  been  described  and  I  have  seen  several  cases  with 
a  purpuric  urticaria.  There  may,  indeed,  be  the  more  aggravated  condi- 
tion of  rheumatic  purpura,  known  as  Schonlein's  peliosis  rheumatica.  Sub- 
cutaneous fibrous  nodules,  which  have  been  noted  by  English  observers  in 
many  cases  of  chorea,  associated  with  rheumatism,  are  extremely  rare  in 
this  country. 

Duration  and  Termination. — From  eight  to  ten  weeks  is  the  av- 
erage duration  of  an  attack  of  moderate  severity.  Chronic  chorea  rarely 
follows  the  minor  disease  which  we  have  been  considering.  The  cases  de- 
scribed under  this  designation  in  children  are  usually  instances  of  cerebral 
sclerosis  or  Friedreich's  ataxia;  but  occasionally  an  attack  which  has  come 
on  in  the  ordinary  way  persists  for  months  or  years,  and  recovery  ulti- 
mately takes  place.  A  slight  grade  of  chorea,  particularly  noticeable  under 
excitement,  may  persist  for  months  in  nervous  children. 

Tbe  tendency  of  chorea  to  recur  has  been  noticed  by  all  writers  since 
Sydenham  first  made  the  observation.  Of  410  cases  analyzed  for  this  pur- 
pose, 240  had  one  attack,  110  had  two  attacks,  35  three  attacks,  10  four 
attacks,  12  five  attacks,  and  3  six  attacks.  The  recurrence  is  apt  to  be 
vernal. 

Eecovery  is  the  rule  in  children.  The  statistics  of  out-patients'  depart- 
ments are  not  favorable  for  determining  the  mortality.  A  reliable  esti- 
mate is  that  of  the  Collective  Investigation  Committee  of  the  British  Medi- 


1086  DISEASES  OF  THE  NERVOUS  SYSTEM. 

cal  Association,  in  which  9  deaths  were  reported  among  439  cases,  about 
2  per  cent. 

The  paralysis  rarely  persists.  Mental  dulness  may  be  present  for  a 
time,  but  usually  passes  away;  permanent  impairment  of  the  mind  is  an 
exceptional  sequence. 

Diagnosis'. — There  are  few  diseases  which  present  more  characteristic 
features,  and  in  a  majority  of  instances  the  nature  of  the  trouble  is  recog- 
nized at  a  glance;  but  there  are  several  affections  in  children  which  may 
simulate  and  be  mistaken  for  it. 

(a)  Multiple  and  diffuse  cerebral  sclerosis.  The  cases  are  often  mis- 
taken for  ordinary  chorea,  and  have  been  described  in  the  literature  as  chorea 
spastica. 

There  are  doubtless  chronic  changes  in  the  cortex.  As  a  rule,  the 
movements  are  readily  distinguishable  from  those  of  true  chorea,  but  the 
simulation  is  sometimes  very  close;  the  onset  in  infancy,  the  impaired  in- 
telligence, increased  reflexes  and  in  some  instances  rigidity,  and  the  chronic 
course  of  the  disease,  separate  them  sharply  from  true  chorea. 

(&)  Friedreich's  ataxia.  Cases  of  this  well-characterized  disease  were 
formerly  classed  as  chorea.  The  slow,  irregular,  incoordinate  movements, 
the  scoliosis,  the  scanning  speech,  the  early  talipes,  the  nystagmus,  and  the 
family  character  of  the  disease  are  points  which  should  render  the  diag- 
nosis easy. 

(c)  In  rare  cases  the  paralytic  form  of  chorea  may  be  mistaken  for 
polio-myelitis  or,  when  both  legs  are  affected,  for  paraplegia  of  spinal 
origin;  but  this  can  only  be  the  case  when  the  choreic  movements  are  very 
slight. 

{d)  Hysteria  may  simulate  chorea  minor  most  closely,  and  unless  there 
are  other  manifestations  it  may  be  impossible  to  make  a  diagnosis.  Most 
commonly,  however,  the  movements  in  the  so-called  hysterical  chorea  are 
rhythmic  and  differ  entirely  from  those  of  ordinary  chorea. 

-(e)  As  mentioned  above,  the  mental  symptoms  in  maniacal  chorea  may 
mask  the  true  nature  of  the  disease  and  patients  have  even  been  sent  to 
the  asylum. 

Treatment. — Abnormally  bright,  active-minded  children  belonging 
to  families  with  pronounced  neurotic  taint  should  be  carefully  watched 
from  the  ages  of  eight  to  fifteen  and  not  allowed  to  overtax  their  mental 
powers.  So  frequently  in  children  of  this  class  does  the  attack  of  chorea 
date  from  the  worry  and  stress  incident  to  school  examinations  that  the 
competition  for  prizes  or  places  should  be  emphatically  forbidden. 

The  treatment  of  the  attack  consists  largely  in  attention  to  hygienic 
measures,  with  which  alone,  in  time,  a  majority  of  the  cases  recover.  Par- 
ents should  be  told  to  scan  gently  the  faults  and  waywardness  of  choreic 
children.  The  psychical  element,  strongly  developed  in  so  many  cases, 
is  best  treated  by  quiet  and  seclusion.  The  child  should  be  confined  to 
bed  in  the  recumbent  posture,  and  mental  as  well  as  bodily  quiet  enjoined. 
In  private  practice  this  is  often  impossible,  but  with  well-to-do  patients 
the  disease  is  always  serious  enough  to  demand  the  assistance  of  a  skilled 
nurse.     Toys  and  dolls  should  not  be 'allowed  at  first,  for  the  child  should 


ACUTE  CHOREA.  1087 

be  kept  amused  without  excitement.  The  rest  allays  the  hyper-excitabil- 
ity and  reduces  to  a  minimum  the  possibility  of  damage  to  the  valve  seg- 
ments should  endocarditis  exist.  Time  and  again  have  I  seen  very  severe 
cases  which  had  resisted  treatment  for  weeks  outside  a  hospital  become 
quiet  and  the  movements  subside  after  two  or  three  days  of  absolute  rest 
in  bed. 

The  child  should  be  kept  apart  from  other  children  and,  if  possible, 
from  other  members  of  the  family,  and  should  see  only  those  persons 
directly  concerned  with  the  nursing  of  the  case.  In  the  latter  period  of 
the  disease  daily  rubbings  may  be  resorted  to  with  great  benefit. 

The  medical  treatment  of  the  disease  is  unsatisfactory;  with  the  ex- 
ception of  arsenic,  no  remedy  seems  to  have  any  influence  in  controlling 
the  progress  of  the  afl'ection.  Without  any  specific  action,  it  certainly 
does  good  in  many  cases,  probably  by  improving  the  general  nutrition. 
It  is  conveniently  given  in  the  form  of  Fowler's  solution,  and  the  good 
effects  are  rarely  seen  until  maxim  am  doses  are  taken.  It  may  be  given 
as  Martin  originally  advised  (1813);^  he  began  "  with  five  drops  and  in- 
creased one  drop  every  day,  until  it  might  begin  to  disagree  with  the  stom- 
ach or  bowels.''  When  the  dose  of  15  minims  is  reached,  it  may  be  con- 
tinued for  a  week,  and  then  again  increased,  if  necessary,  every  day  or  two, 
until  physiological  eft'ects  are  manifest.  ,0n  the  occurrence  of  these  the 
drug  should  be  stopped  for  three  or  four  days.  The  practice  of  resuming 
the  administration  with  smaller  doses  is  rarely  necessary,  as  tolerance  is  usu- 
ally established  and  we  can  begin  with  the  dose  which  the  child  was  taking 
when  the  symptoms  of  saturation  occurred.  I  have  frequently  given  as 
much  as  25  minims  three  times  a  day.  Usually  the  signs  of  saturation  are 
trivial  but  plain,  but  in  very  rare  instances  more  serious  symptoms  develop. 
A  fatal  arsenical  neuritis  followed  in  the  case  of  a  child,  aged  eight,  who 
took  seven  drops  of  Fowler's  solution  three  times  a  day  for  ten  days,  then 
stopped  for  a  week,  and  then  took  seven  drops  three  times  a  day  for  four- 
teen days  (Gary  Gamble,  Jr.). 

Of  other  medicines,  strychnine,  the  zinc  compounds,  nitrate  of  silver, 
bromide  of  potassium,  belladonna,  chloral,  and  especially  cimicifuga,  have 
been  recommended,  and  may  be  tried  in  obstinate  cases. 

For  its  tonic  efl'ect  electricity  is  sometimes  useful;  but  it  is  not  neces- 
sary as  a  routine  treatment.  The  question  of  gymnastics  is  an  important 
one.  Early  in  the  disease,  when  the  movements  are  active,  they  are  not 
advisable;  but  during  convalescence  carefully  graduated  exercises  are  un- 
doubtedly beneficial.  It  is  not  well,  however,  to  send  a  choreic  child  to  a 
school  gymnasium,  as  the  stimulus  of  the  other  children  and  the  excite- 
ment of  the  romping,  violent  play  are  very  prejudicial. 

Other  points  in  treatment  may  be  mentioned.  It  is  important  to  regu- 
late the  bowels  and  to  attend  carefully  to  the  digestive  functions.  For  the 
antemia  so  often  present  preparations  of  iron  are  indicated. 

In  the  severe  cases  with  incessant  movements,  sleeplessness,  dry  tongue, 
and  delirium,  the  important  indication  is  to  procure  rest,  for  which  pur- 
pose chloral  may  be  freely  given,  and,  if  necessary,  morphia.  Chloroform 
inhalations  may  be  necessary  to  control  the  intensity  of  the  paroxysms, 


;1088  DISEASES  OP  THE  NERVOUS  SYSTEM. 

but  the  high  rate  of  mortality  in  this  class  of  cases  illustrates  how  often 
our  best  endeavors  are  fruitless.  The  wet  23ack  is  sometimes  very  soothing 
and  should  be  tried.  As  these  patients  are  apt  to  sink  rapidly  into  a  low 
typhoid  state  with  heart  weakness,  a  supporting  treatment  is  required  from 
the  outset. 

Cases  are  found  now  and  then  which  drag  on  from  month  to  month 
without  getting  either  better  or  worse  and  resist  all  modes  of  treatment. 
Change  of  air  and  scene  is  sometimes  followed  by  rapid  improvement,  and 
in  these  cases  the  treatment  by  rest  and  seclusion  should  always  be  given  a 
full  trial. 

In  all  cases  care  should  be  taken  to  examine  the  nostrils,  and  glaring 
ocular  defects  should  be  properly  corrected  either  by  glasses  or,  if  neces- 
sary, by  operation. 

After  the  child  has  recovered  from  the  attack,  the  parents  should  be 
warned  that  return  of  the  disease  is  by  no  means  infrequent,  and  is  par- 
ticularly liable  to  follow  overwork  at  school  or  debilitating  influences  of 
any  kind.  These  relapses  are  apt  to  occur  in  the  spring.  Sydenham  ad- 
vised purging  in  order  to  prevent  the  vernal  recurrence  of  the  disease. 


IV.    OTHER   AFFECTIONS    DESCRIBED   AS   CHOREA. 

(a)  Chorea  Major ;  Pandemic  Chorea.' — The  common  name,  St.  Vitus's 
dance,  applied  to  chorea  has  come. to  us  from  the  middle  ages,  when  under 
the  influence  of  religious  fervor  there  were  epidemics  characterized  by  great 
excitement,  gesticulations,  and  dancing.  For  the  relief  of  these  symptohas, 
when  excessive,  pilgrimages  were  made,  and  in  the  Rhenish  provinces,  par- 
ticularly to  the  Chapel  of  St.  Vitus  in  Zebern.  Epidemics  of  this  sort 
have  occurred  also  during  this  century,  and  descriptions  of  them  among  the 
early  settlers  in  Kentucky  have  been  given  by  Eobertson  and  Yandell. 
It  was  unfortunate  that  Sydenham  applied  the  term  chorea  to  an  affection 
in  children  totally  distinct  from  this  chorea  major,  which  is  in  reality  an 
^sterical  manifestation  under  the  influence  of  religious  excitement. 

(h)  Habit  Spasm  (Habit  Chorea) ;  Convulsive  Tic  (of  the  French). 

Two  groups  of  cases  may  be  recognized  under  the  designation  of  habit 
spasm — one  in  which  there  are  simply  localized  spasmodic  movements,  and 
the  other  in  which,  in  addition  to  this,  there  are  explosive  utterances  and 
psychical  symptoms,  a  condition  to  which  French  writers  have  given  the 
name  tic  convulsif. 

(1)  Habit  Spasm. — This  is  found  chiefly  in  childhood,  most  frequently 
in  girls  from  seven  to  fourteen  years  of  age  (Mitchell).  In  its  simplest 
form  there  is  a  sudden,  quick  contraction  of  certain  of  the  facial  muscles, 
such  as  rapid  winking  or  drawing  of  the  mouth  to  one  side,  or  the  neck 
muscles  are  involved  and  there  are  unilateral  movements  of  the  head. 
The  head  is  given  a  sudden,  quick  shake,  and  at  the  same  time  the  eyes 
wink.  A  not  infrequent  form  is  the  shrugging  of  one  shoulder.  The 
grimace  or  movement  is  repeated  at  irregular  intervals,  and  is  much  aggra- 
vated by  emotion.     A  short  inspiratory  sniff  is  not  an  uncommon  symp- 


OTHER  AFFECTIONS  DESCRIBED  AS  CHOREA.  1089 

torn.  The  cases  are  found  most  frequently  in  children  who  are  "  out  of 
sorts,"  or  who  have  been  growing  rapidly,  or  who  have  inherited  a  tend- 
ency to  neurotic  disorders.  Allied  to  or  associated  with  this  are  some  of 
the  curious  tricks  of  children.  A  boy  at  my  clinic  was  in  the  habit  every 
few  moments  of  putting  the  middle  finger  into  the  mouth,  biting  it,  and 
at  the  same  time  pressing  his  nose  with  the  forefinger.  Hartley  Cole- 
ridge is  said  to  have  had  a  somewhat  similar  trick,  only  he  bit  his  arm. 
In  all  these  cases  the  habits  of  the  child  should  be  examined  carefully,  the 
nose  and  vault  of  the  pharynx  thoroughly  inspected,  and  the  eyes  accurately 
tested.  As  a  rule  the  condition  is  transient,  and  after  persisting  for  a  few 
months  or  longer  gradually  disappears.  Occasionally  a  local  spasm  persists 
— twitching  of  the  eyelids,  or  the  facial  grimace. 

(2)  Impulsive  Tic  (Gilles  de  la  Tourette's  Disease). — This  remarkable 
afFeetion,  often  mistaken  for  chorea,  more  frequently  for  habit  spasm,  is 
really  a  psychosis  allied  to  hysteria,  though  in  certain  of  its  aspects  it  has 
the  features  of  monomania.  The  disease  begins,  as  a  rule,  in  young  chil- 
dren, occurring  as  early  as  the  sixth  year,  though  it  may  develop  after  pu- 
berty. There  is  usually  a  markedly  neurotic  family  history.  The  special 
features  of  the  complaint  are: 

(a)  Involuntary  muscular  movements,  usually  affecting  the  facial  or 
brachial  muscles,  but  in  aggravated  cases  all  the  muscles  of  the  body  may 
be  involved  and  the  movements  may  be  extremely  irregular  and  violent. 

(h)  Explosive  utterances,  which  may  resemble  a  bark  or  an  inarticulate 
cry.  A  word  heard  may  be  mimicked  at  once  and  repeated  over  and  over 
again,  usually  with  the  involuntary  movements.  To  this  the  term  echo- 
lalia  has  been  applied.  A  much  more  distressing  disturbance  in  these 
cases  is  coprolalia^  or  the  use  of  bad  language.  A  child  of  eight  or  ten 
may  shock  its  mother  and  friends  by  constantly  using  the  word  damn 
when  making  the  involuntary  movements,  or  by  uttering  all  sorts  of  ob- 
scene words.     Occasionally  actions  are  mimicked — eclwTcinesis. 

{c)  Associated  with  some  of  these  cases  are  curious  mental  disturbances; 
the  patient  becomes  the  subject  of  a  form  of  obsession  or  a  fixed  idea.  In 
other  cases  the  fixed  idea  takes  the  form  of  the  impulse  to  touch  objects, 
or  it  is  a  fixed  idea  about  words — onomatomania — or  the  patient  may  feel 
compelled  to  count  a  number  of  times  before  doing  certain  actions — arith- 
momania. 

The  disease  is  well  marked  and  readily  distinguished  from  ordinary 
chorea.  The  movements  have  a  larger  range  and  are  explosive  in  charac- 
ter. Tourette  regards  the  coprolalia  as  the  most  distinctive  feature  of  the 
disease.  The  prognosis  is  doubtful.  I  have,  however,  known  recovery  to 
follow. 

(c)  Saltatory  Spasm  (Laiali;  Myriachit;  Jumpers). — Bamberger  has  de- 
scribed a  disease  in  which  when  the  patient  attempted  to  stand  there  were 
strong  contractions  in  the  leg  muscles,  which  caused  a  jumping  or  spring- 
ing motion.  This  occurs  only  when  the  patient  attempts  to  stand.  The 
affection  has  occurred  in  both  men  and  women,  more  frequently  in  the 
former,  and  the  subjects  have  usually  shown  marked  neurotic  tendencies. 
In  many  cases  the  condition  lias  been  transitory;  in  others  it  has  ])ersisted 


IQQQ  DISEASES  OF  THE  NERVOUS  SYSTEM. 

for  years.  Eemarkable  affections  similar  to  this  in  certain  points  occur 
as  a  sort  of  endemic  neurosis.  One  of  the  most  striking  of  these  occurs 
among  the  "  jumping  Frenchmen  "  of  Maine  and  Canada.  As  described 
by  Beard  and  Thornton,  the  subjects  are  liable  on  any  sudden  emotion  to 
jump  violently  and  utter  a  loud  cry  or  sound,  and  will  obey  any  command 
or  imitate  any  action  without  regard  to  its  nature.  The  condition  of 
echolalia  is  present  in  a  marked  degree.  The  "  jumping  "  prevails  in  cer- 
tain families. 

A  very  similar  disease  prevails  in  parts  of  Eussia  and  in  Java,  where  it  is 
known  by  the  names  of  myriachit  and  latah,  the  chief  feature  of  which  is 
mimicry  by  the  patient  of  everything  he  sees  or  hears. 

(d)  Chronic  Chorea  {Huntington's  Chorea). — An  affection  characterized 
by  irregular  movements,  disturbance  of  speech,  and  gradual  dementia.  It 
is  frequently  hereditary.  The  disease  has  no  connection  with  Sydenham's 
chorea,  and  it  is  unfortunate  that  the  term  was  applied  to  it.  It  was  be- 
scribed  by  Huntington,  of  Pomeroy,  Ohio,  at  the  time  a  practitioner  on 
Long  Island,  and  he  gave  in  three  brief  paragraphs  the  salient  points  in 
connection  with  the  disease — namely,  the  hereditary  nature,  the  associa- 
tion with  psychical  troubles,  and  the  late  onset — between  the  thirtieth  and 
fortieth  years.  The  disease  seems  common  in  this  country,  and  many 
cases  have  been  reported  by  Clarence  King,  Sinkler,  and  others.  I  have 
seen  it  in  two  Maryland  families  within  the  past  few  years.  Under  the 
term  chronic  chorea  may  be  grouped  the  hereditary  form  and  the  cases 
which  come  on  without  family  disposition,  either  at  middle  life  or,  more 
commonly,  in  the  aged — senile  chorea.  It  is  doubtful  whether  the  cases 
in  children  with  chronic  choreiform  movements,  often  with  mental  weak- 
ness and  spastic  condition  of  the  legs,  should  go  into  this  category. 

The  hereditary  character  of  the  disease  is  very  striking;  it  has  been 
traced  through  four  or  five  generations.  Huntington's  father  and  grand- 
father, also  physicians,  had  treated  the  disease  in  the  family  which  he  de- 
scribed. Osborn,  of  East  Hampton,  L.  I.,  writes  (Jan.  28th,  1898)  that  the 
disease  still  continues  to  recur  in  certain  families  described  by  Huntington, 
as  it  has  done,  so  it  is  said,  for  fully  two  centuries.  An  identical  affection 
occurs  without  any  hereditary  disposition.  The  age  of  onset  is  late,  rarely 
before  the  thirtieth  or  the  thirty-fifth  year. 

The  symptoms  are  very  characteristic.  The  irregular  movements  are 
usually  first  seen  in  the  hands,  and  the  patient  has  slight  difficulty  in  per- 
forming delicate  manipulations  or  in  writing.  When  well  established  the 
movements  are  disorderly,  irregular,  incoordinate  rather  than  choreic,  and 
have  not  the  sharp,  brusque  motion  of  Sydenham's  chorea.  In  the  face 
there  are  slow,  involuntary  grimaces.  In  a  well-developed  case  the  gait 
is  irregular,  swaying,  and  somewhat  like  that  of  a  drunken  man.  The 
speech  is  slow  and  difficult,  the  syllables  are  badly  pronounced  and  indis- 
tinct, but  not  definitely  staccato.  The  mental  impairment  leads  finally  to 
dementia. 

Very  few  autopsies  have  been  made.  No  characteristic  lesions  have 
been  found.  Atrophy  of  the  convolutions,  chronic  meningo-encephalitis. 
and  vascular  changes  have  usually  been  present,  the  conditions  which  one 


INFANTILE  CONVULSIONS.  1091 

would  expect  to  find  in  chronic  dementia.  The  recent  study  of  two  cases 
by  Facklan  (Arch.  f.  Psychiatric,  30)  confirms  the  view  expressed  in  former 
editions  that  the  disease  is  a  chronic  meningo-encephalitis  with  atrophy  of 
the  convolutions.  The  cord  and  peripheral  nerves  he  found  perfectly 
healthy.  The  affection  is  evidently  a  neuro-degenerative  disorder,  and  has 
no  connection  with  the  simple  chorea  of  childhood. 

(e)  Rhytliinic  or  Hysterical  Chorea. — This  is  readily  recognized  by  the 
rhythmical  character  of  the  movements.  It  may  affect  the  muscles  of  the 
abdomen,  producing  the  salaam  convulsion,  or  involve  the  sterno-mastoid, 
producing  a  rhythmical  movement  of  the  head,  or  the  psoas,  or  any  group 
of  muscles.     In  its  orderly  rhythm  it  resembles  the  canine  chorea. 


V.    INFANTILE    CONVULSIONS  (Eclampsia). 

Convulsive  seizures  similar  to  those  of  epilepsy  are  not  infrequent  in 
children  and  in  adults.  The  fit  may  indeed  be  identical  with  epilepsy, 
from  which  the  condition  differs  in  that  when  the  cause  is  removed  there 
is  no  tendency  for  the  fits  to  recur.  Occasionally,  however,  the  convul- 
sions in  children  continue  and  develop  into  true  epilepsy. 

Etiology. — A  convulsion  in  a  child  may  be  due  to  many  causes,  all 
of  which  lead  to  an  unstable  condition  of  the  nerve-centres,  permitting  of 
sudden,  excessive,  and  temporary  nervous  discharges.  The  following  are 
the  most  important  of  them: 

(1)  Debility,  resulting  usually  from  gastro-intestinal  disturbance.  Con- 
vulsions frequently  supervene  toward  the  close  of  an  attack  of  entero- 
colitis and  recur,  sometimes  proving  fatal.  Morris  J.  Lewis  has  shown 
that  the  death-rate  in  children  from  eclampsia  rises  steadily  with  that  of 
gastro-intestinal  disorders. 

(2)  Peripheral  irritation.  Dentition  alone  is  rarely  a  cause  of  convul- 
sions, but  is  often  one  of  several  factors  in  a  feeble,  unhealthy  infant. 
The  greatest  mortality  from  convulsions  is  during  the  first  six  months,  be- 
fore the  teeth  have  really  cut  through  the  gums.  Other  irritative  causes  are 
the  overloading  of  the  stomach  with  indigestible  food.  It  has  been  sug- 
gested that  some  of  these  cases  are  toxic,  owing  to  the  absorption  of  poi- 
sonous ptomaines.  Worms,  to  which  convulsions  are  so  frequently  attrib- 
uted, probably  have  little  influence.  Among  other  sources  possible  are 
phimosis  and  otitis. 

(3)  Eickets.  The  observation  of  Sir  William  Jenner  upon  the  associa- 
tion of  rickets  and  convulsions  has  been  amply  confirmed.  The  spasms 
may  be  laryngeal,  the  so-called  child-crowing,  which,  though  convulsive  in 
nature,  can  scarcely  be  reckoned  under  eclampsia.  The  influence  of  this 
condition  is  more  apparent  in  Europe  than  in  this  country,  although  rickets 
is  a  common  disease,  particularly  among  the  colored  people.  Spasms,  local 
or  general,  in  rickets  are  probably  associated  with  the  condition  of  debility 
and  malnutrition  and  with  cranio-tabes. 

(4)  Fever.  In  young  children  the  onset  of  the  infectious  diseases  is  fre- 
quently with  convulsions,  whicii  often  take  the  place  of  a  chill  in  tlic  adult. 


;^092  DISEASES  OF  THE  NERVOUS  SYSTEM. 

It  is  not  known  upon  what  they  depend.    Scarlet  fever,  measles,  and  pneu- 
monia are  most  often  preceded  by  convulsions. 

(5)  Congestion  of  the  brain.  That  extreme  engorgement  of  the  blood- 
vessels may  produce  convulsions  is  shown  by  their  occasional  occurrence 
in  severe  whooping-cough,  but  their  rarity  in  this  disease  really  indicates 
how  small  a  part  mechanical  congestion  plays  in  the  production  of  fits. 

(6)  Severe  convulsions  usher  in  or  accompany  many  of  the  serious  dis- 
eases of  the  nervous  system  in  children.  In  more  than  50  per  cent  of  the 
eases  of  infantile  hemiplegia  the  affection  follows  severe  convulsions.  They 
less  frequently  precede  a  spinal  paralysis.  They  occur  with  meningitis, 
tuberculous  or  simple,  and  with  tumors  and  other  lesions  of  the  brain. 

And,  lastly,  convulsions  may  occur  immediately  after  birth  and  persist 
for  weeks  or  months.  In  such  instances  there  has  probably  been  menin- 
geal haemorrhage  or  serious  injury  to  the  cortex. 

The  most  important  question  is  the  relation  of  convulsions  in  children 
to  true  epilepsy.  In  Gowers'  figures  of  1,450  cases  of  epilepsy,  the  attacks 
began  in  180  during  the  first  three  years  of  life.  Of  460  cases  of  epilepsy 
in  children  which  I  have  analyzed,  in  187  the  fits  began  within  the  first 
three  years.  Of  the  total  list  the  greatest  number,  74,  was  in  the  first 
year.  In  nearly  all  these  instances  there  was  no  interruption  in  the  con- 
vulsions. That  convulsions  in  early  infancy  are  necessarily  followed  by 
epilepsy  in  after  life  is  certainly  a  mistake. 

Symptoms. — The  attack  may  come  on  suddenly  without  any  warn- 
ing; more  commonly  it  is  preceded  by  a  stage  of  restlessness,  accompanied 
by  twitching  and  perhaps  grinding  of  the  teeth.  It  is  rarely  so  complete 
in  its  stages  as  true  epilepsy.  The  spasm  begins  usually  in  the  hands,  most 
commonly  in  the  right  hand.  The  eyes  are  fixed  and  staring  or  are  rolled 
up.  The  body  becomes  stiff  and  breathing  is  suspended  for  a  moment  or 
two  by  tonic  spasm  of  the  respiratory  muscles,  in  consequence  of  which 
the  face  becomes  congested.  Clonic  convulsions  follow,  the  eyes  are  rolled 
about,  the  hands  and  arms  twitch,  or  are  flexed  and  extended  in  rhythmical 
movements,  the  face  is  contorted,  and  the  head  is  retracted.  The  attack 
gradually  subsides  and  the  child  sleeps  or  passes  into  a  state  of  stupor. 
Following  indigestion  the  attack  may  be  single,  but  in  rickets  and  intestinal 
disorders  it  is  apt  to  be  repeated.  Sometimes  the  attacks  follow  each  other 
with  great  rapidity,  so  that  the  child  never  rouses  but  dies  in  a  deep  coma. 
If  the  convulsion  has  been  limited  chiefly  to  one  side  there  may  be  slight 
paresis  after  recovery,  or  in  instances  in  which  the  convulsions  usher  in 
infantile  hemiplegia,  when  the  child  arouses,  one  side  is  completely  para- 
lyzed. During  the  fit  the  temperature  is  often  raised.  Death  rarely  occurs 
from  the  convulsion  itself,  except  in  debilitated  children  or  when  the  at- 
tacks recur  with  great  frequency.  In  the  so-called  hydrocephaloid  state  in 
connection  with  protracted  diarrhoea  convulsions  may  close  the  scene. 

Diagnosis. — Coming  on  when  the  subject  is  in  full  health,  the  attack 
is  probably  due  either  to  an  overloaded  stomach,  to  some  peripheral  irrita- 
tion, or  occasionally  to  trauma.  Setting  in  with  high  fever  and  vomiting, 
it  may  indicate  the  onset  of  an  exanthem,  or  occasionally  be  the  primary 
symptom  of  encephalitis,  or  whatever  the  condition  is  which  causes  infan- 


EPILEPSY.  1093 

tile  hemiplegia.  When  the  attack  is  associated  with  debility  and  with 
rickets  the  diagnosis  is  easily  made.  The  carpopedal  spasms  and  pseudo- 
paralytic rigidity  which  are  often  associated  with  rickets,  laryngismus  stridu- 
lus, and  the  hydrocephaloid  state  are  usually  confined  to  the  hands  and 
arms  and  are  intermittent  and  usually  tonic.  The  convulsions  associated 
with  tumor  or  which  follow  infantile  hemiplegia  are  usually  at  first  Jack- 
sonian  in  character.  After  the  second  year  convulsive  seizures  which  come 
on  irregularly  without  apparent  cause  and  recur  while  the  child  is  appar- 
ently in  good  health  are  likely  to  prove  true  epilepsy. 

Prognosis. — Convulsions  play  an  important  part  in  infantile  mor- 
tality. In  Morris  J.  Lewis's  table  of  deaths  in  children  under  ten,  8.5  per 
cent  were  ascribed  to  convulsions.  West  states  that  22.35  per  cent  of  deaths 
under  one  year  are  caused  by  convulsions,  but  this  is  too  high  an  estimate 
for  this  country.  In  chronic  diarrhoea  convulsions  are  usually  of  ill  omen. 
Those  ushering  in  fevers  are  rarely  serious,  and  the  same  may  be  said  of 
the  fits  associated  with  indigestion  and  peripheral  irritation. 

Treatment. — Every  source  of  irritation  should  be  removed.  If  as- 
sociated with  indigestible  food,  a  prompt  emetic  should  be  given,  followed 
by  an  enema.  The  teeth  should  be  examined,  and  if  the  gum  is  swollen, 
hot,  and  tense,  it  may  be  lanced;  but  never  if  it  looks  normal.  When 
seen  at  first,  if  the  paroxysm  is  severe,  no  time  should  be  lost  by  giving 
a  hot  bath,  but  chloroform  should  be  given  at  once,  and  repeated  if  neces- 
sary. A  child  is  so  readily  put  under  chloroform  and  with  such  a  small 
quantity  that  this  precedure  is  quite  harmless  and  saves  much  valuable 
time.  The  practice  is  almost  universal  of  putting  the  child  into  a  warm 
bath,  and  if  there  is  fever  the  head  may  be  douched  with  cold  water.  The 
temperature  of  the  bath  should  not  be  above  95°  or  96°.  The  very  hot 
bath  is  not  suitable,  particularly  if  the  fits  are  due  to  indigestion.  After 
the  attack  an  ice-cap  may  be  placed  upon  the  head.  If  there  is  much  irri- 
tability, particularly  in  rickets  and  in  severe  diarrhoea,  small  doses  of 
opium  will  be  found  efficacious.  When  the  convulsions  recur  after  the 
child  comes  from  under  the  influence  of  chloroform  it  is  best  to  place  it 
rapidly  under  the  influence  of  opium,  which  may  be  given  as  morphia 
hypodermically,  in  doses  of  from  one  twenty-fifth  to  one  thirtieth  of  a  grain 
for  a  child  of  one  year.  Other  remedies  recommended  are  chloral  by  enema, 
in  5-grain  doses,  and  nitrite  of  amyl.  After  the  attack  has  passed  the 
bromides  are  useful,  of  which  5  to  8  grains  may  be  given  in  a  day  to  a  child 
a  year  old.  Recurring  convulsions,  particularly  if  they  come  on  without 
special  cause,  should  receive  the  most  thorough  and  careful  treatment 
with  bromides.  When  associated  with  rickets  the  treatment  should  be 
directed  to  improving  the  general  condition. 


VI.    EPILEPSY. 

Definition. — An  affection  of  the  nervous  system  characterized  by  at- 
tacks of  unconsciousness,  with  or  without  convulsions. 

The  transient  loss  of  consciousness  without  convulsive  seizures  is  known 


1094  DISEASES  OF  THE  NEUVOUS  SYSTEM. 

as  petit  mal;  the  loss  of  consciousness  with  general  convulsive  seizures  is 
known  as  grand  ,mal.  Localized  convulsions^,  occurring  usually  without 
loss  of  consciousness,  are  known  as  epileptiform,  or  more  frequently  as 
Jacksonian  or  cortical  epilepsy. 

Etiology.— ^^e. — In  a  large  proportion  of  all  cases  the  disease  begins 
before  puberty.  Of  the  1,450  cases  observed  by  Gowers,  in  422  the  disease 
began  before  the  tenth  year,  and  three  fourths  of  the  cases  began  before 
the  twentieth  year.  Of  460  cases  of  epilepsy  in  children  which  I  have 
analyzed  the  age  of  onset  in  427  was  as  follows:  First  year,  74;  second 
year,  62;  third  year,  51;  fourth  year,  24;  fifth  year,  17;  sixth  year,  18; 
seventh  year,  19;  eighth  year,  23;  ninth  year,  17;  tenth  year,  27;  eleventh 
year,  17;  twelfth  year,  18;  thirteenth  year,  15;  fourteenth  year,  21;  fif- 
teenth year,  34.  Arranged  in  hemidecades  the  figures  are  as  follows:  From 
the  first  to  the  fifth  year,  229;  from  the  fifth  to  the  tenth  year,  104;  from 
the  tenth  to  the  fifteenth  year,  95.  These  figures  illustrate  in  a  striking 
manner  the  early  onset  of  the  disease  in  a  large  proportion  of  the  cases. 
It  is  well  always  to  be  suspicious  of  epilepsy  developing  in  the  adult,  for  in 
a  majority  of  such  cases  the  convulsions  are  due  to  a  local  lesion. 

Sex. — No  special  influence  appears  to  be  discoverable  in  this  relation, 
certainly  not  in  children.  Of  433  cases  in  my  tables,  232  were  males  and 
203  were  females,  showing  a  slight  predominance  of  the  male  sex.  After 
pubert)^  unquestionably,  if  a  large  number  of  cases  are  taken,  the  males 
are  in  excess.  The  figures  of  Sieveking  and  Eeynolds  show  that  the  dis- 
ease is  rather  more  prevalent  in  females  than  in  males. 

Heredity. — Much  stress  has  been  laid  upon  this  by  many  authors  as  an 
important  predisposing  cause,  and  the  statistics  collected  give  from  9  to  over 
40  per  cent.  Gowers  gives  35  per  cent  for  his  cases,  which  have  special 
value  apart  from  other  statistics  embracing  large  numbers  of  epileptics  in 
that  they  were  collected  by  him  in  his  own  practice.  In  our  figures  it  ap- 
pears to  play  a  minor  role.  In  the  Infirmary  list  there  were  only  31  cases 
in  which  there  was  a  history  of  marked  neurotic  taint,  and  only  3  in  which 
the  mother  herself  had  been  epileptic.  In  the  Elwyn  cases,  as  might  be 
expected,  the  percentage  is  larger.  Of  the  126  there  was  in  32  a  family  his- 
tory of  nervous  derangement  of  some  sort,  either  paralysis,  epilepsy,  marked 
hysteria,  or  insanity.  It  is  interesting  to  note  that  in  this  group,  in  which 
the  question  of  heredity  is  carefully  looked  into,  there  were  only  two  in 
which  the  mother  had  had  epilepsy,  and  not  one  in  which  the  father  had 
been  affected.  Indeed,  I  was  not  a  little  surprised  to  find  in  the  list  of  my 
cases  that  hereditary  influences  played  so  small  a  part.  I  have  heard  this 
©pinion  expressed  by  certain  French  physicians,  notably  Marie,  who  in  writ- 
ing also  upon  the  question  takes  strong  grounds  against  heredity  as  an  im- 
portant factor  in  epilepsy. 

While,  then,  it  may  be  said  that  direct  inheritance  is  comparatively  un- 
common, yet  the  children  of  neurotic  families  in  which  neuralgia,  insanity, 
and  hysteria  prevail  are  more  liable  to  fall  victims  to  the  disease. 

Chronic  alcoholism  in  the  parents  is  regarded  by  many  as  a  potent  ]yre- 
disposing  factor  in  the  production  of  epilepsy.  Echeverria  has  analyzed 
572  cases  bearing  upon  this  point  and  divided  them  into  three  classes,  of 


EPILEPSY.  1095 

which  257  cases  could  be  traced  directly  to  alcohol  as  a  cause;  126  cases 
in  which  there  were  associated  conditions,  such  as  syphilis  and  traumatism; 
189  cases  in  which  the  alcoholism  was  probably  the  result  of  the  epilepsy. 
Figures  equally  strong  are  given  by  Martin,  who  found  in  150  insane  epi- 
leptics B3  with  a  marked  history  of  parental  intemperance.  Of  the  126 
Elwyn  cases,  in  which  the  family  history  on  this  point  was  carefully  inves- 
tigated, a  definite  statement  was  found  in  only  4  of  the  cases. 

Syphilis. — This  in  the  parents  is  probably  less  a  predisposing  than  an 
actual  cause  of  epilepsy,  which  is  the  direct  outcome  of  local  cerebral  mani- 
festations. There  is  no  reason  for  recognizing  a  special  form  of  syphilitic 
epilepsy.  On  the  other  hand,  convulsive  seizures  due  to  acquired  syphilitic 
disease  of  the  brain  are  very  common. 

Poisons. — Alcohol. — Severe  epileptic  convulsions  may  occur  in  steady 
drinkers. 

Of  exciting  causes  fright  is  believed  to  be  important,  but  is  less  so,  I 
think,  than  is  usually  stated.  Trauma  is  present  in  a  certain  number  of 
instances.  An  important  group  depends  upon  a  local  disease  of  the  brain 
existing  from  childhood,  as  seen  in  the  post-hemiplegic  epilepsy.  Occa- 
sionally cases  follow  the  infectious  fevers.  Masturbation  has  been  stated 
to  be  a  special  cause,  but  its  influence  is  probably  overrated.  A  large  group 
of  convulsive  seizures  allied  to  epilepsy  are  due  to  some  toxic  agent,  as  in 
lead  poisoning  and  in  ura3mia. 

Reflex  Causes. — Dentition  and  worms,  the  irritation  of  a  cicatrix,  some 
local  affection,  such  as  adherent  prepuce,  or  a  foreign  body  in  the  ear  or 
the  nose,  are  given  as  causes.  In  many  of  these  cases  the  fits  cease  after 
the  removal  of  the  cause,  so  that  there  can  be  no  question  of  the  association 
between  the  two.  In  others  the  attacks  persist.  Genuine  cases  of  reflex 
epilepsy  are,  I  believe,  rare.  A  remarkable  instance  of  it  occurred  at  the 
Philadelphia  Infirmary  for  Diseases  of  the  Nervous  System  in-the  case  of 
a  man  with  a  testis  in  the  inguinal  canal,  pressure  upon  which  would  cause 
a  typical  fit.    Removal  of  the  organ  was  followed  by  cure. 

Cardio-vascular  epilepsy  is  usually  a  manifestation  of  advanced  arterio- 
sclerosis, and  is  associated  with  slow  pulse  (see  Stokes- Adams'  Syndrome). 
There  may  be  palpitation  and  uneasy  sensations  about  the  heart  prior  to 
the  attack.  The  passage  of  a  gall-stone  or  the  removal  of  pleuritic  fluid 
may  induce  a  fit.  Indigestion  and  gastric  troubles  are  extremely  common 
in  epilepsy,  and  in  many  instances  the  eating  of  indigestible  articles  seems 
to  precipitate  an  attack.  And  lastly,  epileptic  seizures  may  occur  in  old 
peo])l('  without  obvious  cause. 

Symptoms. — (1)  Grand  Mai. — Preceding  the  fits  there  is  usually  a 
localized  sensation,  known  as  an  aura,  in  some  part  of  the  body.  This 
may  be  somatic,  in  which  the  feeling  comes  from  some  particular  region 
in  the  periphery,  as  from  the  finger  or  hand,  or  is  a  sensation  felt  in  the 
stomach  or  about  the  heart.  The  peripheral  sensations  preceding  the  fit 
are  of  great  value,  particularly  those  in  which  the  aura  always  occurs  in  a 
definite  region,  as  in  one  finger  or  toe.  It  is  the  equivalent  of  the  signal 
symptom  in  a  fit  from  a  brain  tumor.  The  varieties  of  these  sensations 
are  numerous.    The  epigastric  sensations  are  most  common.    In  these  the 


3^096  DISEASES  OF  THE  NERVOUS  SYSTEM. 

patient  complains  of  an  uneasy  sensation  in  the  epigastrium  or  distress  in 
the  intestines,  or  the  sensation  may  not  be  unlike  that  of  heart-burn  and 
may  be  associated  with  palpitation.  These  groups  are  sometimes  known 
as  pneumogastric  aurse  or  warnings. 

Of  psychical  aurse  one  of  the  most  common,  as  described  by  Hiighlings 
Jackson,  is  the  vague,  dreamy  state,  a  sensation  of  strangeness  or  some- 
times of  terror.  The  aurge  may  be  associated  with  special  senses;  of  these 
the  most  common  are  the  visual,  consisting  of  flashes  of  light  or  sensa- 
tions of  color;  less  commonly,  distinct  objects  are  seen.  The  audi- 
tory aurse  consist  of  noises  in  the  ear,  odd  sounds,  musical  tones,  or  occa- 
sionally voices.  Olfactory  and  gustatory  aurse,  unpleasant  tastes  and  odors, 
are  rare. 

Occasionally  the  fit  may  be  preceded  not  by  an  aura,  but  by  certain 
movements;  the  patient  may  turn  round  rapidly  or  run  with  great  speed 
for  a  few  minutes,  the  so-called  epilepsia  procursiva.  In  one  of  the  Elwyn 
cases  the  lad  stood  on  his  toes  and  twirled  with  extraordinary  rapidity,  so 
that  his  features  were  scarcely  recognizable.  At  the  onset  of  the  attack 
the  patient  may  give  a  loud  scream  or  yell,  the  so-called  epileptic  cry.  The 
patient  drops  as  if  shot,  making  no  effort  to  guard  the  fall.  In  consequence 
of  this  epileptics  frequently  injure  themselves,  cutting  the  face  or  head 
or  burning  themselves.  In  the  attack,  as  described  by  Hippocrates,  "  the 
patient  loses  his  speech  and  chokes,  and  foam  issues  from'the  mouth,  the 
teeth  are  fixed,  the  hands  are  contracted,  the  eyes  distorted,  he  becomes 
insensible,  and  in  some  cases  the  bowels  are  affected.  And  these  symptoms 
occur  sometimes  on  the  left  side,  sometimes  on  the  right,  and  sometimes  on 
both."    The  fit  may  be  described  in  three  stages: 

(a)  Tonic  Spasm. — The  head  is  drawn  back  or  to  the  right,  and  the 
jaws  are  fixed.  The  hands  are  clinched  and  the  legs  extended.  This  tonic 
contraction  affects  the  muscles  of  the  chest,  so  that  respiration  is  impeded 
and  the  initial  pallor  of  the  face  changes  to  a  dusky  or  livid  hue.  The 
muscles  of  the  two  sides  are  unequally  affected,  so  that  the  head  and  neck 
are  rotated  or  the  spine  is  twisted.  The  arms  are  usually  flexed  at  the 
elbows,  the  hand  at  the  wrist,  and  the  fingers  are  tightly  clinched  in  the 
palm.    This  stage  lasts  only  a  few  seconds,  and  then  the 

(h)  Clonic  stage  begins.  The  muscular  contractions  become  intermit- 
tent; at  first  tremulous  or  vibratory,  they  gradually  become  more  rapid 
and  the  limbs  are  jerked  and  tossed  about  violently.  The  muscles  of  the 
face  are  in  constant  clonic  spasm,  the  eyes  roll,  the  eyelids  are  opened  and 
closed  convulsively.  The  movements  of  the  muscles  of  the  jaw  are  very 
forcible  and  strong,  and  it  is  at  this  time  that  the  tongue  is  apt  to  be  caught 
between  the  teeth  and  lacerated.  The  cyanosis,  marked  at  the  end  of  the 
tonic  stage,  gradually  lessens.  A  frothy  saliva,  which  may  be  blood-stained, 
escapes  from  the  mouth.  The  fseces  and  urine  may  be  discharged  involun- 
tarily. The  duration  of  this  stage  is  variable.  It  rarely  lasts  more  than 
one  or  two  minutes.  The  contractions  become  less  violent  and  the  patient 
gradually  sinks  into  the  condition  of 

(c)  Coma.  The  breathing  is  noisy  or  even  stertorous,  the  face  con- 
gested, but  no  longer  intensely  cyanotic.     The  limbs  are  relaxed  and  the 


EPILEPSY.  109Y 

unconsciousness  is  profound.  After  a  variable  time  the  patient  can  be 
aroused,  but  if  left  alone  he  sleeps  for  some  hours  and  then  awakes,  com- 
plaining only  of  slight  headache  or  mental  confusion. 

Status  Epilepticus. — This  is  the  climax  of  the  disease,  in  which  attacks 
occur  in  rapid  succession,  and  the  patient  does  not  recover  consciousness. 
The  pulse,  respiration,  and  temperature  rise  in  the  attack.  It  is  a  serious 
condition,  and  often  proves  fatal. 

After  the  attack  the  reflexes  are  sometimes  absent;  more  frequently  they 
are  increased  and  the  ankle  clonus  can  usually  be  obtained.  The  state  of 
the  urine  is  variable,  particularly  as  regards  the  solids.  The  quantity 
is  usually  increased  after  the  attack,  and  albumin  is  not  infrequently 
present. 

Post-epileptic  symptoms  are  of  great  importance.  The  patient  may  be 
in  a  trance-like  condition,  in  which  he  performs  actions  of  which  subse- 
quently he  has  no  recollection.  More  serious  are  the  attacks  of  mania,  in 
which  the  patient  is  often  dangerous  and  sometimes  homicidal.  It  is  held 
by  good  authorities  that  an  outbreak  of  mania  may  be  substituted  for  the 
fit.  And,  lastly,  the  mental  condition  of  an  epileptic  patient  is  often  seri- 
ously impaired,  and  profound  defects  are  common. 

Paralysis,  which  rarely  follows  the  epileptic  fit,  is  usually  hemiplegic 
and  transient. 

Slight  disturbances  of  speech  also  may  occur;  in  some  instances  forms 
of  sensory  aphasia. 

The  attacks  may  occur  at  night,  and  a  person  may  be  epileptic  for  years 
without  knowing  it.  As  Trousseau  truly  remarks,  when  a  person  tells  us 
that  in  the  night  he  has  incontinence  of  urine  and  awakes  in  the  morning 
with  headache  and  mental  confusion,  and  complains  of  difficulty  in  speech 
owing  to  the  fact  that  he  has  bitten  his  tongue;  if,  also,  there  are  on  the 
skin  of  the  face  and  neck  purpuric  spots,  the  probability  is  very  strong  in- 
deed that  he  is  subject  to  nocturnal  epilepsy. 
.  (2)  Petit  Mai. — This  is  epilepsy  wdthout  the  convulsions.  The  attack 
consists  of  transient  unconsciousness,  w^hich  may  come  on  at  any  time,  ac- 
companied or  unaccompanied  by  a  feeling  of  faintness  and  vertigo.  Sud- 
denly, for  example,  at  the  dinner  table,  the  subject  stops  talking  and  eating, 
the  eyes  become  fixed,  and  the  face  slightly  pale.  Anything  which  may 
have  been  in  the  hand  is  usually  dropped.  In  a  moment  or  two  conscious- 
ness is  regained  and  the  patient  resumes  conversation  as  if  nothing  had 
happened.  In  other  instances  there  is  slight  incoherency  or  the  patient 
performs  some  almost  automatic  action.  He  may  begin  to  undress  himself 
and  on  returning  to  consciousness  find  that  he  has  partially  disrobed.  He 
may  rub  his  beard  or  face,  or  may  spit  about  in  a  careless  way.  In  other 
attacks  the  patient  may  fall  without  convulsive  seizures.  A  definite  aura 
is  rare.  Though  transient,  unconsciousness  and  giddiness  are  the  most 
constant  manifestations  of  petit  mal;  there  are  many  other  equivalent  mani- 
festations, such  as  sudden  jerkings  in  the  limbs,  sudden  tremor,  or  a  sudden 
visual  sensation.  Gowers  mentions  no  less  than  seventeen  different  mani- 
festations of  petit  mal.    Occasionally  there  are  cases  in  which  the  patient 


1098  DISEASES  OP  THE  NERVOUS  SYSTEM. 

has  a  sensation  of  losing  his  breath  and  may  even  get  red  in  the  face.  I 
have  seen  such  attacks  also  in  children. 

After  the  attack  the  patient  may  be  dazed  for  a  few  seconds  and  per- 
form certain  automatic  actions^,  which  may  seem  to  be  volitional.  As  men- 
tioned, undressing  is  a  common  action,  but  all  sorts  of  odd  actions  may  be 
performed,  some  of  which  are  awkward  or  even  serious.  One  of  my  pa- 
tients after  an  attack  was  in  the  habit  of  tearing  anything  he  could  lay 
hands  on,  particularly  books.  Violent  actions  have  been  committed  and 
assaults  made,  frequently  giving  rise  to  questions  which  come  before  the 
courts.  This  condition  has  been  termed  masked  epilepsy,  or  epilepsia 
larvata. 

In  a  majority  of  the  cases  of  petit  mal  convulsions  finally  occur,  at  first 
slight,  but  ultimately  the  grand  mal  becomes  well  developed,  and  the  attacks 
may  then  alternate. 

(3)  Jacksonian  Epilepsy. — This  is  also  known  as  cortical,  symptomatic, 
or  partial  epilepsy.  It  is  distinguished  from  the  ordinary  epilepsy  by  the 
important  fact  that  consciousness  is  retained  or  is  lost  late.  The  attacks 
are  usually  the  result  of  irritative  lesions  in  the  motor  zone,  though  there 
are  probably  also  sensory  equivalents  of  this  motor  form.  In  a  typical 
attack  the  spasm  begins  in  a  limited  muscle  group  of  the  face,  arm,  or  leg. 
The  zygomatic  muscles,  for  instance,  or  the  thumb  may  twitch,  or  the  toes 
may  first  be  moved.  Prior  to  the  twitching  the  patient  may  feel  a  sensation 
of  numbness  or  tingling  in  the  part  affected.  The  spasm  extends  and  may 
involve  the  muscles  of  one  limb  only  or  of  the  face.  The  patient  is  con- 
scious throughout  and  watches,  often  with  interest,  the  march  of  the  spasm. 

The  onset  may  be  slow,  and  there  may  be  time,  as  in  a  case  which  I 
have  reported,  for  the  patient  to  place  a  pillow  on  the  floor,  so  as  to  be 
as  comfortable  as  possible  during  the  attack.  The  spasms  may  be  local- 
ized for  years,  but  there  is  a  great  risk  that  the  partial  epilepsy  may  become 
general.  The  condition  is  due,  as  a  rule,  to  an  irritative  lesion  in  the  motor 
zone.  Thus  of  107  cases  analyzed  by  Eoland,  there  were  48  of  tumor,  21 
instances  of  inflammatory  softening,  14  .instances  of  acute  and  chronic 
meningitis,  and  8  cases  of  trauma.  The  remaining  instances  were  due  to 
haemorrhage  or  abscess,  or  were  associated  with  sclerosis  cerebri.  Two 
other  conditions  may  be  mentioned,  which  may  cause  typical  Jacksonian 
epilepsy — namely,  ursemia  and  progressive  paralysis  of  the  insane.  A  con- 
siderable number  of  the  cases  of  Jacksonian  epilepsy  are  found  in  children 
following  hemiplegia,  the  so-called  post-hemiplegic  epilepsy.  The  con- 
vulsions usually  begin  on  the  affected  side,  either  in  the  arm  o/leg,  and  the 
fit  may  be  unilateral  and  without  loss  of  consciousness.  Ultimately  they 
become  more  severe  and  general. 

Diagnosis. — In  major  epilepsy  the  suddenness  of  the  attack,  the 
abrupt  loss  of  consciousness,  the  order  of  the  tonic  and  clonic  spasm,  and 
the  relaxation  of  the  sphincters  at  the  height  of  the  attack  arc  distinctive 
features.  The  convulsive  seizures  due  to  ura?mia  are  epileptic  in  character 
and  usually  readily  recognized  by  the  existence  of  greatly  increased  ten- 
sion and  the  condition  of  the  urine.  Practically  in  young  adults  hysteria 
causes  the  greatest  difliculty,  and  may  closely  simulate  true  epilepsy.    The 


EPILEPSY. 


1099 


following  table  from  Gowers'  work  draws  clearly  the  chief  difEerences  be- 
tween them: 


Apparent  cause. . . . 
Warning 

Onset 

Scream 

Convulsion 

Biting 

Micturition 

Defecation 

Talking 

Duration 

Restraint  necessary 
Termination 


Epileptic. 


none. 

any,  but  especially  unilateral 
or  epigastric  aurae. 

always  sudden. 

at  onset. 

rigidity  followed  by  "jerk- 
ing," rarely  rigidity  alone. 

tongue. 

frequent. 

occasional. 

never. 

a  few  minutes. 

to  prevent  accident, 
spontaneous. 


Hystkroid. 


emotion. 

palpitation,  malaise,  choking,  bi- 
lateral foot  aura. 

often  gradual. 

during  course. 

rigidity  or  "  struggling,"  throwing 
about  of  limbs  or  head,  arching 
of  back. 

lips,  hands,  or  other  people  and 
things. 

never. 

never, 

frequent. 

more  than  ten  minutes,  often  much 
longer. 

to  control  violence. 

spontaneous  or  induced  (water, 
etc.). 


Eeciirring  epileptic  seizures  in  a  person  over  thirty  who  has  not  had 
previous  attacks  is  always  suggestive  of  organic  disease.  According  to  H. 
C.  Wood,  whose  opinion  is  supported  by  that  of  Fournier^  in  9  cases  out  of 
10  the  condition  is  due  to  syphilis. 

Petit  mal  must  be  distinguished  from  attacks  of  syncope,  and  the  ver- 
tigo of  Meniere's  disease,  of  a  cardiac  lesion,  and  of  indigestion.  In  these' 
cases  there  is  no  actual  loss  of  consciousness,  which  forms  a  characteristic 
though  not  an  invariable  feature  of  petit  mal. 

Jacksonian  epilepsy  has  features  so  distinctive  and  peculiar  that  it  is 
at  once  recognized.  It  is  by  no  means  easy,  however,  always  to  determine 
upon  what  the  spasm  depend^.  Irritation  in  the  motor  centres  may  be  due 
to  a  great  variety  of  causes,  ^among  which  tumors  and  localized  meningo- 
encephalitis are  the  most  frequent;  but  it  must  not  be  forgotten  that  in 
uraemia  localized  epilepsy  may  occur.  The  most  typical  Jacksonian  spasms 
also  arc  not  infrequent  in  general  paresis  of  the  insane. 

Prognosis. — This  may  be  given  to-day  in  the  words  of  Hippocrates: 
"  The  prognosis  in  epilepsy  is  unfavorable  when  the  disease  is  congenital, 
and  when  it  endures  to  manhood,  and  when  it  occurs  in  a  grown  person 
without  any  previous  cause.  .  .  .  The  cure  may  be  attempted  in  young 
persons,  but  not  in  old." 

Death  during  the  fit  rarely  occurs,  but  it  may  happen  if  the  patient 
falls  into  the  water  or  if  the  fit  comes  on  while  he  is  eating.  Occasionally 
the  fits  seem  to  stop  spontaneously.  This  is  particularly  the  case  in  the 
epilepsy  in  children  which  has  followed  the  convulsions  of  teething  or  of 
the  fevers.  Frc(iuency  of  the  attacks  and  marked  mental  disturl)ance  are 
unfavorable  indications.  Hereditary  prodis])osition  is  apparently  of  no 
moment  in  the  prognosis.  The  outlook  is  bettor  in  males  than  in  females. 
The  post-hemiplegic  epilepsy  is  rarely  arrested.     Of  Ihc  cases  coming  on 


-^^IQQ  DISEASES  OF  THE  NERVOUS  SYSTEM. 

in  adults,  those  due  to  syphilis  and  to  local  affections  of  the  brain  allow  a 
more  favorable  prognosis. 

Treatment. — General. — In  the  case  of  children  the  parents  should 
be  made  to  understand  from  the  outset  that  epilepsy  in  the  great  majority  of 
cases  is  an  incurable  affection,  so  that  the  disease  may  interfere  as  little  as 
possible  with  the  education  of  the  child.  The  subjects  need  firm  but  kind 
treatment.  Indulgence  and  yielding  to  caprices  and  whims  are  -followed 
by  weakening  of  the  moral  control,  which  is  so  necessary  in  these  cases. 
The  disease  does  not  incapacitate  a  person  for  all  occupation.  It  is  much 
better  for  epileptics  to  have  some  definite  pursuit.  There  are  many  in- 
stances in  which  they  have  been  persons  of  extraordinary  mental  and  bodily 
vigor,  as,  for  example,  Julius  Csesar  and  Napoleon.  One  of  the  most  dis- 
tressing features  in  epilepsy  is  the  gradual  mental  impairment  which  fol- 
lows in  a  certain  number  of  cases.  If  such  patients  become  extremely  irri- 
table or  show  signs  of  violence  they  should  be  placed  under  supervision  in 
an  asylum.  Marriage  should  be  forbidden  to  epileptics.  During  the  attack 
a  cork  or  bit  of  rubber  should  be  placed  between  the  teeth  and  the  clothes 
should  be  loosened.  The  patient  should  be  in  the  recumbent  posture.  As 
the  attack  usually  passes  off  with  rapidity,  no  special  treatment  is  necessary, 
but  in  cases  in  which  the  convulsion  is  prolonged  a  few  whiffs  of  chloro- 
form or  nitrite  of  amyl  or  a  hypodermic  of  a  quarter  of  a  grain  of  morphia 
may  be  given. 

Dietetic. — The  old  authors  laid  great  stress  upon  regimen  in  epilepsy. 
The  important  point  is  to  give  the  patient  a  light  diet  at  fixed  hours,  and 
on  no  account  to  permit  overloading  of  the  stomach.  Meat  should  not  be 
given  more  than  once  a  day.  There  are  cases  in  which  animal  food  seems 
injurious.  A  strict  vegetable  diet  has  been  warmly  recommended.  The 
patient  should  not  go  to  sleep  until  the  completion  of  gastric  digestion. 

Medicinal. — The  bromides  are  the  only  remedies  which  have  a  special 
influence  upon  the  disease.  Either  the  sodium  or  potassium  salt  may  be 
given.  Sodium  bromide  is  probabty  less  irritating  and  is  better  borne  for 
a  long  period.  It  may  be  given  in  milk,  in  which  it  is  scarcely  tasted.  In 
all  instances  the  dilution  should  be  considerable.  In  adults  it  is  well  taken 
in  soda  water  or  in  some  mineral  water.  The  dose  for  an  adult  should  be 
from  half  a  drachm  to  a  drachm  and  a  half  daily.  As  Seguin  recommends, 
it  is  often  best  to  give  but  a  single  dose  dail}",  about  four  to  six  hours  before 
the  attacks  are  most  likely  to  occur.  For  instance,  in  the  case  of  nocturnal 
epilepsy  a  drachm  should  be  given  an  hour  or  two  after  the  evening  meal. 
If  the  attack  occurs  early  in  the  morning,  the  patient  should  take  a  full 
dose  when  he  awakes.  Wlien  given  three  times  a  day  it  is  less  disturbing 
after  meals.  Each  case  should  be  carefully  studied  to  determine  how  much 
bromide  should  be  used.  The  individual  susceptibility  varies  and  some 
patients  require  more  than  others.  Fortunately,  children  take  the  drug 
well  and  stand  proportionately  larger  doses  than  adults.  Saturation  is 
indicated  by  certain  unpleasant  effects,  particularly  drowsiness,  mental 
torpor,  and  gastric  and  cardiac  distress.  Loss  of  palate  reflex  is  one  of  the 
earliest  indications  that  the  system  is  under  the  influence  of  the  bromides, 
and  is  a  condition  which  should  be  attained.    A  very  unpleasant  feature 


EPILEPSY.  110:1 

is  the  development  of  acne,  which,  liowever,  is  no  indication  of  bromism. 
Segnin  states  that  the  tendency  to  this  is  much  diminished  by  giving  the 
drug  largely  diluted  in  alkaline  waters  and  administering  from  time  to  time 
full  doses  of  arsenic.  To  be  effectual  the  treatment  should  be  continued 
for  a  prolonged  period  and  the  cases  should  be  incessantly  watched  in  order 
to  prevent  bromism.  The  medicine  should  be  continued  for  at  least  two 
years  after  the  cessation  of  the  fits;  indeed,  Seguin  recommends  that  the 
reduction  of  the  bromides  should  not  be  begun  until  the  patient  has  been 
three  years  without  any  manifestations.  Written  directions  should  be  given 
to  the  mother  or  to  the  friends  of  the  patient,  and  he  should  not  himself 
be  held  responsible  for  the  administration  of  the  medicine.  A  book  should 
be  provided  in  which  the  daily  number  of  attacks  and  the  amount  of  medi- 
cine taken  should  be  noted.  The  addition  of  belladonna  to  the  bromide  is 
warmly  recommended  by  Black,  of  Glasgow.  In  very  obstinate  cases  Flech- 
sig  uses  opium,  5  or  6  grains,  in  three  doses  daily;  then  at  the  end  of  six 
weeks  opium  is  stopped  and  the  bromides  in  large  amounts,  75  to  100  grains 
daily,  are  used  for  two  months. 

Among  other  remedies  which  have  been  recommended  as  controlling 
epilepsy  are  chloral,  cannabis  indica,  zinc,  nitroglycerin,  and  borax.  Nitro- 
glycerin is  sometimes  advantageous  in  petit  mat,  but  is  not  of  much  service 
in  the  major  form.  To  be  beneficial  it  must  be  given  in  full  doses,  from  2 
to  5  minims  of  the  l-per-cent  solution,  and  increased  until  the  physiological 
effects  are  produced.  Counter-irritation  is  rarely  advisable.  When  the 
aura  is  very  definite  and  constant  in  its  onset,  as  from  the  hand  or  from  the 
toe,  a  blister  about  the  part  or  a  ligature  tightly  applied  may  stop  the  on- 
coming fit.  In  children,  care  should  be  taken  that  there  is  no  source  of 
peripheral  irritation.  In  boys,  adherent  prepuce  may  occasionally  be  the 
cause.  The  irritation  of  teething,  the  presence  of  worms,  and  foreign  bodies 
in  the  ears  or  nose  have  been  associated  with  epileptic  seizures. 

The  subjects  of  a  chronic  and,  in  most  cases,  a  hopelessly  incurable 
disease,  epileptic  patients  form  no  small  portion  of  the  unfortunate  victims 
of  charlatans  and  quacks,  who  prescribe  to-day,  as  in  the  time  of  the  father 
of  medicine,  "  purifications  and  spells  and  other  illiberal  practices  of  like 
kind." 

Surgical. — In  Jacksonian  epilepsy  the  propriety  of  surgical  interfer- 
ence is  universally  granted.  It  is  questionable,  however,  whether  in  the 
epilepsy  following  hemiplegia,  considering  the  anatomical  condition,  it  is 
likely  to  be  of  any  benefit.  In  idiopathic  epilepsy,  when  the  fit  starts  in 
a  certain  region — the  thumb,  for  instance — and  the  signal  symptom  is  in- 
variable, the  centre  controlling  this  part  may  be  removed.  This  procedure 
has  been  practised  by  Macewen,  Horsley,  Keen,  and  others,  but  time  alone 
can  determine  its  value.  The  traumatic  epilepsy,  in  which  the  fit  follows 
fracture,  is  much  more  hopeful. 

The  operation,  per  se,  appears  in  some  cases  to  have  a  curative  effect. 
Thus  of  50  cases  of  trephining  for  epilepsy  in  which  nothing  abnormal  was 
found  to  account  for  the  s3'mptoms,  25  were  reported  as  cured  and  18  as  im- 
proved. The  operations  have  not  been  always  on  the  skull,  and  White 
has  collected  an  interesting  series  in  which  various  surgical  procedures  have 


/ 

IIQ2  DISEASES  OP  THE  NERVOUS  SYSTEM. 

been  resorted  to,  often  with  curative  effect,  such  as  ligation  of  the  carotid 
artery,  castration,  tracheotomy,  excision  of  the  superior  cervical  ganglia, 
incision  of  the  scalp,  circumcision,  etc. 


VII.    MIGRAINE   {Eemicrania ;  Sick  Headache). 

Definition. — A  paroxysmal  affection  characterized  by  severe  headache, 
usually  unilateral,  and  often  associated  with  disorders  of  vision. 

Etiology. — The  disease  is  frequently  hereditary  and  has  occurred 
through  several  generations.  Women  and  the  members  of  neurotic  fami- 
lies are  most  frequently  attacked.  It  is  an  affection  from  which  many  dis- 
tinguished men  have  suffered  and  have  left  on  record  an  account  of  the  dis- 
ease, notably  the  astronomer  Airy.  Edward  Liveing's  work  is  the  standard 
authority  upon  which  most  of  the  subsequent  articles  have  been  based.  A 
gouty  or  rheumatic  taint  is  present  in  many  instances.  Sinkler  has  called 
special  attention  to  the  frequency  of  reflex  causes.  Migraine  has  long  been 
known  to  be  associated  with  uterine  and  menstrual  disorders.  Nutritive 
disturbances  are  common,  and  attempts  have  been  made  by  Haig  and  others 
to  associate  the  attacks  with  disturbed  uric-acid  output.  Certainly  the 
amount  of  uric  acid  excreted  just  prior  to  and  during  an  attack  is  reduced. 
Others  regard  the  disease  as  a  toxeemia  from  disordered  intestinal  digestion. 
Many  of  the  headaches  from  eye-strain  are  of  the  hemicranial  type.  Brun- 
ton  refers  to  caries  of  the  teeth  as  a  cause  of  these  headaches,  even  when 
not  associated  with  toothache.  Cases  have  been  described  in  connection 
with  adenoid  growths  in  the  pharynx,  and  particularly  with  abnormal  con- 
ditions of  the  nose.  Many  of  the  attacks  of  severe  headaches  in  children  are 
of  this  nature,  and  the  eyes  and  nostrils  should  be  examined  with  great 
care.  Sinkler  refers  to  a  case  in  a  child  of  two  years,  and  Gowers  states  that 
a  third  of  all  the  cases  begin  between  the  fifth  and  tenth  years  of  age.  The 
direct  influences  inducing  the  attack  are  very  varied.  Powerful  emotions 
of  all  sorts  are  the  most  potent.  Mental  or  bodily  fatigue,  digestive  dis- 
turbances, or  the  eating  of  some  particular  article  of  food  may  be  followed 
by  the  headache.  The  paroxysmal  character  is  one  of  the  most  striking 
features,  and  the  attacks  may  recur  on  the  same  day  every  week,  every  fort- 
night, or  every  month.  Headaches  of  the  migraine  type  may  recur  for 
years  in  connection  with  chronic  Bright's  disease. 

Symptoms. — Premonitory  signs  are  present  in  many  cases,  and  the 
patient  can  tell  when  an  attack  is  coming  on.  Eemarkable  prodromata 
have  been  described,  particularly  in  connection  with  vision.  Apparitions 
may  appear — visions  of  animals,  such  as  mice,  dogs,  etc.  Transient  hemi- 
anopia  or  scotoma  may  be  present.  In  other  instances  there  is  spasmodic 
action  of  the  pupil  on  the  affected  side,  which  dilates  and  contracts  alter- 
nately, the  condition  known  as  liippus.  Frequently  the  disturbance  of 
vision  is  only  a  blurring,  or  there  are  balls  of  light,  or  zigzag  lines,  or  the 
so-called  fortification  spectra  (teichopsia),  which  may  be  illuminated  with 
gorgeous  colors.  Disturbances  of  the  other  senses  are  rare.  Numbness  of 
the  tongue  and  face  and  occasionally  of  the  hand  may  occur  with  tingling. 


MIGRAINE.  1103 

More  rarely  there  are  cramps  or  spasms  in  the  muscles  of  the  affected  side. 
Transient  aphasia  has  also  been  noted.  Some  patients  show  marked  psy- 
chical disturbance,  either  excitement  or,  more  commonly,  mental  confusion 
or  great  depression.  Dizziness  occurs  in  some  cases.  The  headache  follows 
a  short  time  after  the  prodromal  symptoms  have  appeared.  It  is  cumulative 
and  expansile  in  character,  beginning  as  a  localized  small  spot,  which  is 
generally  constant  either  on  the  temple  or  forehead  or  in  the  eyeball.  It 
is  usually  described  as  of  a  penetrating,  sharp,  boring  character.  At  first 
unilateral,  it  gradually  spreads  and  involves  the  side  of  the  head,  sometimes 
the  neck,  and  the  pains  may  pass  into  the  arm.  In  other  cases  both  sides 
are  affected.  Nausea  and  vomiting  are  common  symptoms.  If  the  attack 
comes  on  when  the  stomach  is  full,  vomiting  usually  gives  relief.  Vaso- 
motor symptoms  may  be  present.  The  face,  for  instance,  may  be  pale,  and 
there  may  be  a  marked  difference  between  the  two  sides.  Subsequently  the 
face  and  ear  on  the  affected  side  may  become  a  burning  red  from  the  vaso- 
dilator influences.  The  pulse  may  be  slow.  The  temporal  artery  on  the 
affected  side  may  be  firm  and  hard,  and  in  a  condition  of  arterio-sclerosis — 
a  fact  which  has  been  confirmed  anatomically  by  Thoma.  Few  affections 
are  more  prostrating  than  migraine,  and  during  the  paroxysm  the  patient 
may  scarcely  be  able  to  raise  the  head  from  the  pillow.  The  slightest  noise 
or  light  aggravates  the  condition. 

The  duration  of  the  entire  attack  is  variable.  The  severer  forms  usually 
incapacitate  the  person  for  at  least  three  days.  In  other  instances  the  en- 
tire attack  is  over  in  a  day.  The  disease  recurs  for  years,  and  in  cases  with 
a  marked  hereditary  tendency  may  persist  throughout  life.  In  women  the 
attacks  often  cease  after  the  climateric,  and  in  men  after  the  age  of  fifty. 
Two  of  the  greatest  sufferers  I  have  known,  Avho  had  recurring  attacks 
every  few  weeks  from  early  boyhood,  now  have  complete  freedom. 

The  nature  of  the  disease  is  unknown.  Liveing's  view,  that  it  is  a 
nerve  storm  or  form  of  periodic  discharge  from  certain  sensory  centres  and 
is  related  to  epilepsy,  has  found  much  favor.  According  to  this  view,  it 
is  the  sensory  equivalent  of  a  true  epileptic  attack.  Mollendorf,  Latham, 
and  others  regard  it  as  a  vaso-motor  neurosis,  and  hold  that  the  early  symp- 
toms are  due  to  vaso-constrictor  and  the  later  symptoms  to  vaso-dilator 
influences.  The  fact  of  the  development  of  arterio-sclerosis  in  the  arteries 
of  the  aft'ectod  side  is  a  point  of  interest  bearing  upon  this  view. 

Treatment. — The  patient  is  fully  aware  of  the  causes  which  precipi- 
tate an  attack.  Avoidance  of  excitement,  regularity  in  the  meals,  and 
moderation  in  diet  are  important  rules.  I  have  known  cases  greatly  bene- 
fitted by  a  strict  vegotal)le  diet.  The  treatment  should  be  directed  toward 
the  removal  of  the  conditions  upon  which  the  attacks  depend.  In  children 
much  may  be  done  by  watchfulness  and  care  on  the  part  of  the  mother  in 
regulating  the  bowels  and  watching  the  di,et  of  the  child.  Errors  of  re- 
fraction should  be  adjusted.  On  no  account  should  such  children  be  allowed 
to  compete  in  school  for  prizes.  A  prolonged  course  of  bromides  sometimes 
proves  successful.  If  anasmia  is  present,  iron  and  arsenic  should  be  given. 
'V\nien  the  arterial  tension  is  increased  a  course  of  nitroglycerin  may  be 
tried.    Not  too  much,  however,  should  be  expected  of  the  preventive  treat- 


1104  DISEASES  OP  THE  NERVOUS  SYSTEM. 

ment  of  migraine.  It  must  be  confessed  that  in  a  very  large  proportion  of 
the  cases  the  headaches  recur  in  spite  of  all  we  can  do.  Herter  advises,  so 
soon  as  the  patient  has  any  intimation  of  the  attack,  to  wash  out  the  stom- 
ach with  water  at  105°,  and  to  give  a  brisk  saline  cathartic.  During  the 
paroxysm  the  patient  should  be  kept  in  bed  and  absolutely  quiet.  If  the 
patient  feels  faint  and  nauseated,  a  small  cup  of  hot,  strong  coffee  or  20 
drops  of  chloroform  give  relief.  Cannabis  indica  is  probably  the  most  satis- 
factory remedy.  Seguin  recommends  a  prolonged  course  of  the  drug. 
Antipyrin,  antifebrin,  and  phenacetin  have  been  much  used  of  late.  When 
given  early,  at  the  very  outset  of  the  paroxysm,  they  are  sometimes  effect- 
ive. Smaller,  repeated  doses  are  more  satisfactory.  Of  other  remedies, 
caffeine,  in  5-grain  doses  of  the  citrate,  nux  vomica,  and  ergot  have  been 
recommended.  Electricity  does  not  appear  to  be  of  much  service.  And 
lastly,  in  obstinate  cases,  an  ordinary  tape  seton  may  be  inserted  through 
the  skin  at  the  back  of  the  neck,  to  be  worn  for  three  months,  a  plan  of 
treatment  which  has  the  strongest  possible  recommendation  from  Mr. 
Whitehead,  of  Manchester, 

VIII.    NEURALGIA. 

Definition. — A  painful  affection  of  the  nerves,  due  either  to  functional 
disturbance  of  their  central  or  peripheral  extremities  or  to  neuritis  in  their 
course. 

Etiology." — Members  of  neuropathic  families  are  most  subject  to  the 
disease.  It  affects  women  more  than  men.  Children  are  rarely  attacked. 
Of  all  causes,  debility  is  the  most  frequent.  It  is  often  the  first  indication 
of  an  enfeebled  nervous  system.  The  various  forms  of  anaemia  are  fre- 
quently associated  with  neuralgia.  It  may  be  a  prominent  feature  at  the 
onset  of  certain  acute  diseases,  particularly  typhoid  fever.  Malaria  is  be- 
lieved to  be  a  potent  cause,  but  it  has  not  been  shown  that  neuralgia  is 
more  frequent  in  malarial  districts,  and  the  error  has  probably  arisen  from 
regarding  periodicity  as  a  special  manifestation  of  paludism.  It  occasion- 
ally occurs  in  malarial  cachexia.  Exposure  to  cold  is  a  cause  in  very  sus- 
ceptible persons.  Eeflex  irritation,  particularly  from  carious  teeth,  may 
induce  neuralgia  of  the  fifth  nerve.  The  disease  occurs  sometimes  in  rheu- 
matism, gout,  lead  poisoning,  and  diabetes.  Persistent  neuralgia  may  be 
a  feature  of  latent  Bright's  disease. 

Symptoms. — Before  the  onset  of  the  pain  there  may  be  uneasy  sen- 
sations, sometimes  tingling  in  the  part  which  will  be  affected.  The  pain 
is  localized  to  a  certain  group  or  division  of  nerves,  usually  affecting  one 
side.  The  pain  is  not  constant,  but  paroxysmal,  and  is  described  as  stab- 
bing, burning,  or  darting  in  character.  The  skin  may  be  exquisitely  ten- 
der in  the  affected  region,  particularly  over  certain  points  along  the  course 
of  the  nerve,  the  so-called  tender  points.  Movements,  as  a  rule,  are  pain- 
ful. Trophic  and  vaso-motor  changes  may  accompany  the  paroxysm;  the 
skin  may  be  cool,  and  subsequently  hot  and  burning;  occasionally  local 
oedema  or  erythema  occurs.  More  remarkable  still  are  tlio  changes  in  the 
hair,  which  may  become  blanched  (canities),  or  even  fall  out.    Fortunately, 


NEURALGIA.  1105 

such  alterations  are  rare.  Twitchings  of  the  muscles,  or  even  spasms, 
may  be  present  during  the  paroxysm.  After  lasting  a  variable  time — from 
a  few  minutes  to  many  hours — the  attack  subsides.  Recurrence  may  be 
at  definite  intervals — every  day  at  the  same  hour,  or  at  intervals  of  two, 
three,  or  even  seven  days.  Occasionally  the  paroxysms  develop  only  at  the 
catamenia.  This  periodicity  is  quite  as  marked  in  non-malarial  as  in  ma- 
larial regions. 

Clinical  Varieties,  depending  on  the  Nerve  Groups  affected. — (1)  Tri- 
facial XeuraUjia;  Tic  Douloureux;  Frosopalyia. — All  the  branches  are 
rarely  involved  together.  The  ophthalmic  is  most  often  affected,  but  in 
severe  attacks  the  pains,  though  more  intense  in  one  division,  radiate  over 
the  other  branches.  At  the  outset  there  may  be  hyperaesthesia  of  the  skin 
and  sensitiveness  of  the  mucous  membrane.  Pressure  is  painful  at  the  points 
of  emergence  of  the  nerve  trunk,  and  where  the  nerves  enter  the  muscles. 
Sometimes  in  addition,  as  Trousseau  pointed  out,  there  are  pains  at  the 
occipital  protuberance  and  in  the  upper  cervical  spines.  When  the  oph- 
thalmic division  is  affected  the  eye  may  weep  and  the  conjunctivas  are  in- 
jected and  painful.  In  the  upper  maxillary  division  there  is  a  tender  point 
where  the  nerve  leaves  the  infraorbital  canal,  and  the  pain  is  specially 
marked  along  the  upper  teeth.  In  the  lower  branches,  which  are  more 
frequently  involved,  there  are  painful  points  along  the  auriculo-temporal 
nerve  and  the  pain  radiates  in  the  region  of  the  ear  along  the  lower  jaw 
and  teeth.  The  movements  of  mastication  and  speaking  may  be  painful. 
Salivation  is  not  uncommon.  Herpes  may  occur  about  the  eye  or  the  lips. 
In  protracted  cases  there  may  be  atrophy  or  induration  of  the  skin.  Some 
of  the  forms  of  facial  neuralgia  are  of  frightful  intensity  and  the  recurring 
attacks  render  the  patient's  life  almost  insupportable. 

(2)  Cervico-occipital  neuralgia  involves  the  posterior  branches  of  the 
first  four  cervical  nerves,  particularly  the  inferior  occipital,  at  the  emer- 
gence of  which  there  is  a  painful  point  about  half-way  between  the  mastoid 
process  and  the  first  cervical  vertebra.  It  may  be  caused  by  cold,  and  these 
nerves  are  often  affected  in  cervical  caries. 

(3)  Cervico-hrachial  neuralgia  involves  the  sensory  nerves  of  the  brachial 
plexus,  particularly  in  the  cubital  division.  When  the  circumflex  nerve  is 
involved  the  pain  is  in  the  deltoid.  The  pain  is  most  commonly  about  the 
shoulder  and  down  the  course  of  the  ulnar  nerve.  There  is  usually  a 
marked  tender  point  upon  this  nerve  at  the  elbow.  This  form  rarely  fol- 
lows cold,  but  more  frequently  results  from  rheumatic  affections  of  the 
joints,  and  trauma. 

(4)  Neuralgia  of  the  phrenic  nerve  is  rare.  It  is  sometimes  found  in 
pleurisy  and  in  pericarditis.  The  pain  is  chiefly  at  the  lower  part  of  the 
thorax  on  a  line  with  the  inserjtion  of  the  diaphragm,  and  here  may  ])e 
painful  points  on  deep  pressure.  Full  inspiration  is  painful,  and  there  is 
great  sensitiveness  on  coughing  or  in  the  performance  of  any  movement  by 
which  the  diaphragm  is  suddenly  depressed. 

(.5)  Tiiferrnstal  Neuralgia. — Next  to  the  tic  douloureux  this  is  the  most 
important  form.    It  is  most  frequent  in  women  and  very  common  in  hys- 
teria.    The  jiiiiu  ill  caries  and  aneurism  is  folt  in  tlio  intercostal  nerves. 
GO 


1106  DISEASES   OF   THE  NERVOUS  SYSTEM. 

Heepes  Zostee  (Acute  Hcemorrhagic  Infiammation  of  the  Posterior 

Ganglia). 

The  researches  of  Head  and  Campbell  make  it  very  probable  that  herpes 
zoster  is  an  acute  specific  disease  of  the  nervous  system,  with  a  localization 
in  the  ganglia  of  the  posterior  roots.  There  is  often  a  prodromal  period, 
in  which  the  patient  feels  ill,  has  pain,  and  the  rash  comes  out  on  the 
third  or  fourth  day.  It  often  has  a  seasonal  prevalence.  The  changes  in 
the  posterior  root  ganglion  resemble  very  closely  those  of  the  gray  matter 
of  the  ventral  horn  in  anterior  poliomyelitis.  There  are  hEemorrhages  and 
inflammatory  foci,  with  destruction  of  certain  of  the  ganglion-cells.  A 
single  ganglion  is  usually  affected,  more  commonly  those  which  receive 
afferent  impulses  from  the  viscera.  A  degeneration  occurs  in  those  fibres 
entering  the  spinal  cord  from  the  nerve  which  run  up  into  the  posterior 
column.  The  pain  of  zona  may  persist  indefinitely,  and  it  has  been  kno-«Ti 
to  be  so  intractable  that  in  despair  the  person  has  committed  suicide. 

(6)  Lumbar  Neuralgia. — The  affected  nerves  are  the  posterior  fibres  of 
the  Jumbar  plexus,  particularly  the  ilio-scrotal  branch.  The  pain  is  in 
the  region  of  the  iliac  crest,  along  the  inguinal  canal,  in  the  spermatic 
cord,  and  in  the  scrotum  or  labium  majus.  The  aft'ection  known  as  irritable 
testis,  probably  a  neuralgia  of  this  nerve,  may  be  very  severe  and  accom- 
panied by  syncopal  sensations. 

(7)  Coccydynia. — This  is  regarded  as  a  neuralgia  of  the  coccygeal  plexus. 
It  is  most  common  in  women,  and  is  aggravated  by  the  sitting  posture.  It 
is  very  intractable,  and  may  necessitate  the  removal  of  the  coccyx,  an  opera- 
tion, however,  which  is  not  always  successful.  ISTeuralgias  of  the  nerves 
of  the  leg  have  already  been  considered. 

(8)  Neuralgias  of  the  Nerves  of  the  Feet. 

Painful  Heel. — Both  in  women  and  men  there  may  be  about  the  heel 
severe  pains  which  interfere  seriously  with  walking — the  pododynia  of  S. 
D.  Gross.  There  may  be  little  or  no  swelling,  no  discoloration,  and  no 
affection  of  the  joints. 

Plantar  Neuralgia. — This  is  often  associated  with  a  definite  neuritis, 
such  as  follows  typhoid  fever,  and  has  been  seen  in  an  aggravated  form 
in  caisson  disease  (Hughes).  The  pain  may  be  limited  to  the  tips  of  the 
toes  or  to  the  ball  of  the  great  toe.  ISTumbness,  tingling,  and  hyperesthesia 
or  sweating  may  occur  with  it.  Following  the  cold-bath  treatment  in  ty- 
phoid fever  it  is  not  uncommon  for  patients  to  complain  of  great  sensi- 
tiveness in  the  toes. 

Metatarsalgia. — Morton's  (Thomas  G.)  "  painful  affection  of  the  fourth 
metatarso-phalangeal  articulation  "  is  a  peculiar  and  very  trying  disorder, 
seen  most  frequently  in  women,  and  usually  in  one  foot.  I\Iorton  regards 
it  as  due  to  a  pinching  of  the  metatarsal  n'erve.  The  disease  rarely  gets  well 
without  operation.  The  red,  painful  neuralgia — erythromelalgia — ^is  de- 
scribed under  the  vaso-motor  and  trophic  disturbances. 

(9)  Visceral  Neuralgias. — The  more  important  of  these  have  already 
been  referred  to  in  connection  with  the  cardiac  and  the  gastric  neuroses. 
They  are  most  frequent  in  women,  and  are  constant  accompaniments  of 
neurasthenia  and  hysteria.  The  pains  are  most  common  in  the  pelvic 
region,  particularly  about  tho  ovaries.    Nephralgia  is  of  great  interest,  for. 


PROFESSIONAL  SPASMS;  OCCUPATION  N^EUROSES.  HOT 

as  has  already  been  mentioned,  the  symptoms  may  closely  simulate  those 
of  stone. 

Treatment. — Causes  of  reflex  irritation  should  be  carefully  removed. 
The  neuralgia,  as  a  rule,  recurs  unless  the  general  health  improves;  so  that 
tonic  and  hygienic  measures  of  all  sorts  should  be  employed.  Often  a 
change  of  air  or  surroundings  will  relieve  a  severe  neuralgia.  I  have 
known  obstinate  cases  to  be  cured  by  a  prolonged  residence  in  the  moun- 
tains, with  an  out-of-door  life  and  plenty  of  exercise.  A  strict  vegetable 
diet  will  sometimes  relieve  the  neuralgia  or  headache  of  a  gouty  person.  Of 
general  remedies,  iron  is  often  a  specific  in  the  cases  associated  with  chloro- 
sis and  anaemia.  Arsenic,  too,  is  very  beneficial  in  these  forms,  and  should 
be  given  in  ascending  doses.  The  value  of  quinine  has  been  much  over- 
rated. It  probably  has  no  more  influence  than  any  other  bitter  tonic,  ex- 
cept in  the  rare  instances  in  which  the  neuralgia  is  definitely  associated  with 
malarial  poisoning.  Strychnine,  cod-liver  oil,  and  phosphorus  are  also  ad- 
vantageous. Of  remedies  for  the  pain,  the  new  analgesics  should  first  be 
tried — antipyrin,  antifebrin,  and  phenacetin — for  they  are  sometimes  of 
service.  Morphia  should  be  given  with  great  caution,  and  only  after  other 
remedies  have  been  tried  in  vain.  On  no  consideration  should  the  patient 
be  allowed  to  use  the  hypodermic  syringe.  Gelsemium  is  highly  recom- 
mended. Of  nervine  stimulants,  valerian  and  ether,  Avhich  often  act  well 
together,  may  be  given.  Alcohol  is  a  valuable  though  dangerous  remedy, 
and  should  not  be  ordered  for  women.  In  the  trifacial  neuralgia  nitro- 
glycerin in  large  doses  may  be  tried.  Aeonitia  in  doses  of  from  one  two- 
hundredth  to  one  one-hundred-and-fiftieth  of  a  grain  may  be  tried.  In 
gouty  and  rheumatic  subjects  cannabis  indica  and  cimieifuga  are  recom- 
mended with  the  lithium  salts. 

Of  local  applications,  the  thermo-cautery  is  invaluable,  particularly  in 
zona  and  the  more  chronic  forms  of  neuralgia.  Acupuncture  may  be  used, 
or  aquapuncture,  the  injection  of  distilled  water  beneath  the  skin.  Chloro- 
form liniment,  camphor  and  chloral,  menthol,  the  oleates  of  morphia,  atro- 
pia,  and  belladonna  used  with  lanolin  may  be  tried.  Freezing  over  the 
tender  point  with  ether  spray  is  sometimes  successful.  The  continuous 
current  may  be  used.  The  sponges  should  be  warm,  and  the  positive  pole 
should  be  placed  near  the  seat  of  the  pain.  The  strength  of  the  current 
should  be  such  as  to  cause  a  slight  tingling  or  burning,  but  not  pain. 

The  surgical  treatment  of  intractable  neuralgia  embraces  nerve  stretch- 
ing and  excision.  The  latter  is  the  more  satisfactory,  but  too  often  the 
pain  returns. 


IX.    PROFESSIONAL  SPASMS;    OCCUPATION  NEUROSES. 

The  continuous  and  excessive  use  of  the  muscles  in  performing  a  cer- 
tain movement  may  be  followed  by  an  irregular,  involuntary  spasm  or 
cramp,  which  may  completely  check  the  performance  of  the  action.  The 
condition  is  found  most  frequently  in  writers,  hence  the  term  writer's  cramp 
or  scrivener's  palsy;  but  it  is  also  common  in  piano  and  violin  players  and 


1108  DISEASES  OP  THE  NERVOUS  SYSTEM. 

in  telegraph  operators.  The  spasms  occur  in  many  other  persons,  such  as 
milkmaids,  weavers,  and  cigarette-rollers. 

The  most  common  form  is  writer's  cramp,  which  is  much  more  fre- 
quent in  men  than  in  women.  Of  75  cases  of  impaired  writing  power  re- 
ported by  Poore,  all  of  the  instances  of  undoubted  writer's  cramp  were  in 
men.  Morris  J.  Lewis  states  that  in  this  country,  in  the  telegrapher's 
cramp,  women,  who  are  employed  a  great  deal  in  telegraphy,  are  much 
less  frequently  affected  (only  4  out  of  43  cases).  Persons  of  a  nervous 
temperament  are  more  liable  to  the  disease.  Occasionally  it  follows  slight 
injury. 

Gowers  states  that  in  a  majority  of  the  cases  a  faulty  method  of  writing 
has  been  employed,  using  either  the  little  finger  or  the  wrist  as  the  fixed 
point.  Persons  who  write  from  the  middle  of  the  forearm  or  from  the  elbow 
are  rarely  affected. 

ISTo  anatomical  changes  have  been  found.  The  most  reasonable  ex- 
planation of  the  disease  is  that  it  results  from  a  deranged  action  of  the 
nerve  centres  presiding  over  the  muscular  movements  involved  in  the  act 
of  writing,  a  condition  which  has  been  termed  irritable  weakness.  "  The 
education  of  centres  which  may  be  widely  separated  from  each  other  for  the 
performance  of  any  delicate  movement  is  mainly  accomplished  by  lessen- 
ing the  lines  of  resistance  between  them,  so  that  the  movement,  which  was 
at  first  produced  by  a  considerable  mental  effort,  is  at  last  executed  almost 
unconsciously.  If,  therefore,  through  prolonged  excitation,  this  lessened 
resistance  be  carried  too  far,  there  is  an  increase  and  irregular  discharge 
of  nerve  energy,  which  gives  rise  to  spasm  and  disordered  movement.  Ac- 
cording to  this  view,  the  muscular  weakness  is  explained  by  an  impairment  of 
nutrition  accompanying  that  of  function,  and  the  diminished  faradie  excita- 
bility by  the  nutritional  disturbance  descending  the  motor  nerves  "  (Gray). 

Symptoms. — These  may  be  described  under  five  heads  (Lewis). 

(a)  Cramp  or  Spasm. — This  is  often  an  early  symptom  and  most  com- 
monly affects  the  forefinger  and  thumb;  or  there  may  be  a  combined  move- 
ment of  flexion  and  adduction  of  the  thumb,  so  that  the  pen  may  be  twisted 
from  the  grasp  and  thrown  to  some  distance.  Weir  Mitchell  has  described 
a  lock-spasm,  in  which  the  fingers  become  so  firmly  contracted  upon  the 
pen  that  it  cannot  be  removed. 

(b)  Paresis  and  Paralysis. — This  may  occur  with  the  spasm  or  alone. 
The  patient  feels  a  sense  of  weakness  and  debility  in  the  muscles  of  the 
hand  and  arm  and  holds  the  pen  feebly.  Yet  in  these  circumstances  the 
grasp  of  the  hand  may  be  strong  and  there  may  be  no  paralysis  for  ordinary 
acts. 

(c)  Tremor. — This  is  most  commonly  seen  in  the  forefinger  and  may 
be  a  premonitory  symptom  of  atrophy.  It  is  not  an  important  symptom, 
and  is  rarely  sufiicient  to  produce  disability. 

(d)  Pain. — Abnormal  sensations,  particularly  a  tired  feeling  in  the 
muscles,  are  very  constantly  present.  Actual  pain  is  rare,  but  there  may 
be  irregular  shooting  pains  in  the  arm.  Numbness  or  soreness  may  exist. 
If,  as  sometimes  happens,  a  subacute  neuritis  develops,  there  may  be  pain 
over  the  nerves  and  numbness  or  tingling  in  the  fingers. 


TETANY.  ^  1109 

(e)  Vaso-motor  Disturbances. — These  may  occur  in  severe  cases.  There 
may  be  hyperaesthesia.  Occasionally  the  skin  becomes  glossy,  or  there  is 
a  condition  of  local  asphyxia  resembling  chilblains.  In  attempting  to 
write,  the  hand  and  arm  may  become  flushed  and  hot  and  the  veins  in- 
creased in  size.  Early  in  the  disease  the  electrical  reactions  are  normal,  but 
in  advanced  cases  there  may  be  diminution  of  faradic  and  sometimes  in- 
crease in  the  galvanic  irritability. 

Diagnosis. — A  well-marked  case  of  writers  cramp  or  palsy  could 
scarcely  be  mistaken  for  any  other  affection.  Care  must  be  taken  to  ex- 
clude the  existence  of  any  cerebro-spinal  disease,  such  as  progressive  mus- 
cular atrophy  or  hemiplegia.  The  physician  is  sometimes  consulted  by 
nervous  persons  who  fancy  they  are  becoming  subject  to  the  disease  and 
complain  of  stiffness  or  weakness  without  displaying  any  characteristic 
features.    , 

Prognosis. — The  course  of  the  disease  is  usually  chronic.  If  taken 
in  time  and  if  the  hand  is  allowed  perfect  rest,  the  condition  may  im- 
prove rapidly,  but  too  often  there  is  a  strong  tendency  to  recurrence.  The 
patient  may  learn  to  write  with  the  left  hand,  but  this  also  may  after  a 
time  be  attacked. 

Treatment. — Various  prophylactic  measures  have  been  advised.  As 
mentioned,  it  is  important  that  a  proper  method  of  writing  be  adopted. 
Gowers  suggests  that  if  all  persons  wrote  from  the  shoulder  writer's  cramp 
would  practically  not  occur.  Various  devices  have  been  invented  for  re- 
lieving the  fatigue,  but  none  of  them  are  very  satisfactory.  The  use  of  the 
type-writer  has  diminished  very  much  the  frequency  of  scrivener's  palsy. 
Rest  is  essential.  No  measures  are  of  value  without  this.  Massage  and 
manipulation,  when  combined  with  systematic  gymnastics,  give  the  best 
results.  Poore  recommends  the  galvanic  current  applied  to  the  muscles, 
which  are  at  the  same  time  rhythmically  exercised.  In  very  obstinate  cases 
the  condition  remains  incurable.  I  saw  a  few  years  ago  a  distinguished 
gynaecologist  who  had  had  writer's  cramp  twenty  years  before,  and  Avho  had 
all  sorts  of  treatment,  including  the  Wolff's  method,  without  any  avail. 
He  still  has  it  in  aggravated  form,  but  he  can  do  all  the  finer  manipulations 
of  operative  work  without  any  difficulty. 

The  nutrition  of  the  patients  is  apt  to  be  much  impaired,  and  cod-liver 
oil,  strychnia,  and  other  tonics  will  be  found  advantageous.  Local  appli- 
cations are  of  little  benefit.  Tenotomy  and  nerve-stretching  have  been 
abandoned. 

X.    TETANY. 

Definition. — An  affection  characterized  by  peculiar  bilateral  tonic 
spasms,  cither  paroxysmal  or  continued,  of  the  extremities. 

Etiology. — The  disease  occurs  under  very  different  conditions,  of 
which  the  following  may  be  recognized: 

(a)  Epidemic  tetany,  also  known  as  rheumatic  tetany.  In  certain 
parts  of  the  continent  of  Europe  the  disease  has  prevailed  widely,  particu- 
larly in  the  winter  season.     Von  Jaksch,  who  has  described  an  epidemic 


1110  DISEASES  OF  THE  NERVOUS  SYSTEM. 

form  occurring  in  young  men  of  the  working  classes,  sometimes  with  slight 
fever,  regards  the  disease  as  infectious.  This  form  is  acute,  lasting  only 
two  or  three  weeks  and  rarely  proving  fatal. 

(b)  A  majority  of  the  cases  are  found  in  association  with  debility  fol- 
lowing lactation  and  chronic  diarrhoea,  or  in  the  malnutrition  of  rickets. 
From  its  occurrence  in  nursing  women  Trousseau  called  it  nurse's  con- 
tracture. It  may  also  develop  during  pregnancy  or  recur  in  successive 
pregnancies.  It  has  been  found  as  a  sequence  of  the  acute  fevers,  and  in 
some  typhoid  epidemics  many  cases  have  occurred. 

(c)  Tetany  may  follow  removal  of  the  thyroid  gland.  Thirteen  cases, 
for  example,  followed  78  operations  on  enlarged  thyroid  in  Billroth's  clinic, 
and  6  of  them  proved  fatal.  James  Stewart  has  reported  an  instance  in 
which  with  the  tetany  there  were  symptoms  of  myxcedema,  and  no  trace  of 
the  thyroid  gland.    Eemoval  of  the  thyroid  in  dogs  is  followed  by^  tetany. 

(d)  And,  lastly,  there  is  a  form  of  tetany  which  is  associated  with  dila- 
tation of  the  stomach,  particularly  after  the  organ  has  been  washed  out. 

On  this  continent  true  tetany  is  an  extremely  rare  disease.  Grifiith 
has  collected  73  cases,  among  which,  however,  cases  of  carpo-pedal  spasm 
are  included. 

The  nature  of  the  disease  is  unknown;  certain  forms  depend  undoubt- 
edly on  loss  of  the  function  of  the  thyroid  gland. 

Symptoms. — In  cases  associated  with  general  debility  or  in  children 
with  rickets  the  spasm  is  limited  to  the  hands  and  feet.  The  fingers  are 
bent  at  the  metacarpo-phalangeal  joint,  extended  at  the  terminal  joints, 
pressed  close  together,  and  the  thumb  is  contracted  in  the  palm  of  the 
hand.  The  wrist  is  flexed,  the  elbows  are  bent,  and  the  arms  are  folded 
over  the  chest.  In  the  lower  limbs  the  feet  are  extended  and  the  toes  ad- 
ducted.  The  muscles  of  the  face  and  neck  are  less  commonly  involved, 
but  in  severe  cases  there  may  be  trismus,  and  the  angles  of  the  mouth  are 
drawn  out.  The  skin  of  the  hands  and  feet  is  sometimes  tense  and  cedem- 
atous.  The  spasms  are  usually  paroxysmal  and  last  for  a  variable  time. 
In  children  the  attack  may  pass  off  in  a  few  hours.  In  some  of  the  severer 
chronic  cases  in  adults  the  stiffness  and  contracture  may  continue  or  even 
increase  for  many  days,  and  the  attack  may  last  as  long  as  two  weeks.  In 
the  acute  cases  the  temperature  may  be  elevated  and  the  pulge  quickened. 
In  the  severe  paroxysms  there  may  be  involvement  of  the  muscles  of  the 
back  and  of  the  thorax,  inducing  dyspnoea  and  cyanosis.  Certain  addi- 
tional features,  valuable  in  diagnosis,  are  present. 

Trousseau's  symptom:  "  So  long  as  the  attack  is  not  over,  the  parox- 
ysms may  be  reproduced  at  will.  This  is  effected  by  simply  compress- 
ing the  affected  parts,  either  in  the  direction  of  their  principal  nerve 
trunks  or  over  their  blood-vessels,  so  as  to  impede  the  venous  or  arterial 
circulation." 

Chovstek's  symptom  is  shown  in  the  remarkable  increase  in  the  me- 
chanical excitability  of  the  motor  nerves.  A  slight  tap,  for  example,  in 
the  course  of  the  facial  nerve  will  throw  the  muscles  to  which  it  is  dis- 
tributed into  active  contraction.  Erb  has  shown  that  the  electrical  irrita- 
bility of  the  nerves  is  also  greatly  increased,  and  Hofmann  has  demon- 


HYSTERIA.  1111 

strated  the  heightened  excitability  of  the  sensory  nerves,  the  slightest 
pressure  on  which  may  cause  para?stliesia  in  the  region  of  distribution. 

Diagnosis.— The  disease  is  readily  recognized.  It  is  a  mistake  to  call 
instances  of  carpo-pedal  spasm  of  children  true  tetany.  It  is  common  to 
find  in  rickety  children  or  in  cases  of  severe  gastro-intestinal  catarrh  a 
transient  spasm  of  the  fingers  or  even  of  the  arms.  By  many  authors  these 
are  considered  cases  of  mild  tetany,  and  there  are  all  grades  in  rickety  chil- 
dren between  the  simple  carpo-pedal  spasm  and  the  condition  in  which 
the  four  extremities  are  involved;  but  it  is  well,  I  think,  to  limit  the  term 
tetany  to  the  severer  affection. 

With  true  tetanus  the  disease  is  scarcely  ever  confounded,  as  the  com- 
mencement of  the  spasm  in  the  extremities,  the  attitude  of  the  hands,  and 
the  etiological  factors  are  very  different.  Hysterical  contractures  are  usually 
unilateral. 

Treatment. — In  the  case  of  children  the  condition  with  which  the 
tetany  is  associated  should  be  treated.  Baths  and  cold  sponging  are  recom- 
mended and  often  relieve  the  spasm  as  promptly  as  in  child-crowing.  Bro- 
mide of  potassium  may  be  tried.  In  severe  cases  chloroform  inhalations 
may  be  given.  Massage,  electricity,  and  the  spinal  ice-bag  have  also  been 
used  with  success.  Cases,  however,  may  resist  all  treatment,  and  the  spasms 
recur  for  many  years.  The  thyroid  extract  should  be  tried.  Gottstein  re- 
ports relief  in  a  case  of  long  standing,  and  Bramwell  reports  one  case  of 
operative  tetany  and  one  of  the  idiopathic  form  successfully  treated  in 
this  way. 

XI.    HYSTERIA. 

Definition. — A  state  in  which  ideas  control  the  body  and  produce 
morbid  changes  in  its  functions  (Mobius). 

Etiology. — The  affection  is  most  common  in  women,  and  usually  ap- 
pears first  al)0ut  the  time  of  puberty,  but  the  manifestations  may  continue 
until  the  menopause,  or  even  until  old  age.  Men,  however,  are  by  no  means 
exempt,  and  of  late  years  hysteria  in  the  male  has  attracted  much  attention. 
It  occurs  in  all  races,  but  is  much  more  prevalent,  particularly  in  its 
severer  forms,  in  members  of  the  Latin  race.  In  this  country  the  milder 
grades  are  common,  but  the  graver  forms  are  rare  in  comparison  with  the 
frequency  with  which  they  are  seen  in  France. 

Children  under  twelve  years  of  age  are  not  very  often  affected,  but  the 
disease  may  be  well  marked  as  early  as  the  fifth  or  sixth  year.  One  of 
the  saddest  chapters  in  the  history  of  human  deception,  that  of  the 
Salem  A\-itches,  might  be  headed  hysteria  in  cliildren,  since  the  tragedy 
resulted  directly  from  the  hysterical  pranks  of  girls  under  twelve  years 
of  age. 

Of  predisposing  causes,  two  are  important — heredity  and  education. 
The  former  acts  by  endowing  the  child  with  a  mobile,  abnormally  sensi- 
tive nervous  organization.  We  see  cases  most  frequently  in  families  with 
marked  neuropathic  tendencies,  the  members  of  which  have  suffered  from 
neuroses  of  various  sorts.     Education  at  home  too  often  fails  to  inculcate 


1112 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


habits  of  self-control.  A  child  grows  to  girlhood  with  an  entirely  errone- 
ous idea  of  her  relations  to  others,  and  accustomed  to  have  every  whim 
gratified  and  abundant  sympathy  lavished  on  every  woe,  however  trifling, 
she  reaches  womanhood  with  a  moral  organization  unfitted  to  withstand 
the  cares  and  worries  of  every-day  life.  At  school,  between  the  ages  of 
twelve  and  fifteen,  the  most  important  period  in  her  life,  when  the  vital 
energies  are  absorbed  in  the  rapid  development  of  the  body,  she  is  often 
cramming  for  examinations  and  cooped  in  close  school-rooms  for  six  or 
eight  hours  daily.  The  result  too  frequently  is  an  active,  bright  mind  in 
an  enfeebled  body,  ill  adapted  to  subserve  the  functions  for  which  it  was 
framed,  easily  disordered,  and  prone  to  react  abnormally  to  the  ordinary 
stimuli  of  life.  Among  the  more  direct  influences  are  emotions  of  various 
kinds,  fright  occasionally,  more  frequently  love  affairs,  grief,  and  domestic 
worries.  Physical  causes  less  often  bring  on  hysterical  outbreaks,  but  they 
may  follow  directly  upon  an  injury  or  develop  during  the  convalescence 
from  an  acute  illness  or  be  associated  with  disease  of  the  generative  organs. 
The  name  hysteria  indicates  how  important  was  believed  to  be  the  part 
played  by  the  uterus  in  the  causation  of  the  disease.  Opinions  differ  a 
good  deal  on  this  question,  but  undoubtedly  in  many  cases  there  are  ova- 
rian and  uterine  disorders  the  rectification  of  which  sometimes  cures  the 
disease.  Sexual  excess,  particularly  masturbation,  is  an  important  factor, 
both  in  girls  and  boys. 

Sjnnptoms. — A  useful  division  is  into  the  convulsive  and  non-conTul- 
sive  varieties. 

Convulsive  Hysteria. — (a)  Minor  Forms. — The  attack  most  commonly 
follows  emotional  disturbance.  It  may  set  in  suddenly  or  be  preceded  by 
symptoms,  called  by  the  laity  "  hysterical,"  such  as  laughing  and  crying 
alternately,  or  a  sensation  of  constriction  in  the  neck,  or  of  a  ball  rising  in 
the  throat — the  globus  hystericus.  Sometimes,  preceding  the  convulsive 
movements,  there  may  be  painful  sensations  arising  from  the  pelvic,  ab- 
dominal, or  thoracic  regions.  From  the  description  these  sensations  re- 
semble aurge.  They  become  more  intense  with  the  rising  sensation  of 
choking  in  the  neck  and  diflGiculty  in  getting  breath,  and  the  patient  falls 
into  a  more  or  less  violent  convulsion.  It  will  be  noticed  that  the  fall  is 
not  sudden,  as  in  epilepsy,  but  the  subject  goes  down,  as  a  rule,  easily,  often 
picking  a  soft  spot,  like  a  sofa  or  an  easy-chair,  and  in  the  movements 
apparently  exercises  care  to  do  herself  no  injury.  Yet  at  the  same  time 
she  appears  to  be  quite  unconscious.  The  movements  are  clonic  and  dis- 
orderly, consisting  of  to-and-fro  motions  of  the  trunk  or  pelvic  muscles, 
while  the  head  and  arms  are  thrown  about  in  an  irregular  manner.  The 
paroxysm  after  a  few  minutes  slowly  suhsides,  then  the  patient  becomes 
emotional,  and  gradually  regains  consciousness.  When  questioned  the 
patient  may  confess  to  having  some  knowledge  of  the  events  which  have 
taken  place,  but,  as  a  rule,  has  no  accurate  recollection.  During  the  at- 
tack the  abdomen  may  be  much  distended  with  flatus,  and  subsequently  a 
large  amount  of  clear  urine  may  be  passed.  These  attacks  vary  greatly  in 
character.  There  may  be  scarcely  any  movements  of  the  li7nbs.  but  after 
a  nerve  storm  the  patient  sinks  into  a  torpid,  semi-unconscious  condition. 


HYSTERIA.  1113 

from  which  she  is  roused  with  great  difficulty.  In  some  cases  from  this 
state  the  patient  passes  into  a  condition  of  cataleps}'. 

(b)  Major  Forms;  Hystero-epilepsy. — This  condition  has  heen  especially 
studied  by  Charcot  and  his  pupils.  Typical  instances  passing  through  the 
various  phases  are  very  rare  in  this  country.  The  attack  is  initiated  by 
certain  prodromata,  chiefly  minor  hysterical  manifestations,  either  foolish 
or  unseemly  behavior,  excitement,  sometimes  dyspeptic  symptoms  with 
tympanites,  or  frequent  micturition.  Areas  of  hypergesthesia  may  at  this 
time  be  marked,  the  so-called  hysterogenic  spots  so  elaborately  described 
by  Richet.  These  are  usually  symmetrical  and  situated  over  the  upper 
dorsal  vertebra,  and  in  front  in  a  series  of  symmetrically  placed  spots  on 
the  chest  and  abdomen,  the  most  marked  being  those  in  the  inguinal  re- 
gions over  the  ovaries.  Painful  sensations  or  a  feeling  of  oppression  and  a 
globus  rising  in  the  throat  may  be  complained  of  prior  to  the  onset  of  the 
convulsion,  which,  according  to  French  writers,  has  four  distinct  stages: 
(1)  Epileptoid  condition,  which  closely  simulates  a  true  epileptic  attack 
with  tonic  spasm  (often  leading  to  opisthotonos),  grinding  of  the  teeth, 
congestion  of  the  face,  followed  by  clonic  convulsions,  gradual  relaxation, 
and  coma.  This  attack  lasts  rather  longer  than  a  true  epileptic  attack.  (2) 
Succeeding  this  is  the  period  which  Charcot  has  termed  clownism,  in  which 
there  is  an  emotional  display  and  a  remarkable  series  of  contortions  or  of 
cataleptic  poses.  (3)  Then  in  typical  cases  there  is  a  stage  in  which  the 
patient  assumes  certain  attitudes  expressive  of  the  various  passions — ecstasy, 
fear,  beatitude,  or  erotism.  (4)  Finally  consciousness  returns  and  the  pa- 
tient enters  upon  a  stage  in  which  she  may  display  very  varied  symp- 
toms, chiefly  manifestations  of  a  delirium  with  the  most  extraordinary 
hallucinations.  Visions  are  seen,  voices  heard,  and  conversations  held  with 
imaginary  persons.  In  this  stage  patients  will  relate  with  the  utmost 
solemnity  imaginary  events,  and  make  extraordinary  and  serious  charges 
against  individuals.  This  sometimes  gives  a  grave  aspect  to  these  seizures, 
for  not  only  will  the  patient  at  this  stage  make  and  believe  the  state- 
ments, but  when  recovery  is  complete  the  hallucination  sometimes  per- 
sists. We  seldom  see  in  this  country  attacks  having  this  orderly  se- 
quence. Much  more  commonly  the  convulsions  succeed  each  other  at 
intervals  for  several  days  in  succession.  Here  is  a  striking  difference 
between  hystero-epilepsy  and  true  epilepsy.  In  the  latter  the  status 
epilepticus,  if  persistent,  is  always  serious,  associated  with  fever,  and  fre- 
quently fatal,  while  in  hystero-epilepsy  attacks  may  recur  for  days  with- 
out special  danger  to  life.  After  an  attack  of  hystero-epilepsy  the  pa- 
tient may  sink  into  a  state  of  trance  or  lethargy,  in  which  she  may  remain 
for  da}'?. 

Non-convulsive  Forms. — So  complex  and  varied  is  the  clinical  picture  of 
hysteria  that  various  manifestations  are  best  considered  according  to  the 
systems  which  are  involved. 

(1)  Disorders  of  Motion. — (a)  Paralyses. — These  may  be  hemiplegic, 
paraplegic,  or  monoplegic.  Hysterical  diplegia  is  extremely  rare.  The 
paralysis  either  sets  in  abruptly  or  gradually,  and  may  take  weeks  to  attain 
its  full  development.     There  is  no  type  or  form  of  organic  paralysis  which 


]^114  DISEASES  OF  THE  NERVOUS  SYSTEM. 

may  not  he  simulated  in  hysteria.  According  to  Weir  Mitchell,  the  hemi- 
plegias are  most  frequent  in  the  ratio  of  four  on  the  left  to  one  on  the 
right  side.  The  face  is  not  affected;  the  neck  may  he  involved,  hut  the 
leg  suffers  most.  Sensation  is  either  lessened  or  lost  on  the  affected  side. 
The  hysterical  paraplegia  is  more  common  than  hemiplegia.  The  loss  of 
power  is  not  absolute;  the  legs  can  usually  be  moved,  but  do  not  support 
the  patient.  The  reflexes  may  be  increased,  though  the  knee-jerk  is  often 
normal.  A  spurious  ankle  clonus  may  sometimes  be  present.  The  feet 
are  usually  extended  and  turned  inward  in  the  equino-varus  position.  The 
muscles  do  not  waste  and  the  electrical  reactions  are  normal.  Other  mani- 
festations, such  as  paralysis  of  the  bladder  or  aphonia,  are  usually  associ- 
ated with  the  hysterical  paraplegia.  Hysterical  monoplegias  may  be  facial, 
crural,  or  brachial.  A  condition  of  ataxia  sometimes  occurs  with  paresis. 
The  incoordination  may  be  a  marked  feature,  and  there  are  usually  sensory 
manifestations. 

(&)  Contractures  and  Spasms. — An  extraordinary  variety  of  spasmodic 
affections  occurs  in  hysteria,  of  which  the  most  common  are  the  follow- 
ing: The  hysterical  contractures  may  attack  almost  any  group  of  volun- 
tary muscles  and  be  of  the  hemiplegic,  paraplegic,  or  mopoplegic  type. 
They  may  come  on  suddenly  or  slowly,  persist  for  months  or  years,  and 
disappear  rapidly.  The  contracture  is  most  commonly  seen  in  the  arm, 
which  is  flexed  at  the  elbow  and  wrist,  while  the  finggrs  tightly  grasp  the 
thumb  in  the  palm  of  the  hand;  more  rarely  the  terminal  phalanges  are 
hyperextended  as  in  athetosis.  It  may  occur  in  one  or  in  both  legs,  more 
commonly  the  former.  The  ankle  clonus  is  present;  the  foot  is  inverted 
and  the  toes  are  strongly  flexed.  These  cases  may  be  mistaken  for  lateral 
sclerosis  and  the  difficulty  in  diagnosis  may  really  be  very  great.  The 
spastic  gait  is  very  typical,  and  with  the  exaggerated  knee-jerk  and  ankle 
clonus  the  picture  may  be  characteristic.  In  1879  I  frequently  showed 
such  a  case  at  the  Montreal  General  Hospital  as  a  typical  example  of  lat- 
eral sclerosis.  The  condition  persisted  for  more  than  eighteen  months  and 
then  disappeared  completely.  Other  forms  of  contracture  may  be  in  the 
muscles  of  the  hip,  shoulder,  or  neck;  more  rarely  in  those  of  the  jaws — 
hysterical  trismus — or  in  the  tongue.  Eemarkable  indeed  are  the  local  con- 
tractures in  the  diaphragm  and  abdominal  muscles,  producing  a  phantom 
tumor,  in  which  just  below  and  in  the  neighborhood  of  the  umbilicus  is  a 
firm,  apparently  solid  growth.  According  to  Gowers,  this  is  produced  by 
relaxation  of  the  recti  and  a  spasmodic  contraction  of  the  diaphragm,  to- 
gether with  inflation  of  the  intestines  with  gas  and  an  arching  forward  of 
the  vertebral  column.  They  are  apt  to  occur  in  middle-aged  women  about 
the  menopause,  and  are  frequently  associated  with  the  symptoms  of  spu- 
rious pregnancy — pseudo-cyesis.  The  resemblance  to  a  tumor  may  be  strik- 
ing, and  I  have  known  skilful  diagnosticians  to  be  deceived.  The  only 
safeguard  is  to  be  found  in  complete  ansesthesia,  when  the  tumor  entirely 
disappears.  Some  years  ago  I  went  by  chance  into  the  operating-room  of 
a  hospital  and  found  a  patient  on  the  table  under  chloroform  and  the  sur- 
geon prepared  to  perform  ovariotomy.  The  tumor,  however,  had  com- 
pletely disappeared  with  full  anaesthesia.    Mitchell  has  reported  an  instance 


HYSTERIA.  ^  1115 

of  a  phantom  tnmor  in  the  left  pectoral  region  just  above  the  breast,  which 
was  tender,  hard,  and  dense. 

Clonic  spasms  are  more  common  in  hysteria  in  this  country  than  con- 
tractures. The  following  are  the  important  forms:  Rhythmic  hysterical 
spasm,.  This,  unfortunately,  is  sometimes  known  as  rhythmic  chorea  or 
hysterical  chorea.  The  movements  may  be  of  the  arm,  either  flexion  and 
extension,  or,  more  rarely,  pronation  and  supination.  Clonic  contractions 
of  the  sterno-cleido-mastoid  or  of  the  muscles  of  the  jaws  or  of  the  rota- 
tory muscles  of  the  head  may  produce  rhythmic  movements  of  these  parts. 
The  spasm  may  be  in  one  or  both  psoas  muscles,  lifting  the  leg  in  a  rhythmic 
manner  eight  or  ten  times  in  a  minute.  In  other  instances  the  muscles 
of  the  trunk  are  affected,  and  every  few  moments  there  is  a  bowing  move- 
ment— salaam  convulsions — or  the  muscles  of  the  back  may  contract,  caus- 
ing strong  arching  of  the  vertebral  column  and  retraction  of  the  head. 
These  movements  may  often  alternate,  as  in  a  case  in  my  wards,  in  which 
the  patient  on  fine  days  had  regular  salaam  convulsions,  while  on  wet  days 
the  rhythmic  spasm  was  in  the  muscles  of  the  back  and  neck.  Mitchell 
has  described  a  rotatory  spasm 'in  which  the  patient  rotated  involuntarily, 
usually  to  the  left.  More  unusual  cases  are  those  in  which  the  contractions 
closely  simulate  paramyoclonus  multiplex.  Hysterical  athetosis  is  a  rare 
form  of  spasm.  Tremor  may  be  a  purely  hysterical  manifestation,  occur- 
ring either  alone  or  with  paralysis  and  contracture.  It  most  commonly  in- 
volves the  hands  and  arms;  more  rarely  the  head  and  legs.  The  move- 
ments are  small  and  quick.  In  the  type  Rendu  the  tremor  may  or  may 
not  persist  during  repose,  but  it  is  increased  or  provoked  by  volitional  move- 
ments. Volitional  or  intentional  tremor  may  exist,  simulating  closely 
the  movements  of  insular  sclerosis.  Buzzard  states  that  many  instances 
of  this  disease  in  young  girls  are  mistaken  for  hysteria. 

(2)  Disorders  of  Sensation. — Ancesthesia  is  most  common,  and  usually 
confined  to  one  half  of  the  body.  It  may  not  be  noticed  by  the  patient. 
Usually  it  is  accurately  limited  by  the  middle  line  and  involves  the  mucous 
surfaces  and  deeper  parts.  The  conjunctiva,  however,  is  often  spared. 
There  may  be  hemianopia.  This  symptom  may  come  on  slowly  or  follow 
a  convulsive  attack.  Sometimes  the  various  sensations  are  dissociated  and 
the  ana?sthesia  may  be  only  to  pain  and  to  touch.  The  skin  of  the  affected 
side  is  usually  pale  and  cool,  and  a  pin-prick  may  not  be  followed  by  blood. 
With  the  loss  of  feeling  there  may  be  loss  of  muscular  power.  Curious 
trophic  changes  may  be  present,  as  in  an  interesting  case  of  Weir  Mitchell's, 
in  which  there  was  unilateral  swelling  of  the  hemiplegie  side. 

A  phenomenon  to  which  much  attention  has  been  paid  is  that  of  trans- 
ference. By  metallotherapy,  the  application  of  certain  metals,  the  anaes- 
thesia or  analgesia  can  be  transferred  to  the  other  side  of  the  body.  It 
has  been  shown,  however,  that  this  phenomenon  may  be  caused  by  the 
electro-magnet  and  by  wood  and  various  other  agents,  and  is  probably  en- 
tirely a  mental  effect.  The  subject  has  no  practical  importance,  but  it 
remains  an  interesting  and  instructive  chapter  in  Gallic  medical  history. 

TTypero'stliesia. — Increased  sensitiveness  and  pains  occur  in  various  parts 
of  the  ])ody.     One  of  the  most  frequent  complaints  is  of  pain  in  the  head, 


IIIQ  DISEASES   OF  THE  NERVOUS  SYSTEM. 

usually  over  the  sagittal  suture,  less  frequently  in  the  occiput.  This  is 
described  as  agonizing,  and  is  compared  to  the  driving  of  a  nail  into  the 
part;  hence  the  name  clavus  hystericus.  Neuralgias  are  common.  Hyper- 
gesthetic  areas,  the  hysterogenic  points,  exist  on  the  skin  of  the  thorax  and 
abdomen,  pressure  upon  which  may  cause  minor  manifestations  or  even 
a  convulsive  attack.  Increased  sensitiveness  exists  in  the  ovarian  region, 
but  is  not  peculiar  to  hysteria.  Pain  in  the  back  is  an  almost  constant 
complaint  of  hysterical  patients.  The  sensitiveness  may  be  limited  to  cer- 
tain spinous  processes,  or  it  may  be  diffuse.  In  hysterical  women  the  pains 
in  the  abdomen  may  simulate  those  of  gastralgia  and  of  gastric  ulcer,  or 
the  condition  may  be  almost  identical  with  that  of  peritonitis;  more  rarely 
the  abdominal  pains  closely  resemble  those  of  appendix  disease. 

Special  Senses. — Disturbances  of  taste  and  smell  are  not  uncommon 
and  may  cause  a  good  deal  of  distress.  Of  ocular  symptoms,  retinal  hyper- 
esthesia is  the  most  common,  and  the  patients  always  prefer  to  be  in  a 
darkened  room.  Eetraction  of  the  field  of  vision  is  common  and  usually 
follows  a  convulsive  seizure.  It  may  persist  for  years.  The  color  percep- 
tion may  be  normal  even  with  complete  aligesthesia,  and  in  this  country 
the  achromatopsia  does  not  seem  to  be  nearly  so  common  an  hysterical 
manifestation  as  in  Europe.  Hysterical  deafness  may  be  complete  and 
may  alternate  or  come  on  at  the  same  time  with  hysterical  blindness. 
Hysterical  amaurosis  may  occur  in  children.  One  must  carefully  distin- 
guish between  functional  loss  of  power  and  simulation. 

(3)  Yisceral  Manifestations. — Respiratory  Apparatus. — Of  disturbances 
in  the  respiratory  rhythm,  the  most  frequent,  perhaps,  is  an  exaggeration 
of  the  deeper  breath,  which  is  taken  normally  every  fifth  or  sixth  inspira- 
tion, or  there  may  be  a  "  catching  "  breathing,  such  as  is  seen  when  cold 
water  is  poured  over  a  person.  In  hysterical  dyspnoea  there  is  no  special 
distress  and  the  pulse  is  normal.  In  what  is  known  as  the  syndrome  of 
Briquet  there  is  shortness  of  breath,  suppression  of  the  voice,  and  paralysis 
of  the  diaphragm.  The  anhelation  is  extreme.  Among  laryngeal  mani- 
festations aphonia  is  frequent  and  may  persist  for  months  or  even  years 
without  other  special  symptoms  of  the  disease.  Spasm  of  the  muscles  may 
occur  with  violent  inspiratory  efforts  and  great  distress,  and  may  even  lead 
to  cyanosis.  Hiccough,  or  sounds  resembling  it,  may  be  present  for  weeks 
or  months  at  a  time.  Among  the  most  remarkable  of  the  respiratory  mani- 
festations are  the  hysterical  cries.  These  may  mimic  the  sounds  produced 
by  animals,  such  as  barking,  mewing,  or  grunting,  and  in  France  epidemics 
of  them  have  been  repeatedly  observed.  Extraordinary  cries  may  be  pro- 
duced, either  inspiratory  or  expiratory.  I  saw  at  Wagner's  clinic  at  Leipsic 
a  girl  of  thirteen  or  fourteen,  who  had  for  many  weeks  given  utterance  to 
a  remarkable  inspiratory  cry  somewhat  like  the  whoop  of  Avhooping-cough, 
but  so  intense  that  it  was  heard  at  a  long  distance.  It  was  incessant,  and 
the  girl  was  worn  to  a  skeleton.  Attacks  of  gaping,  yawning,  and  sneezing 
may  also  occur. 

The  hysterical  cough  is  a  frequent  symptom,  particularly  in  young 
girls.  It  may  occur  in  paroxysms,  but  is  often  a  dry,  persistent,  croaking 
cough,  extremely  monotonous  and  unpleasant  to  hear.    Sir  Andrew  Clark 


HYSTEEIA.  lllY 

has  called  attention  to  a  loud,  barking  cough  {cynohex  hebetica)  occurring 
about  the  time  of  puberty,  chiefly  in  boys  belonging  to  neurotic  families. 
The  attacks,  which  last  about  a  minute,  recur  frequently. 

There  is  a  i^eculiar  form  of  hasmoptysis  which  may  be  very  deceptive 
and  lead  to  the  diagnosis  of  pulmonary  disorders.  Wagner  describes  the 
sputum  as  a  pale-red  fluid — not  so  bright  in  color  as  in  ordinary  haemop- 
tysis; on  settling  it  presents  a  reddish-brown  sediment.  It  contains  par- 
ticles of  food,  pavement  epithelium,  red  corpuscles,  and  micrococci,  but 
no  cylindrical  or  ciliated  epithelium.  It  probably  comes  from  the  mouth 
or  pharynx. 

Digestive  System. — Disturbed  or  depraved  appetite,  dyspepsia,  and  gas- 
tric pains  are  common  in  h3'sterical  patients.  The  patient  may  have  diffi- 
culty in  swallowing  the  food,  apparently  from  spasm  of  the  gullet.  There 
are  instances  in  which  the  food  seems  to  be  expelled  before  it  reaches  the 
stomach.  In  other  cases  there  is  incessant  gagging.  In  the  hysterical 
vomiting  the  food  is  regurgitated  without  much  effort  and  without  nausea. 
This  feature  may  persist  for  years  without  great  disturbance  of  nutrition. 
The  most  striking  and  remarkable  digestive  disturbance  in  hysteria  is  the 
anorexia  nervosa  described  by  Sir  William  Gull.  "  To  call  it  loss  of  appe- 
tite— anorexia — but  feebly  characterizes  the  symptom.  It  is  rather  an 
annihilation  of  appetite,  so  complete  that  it  seems  in  some  cases  impossible 
ever  to  eat  again.  Out  of  it  grows  an  antagonism  to  food  which  results 
at  last  and  in  its  worst  forms  in  spasm  on  the  approach  of  f-ood,  and  this  in 
turn  gives  rise  to  some  of  those  remarkable  cases  of  survival  for  long  periods 
without  food  "  (Mitchell).  As  this  goes  on  there  may  be  an  extreme  de- 
gree of  muscular  restlessness,  so  that  the  patients  wander  about  until  ex- 
hausted. Nothing  more  pitiable  is  to  be  seen  in  practice  than  an  ad- 
vanced case  of  this  sort.  It  is  usually  in  a  young  girl,  sometimes  as  early 
as  the  eleventh  or  twelfth,  more  commonly  between  the  fifteenth  and  twen- 
tieth years.  The  emaciation  is  frightful,  and  scarcely  exceeded  by  that  of 
cancer  of  the  oesophagus.  The  patient  finally  takes  to  bed,  and  in  extreme 
cases  lies  upon  one  side  with  the  thighs  and  legs  flexed,  and  contractures 
may  occur.  Food  is  either  not  taken  at  all  or  only  upon  urgent  compul- 
sion. The  skin  becomes  wasted,  dry,  and  covered  with  bran-like  scales. 
No  foodTnay  be  taken  for  several  weeks  at  a  time,  and  attempts  to  feed 
may  be  followed  by  severe  spasms.  Although  the  condition  looks  so  alarm- 
ing, those  cases,  when  removed  from  their  home  surroundings  and  treated 
by  Weir  Mitchell's  method,  sometimes  recover  in  a  remarkable  way.  Death, 
however,  may  follow  with  extreme  emaciation.  In  a  fatal  case  under  my- 
care  the  girl  weighed  only  49  pounds.     No  lesions  were  found  post  mortem. 

Among  intestinal  symptoms  flatulency  is  one  of  the  most  distressing, 
and  is  usually  associated  with  tfie  condition  of  peristaltic  unrest  (Kuss- 
maul).  Frequent  discharges  of  faeces  may  be  due  to  disturbance  in  either 
the  small  or  large  bowel.  An  obstinate  form  of  diarrhoea  is  found  in  some 
hysterical  patients,  which  proves  very  intractable  and  is  associated  espe- 
cially with  the  taking  of  food.  It  seems  an  aggravated  form  of  the  loose- 
ness of  bowels  to  which  so  many  nervous  people  are  subject  on  emotion 
or  the  tcndencv  which  some  have  to  diarrlirra  immcdiatolv  after  eating. 


1118  DISEASES  OF   THE   NERVOUS  SYSTEM. 

An  entirely  different  form  is  that  produced  by  wliat  ^Mitchell  calls  the  irri- 
table rectum,  in  -w^hich  scybala  are  passed  frequently  during  the  day,  some- 
times with  great  violence.  Constipation  is  more  frequent,  however,  and 
may  be  due  to  a  loss  of  power  in  the  muscles  of  the  bowel,  or  in  the  ab- 
dominal muscles.  In  extreme  cases  the  bowels  ma}'  not  be  moved  for  two 
or  three  weeks,  leading  to  great  accumulation  of  faeces.  Other  disturbances 
are  ano-spasm  or  intense  pain  in  the  rectum  apart  from  any  fissure. 

Cardio-vascular. — Eapid  action  of  the  heart  on  the  slightest  emotion, 
with  or  without  the  subjective  sensation  of  palpitation,  is  often  a  source  of 
great  distress.  A  slow  pulse  is  less  frequent.  Pains  about  the  heart  may 
simulate  angina.  Flushes  in  various  parts  are  among  the  most  common 
symptoms.  Sweating  may  occur,  or  the  Seborrhoea  nigricans,  causing  a  dark- 
ening of  the  skin  of  the  eyelids. 

Among  the  more  remarkable  vaso-motor  phenomena  are  the  so-called 
stigmata  or  haemorrhages  in  the  skin,  such  as  were  present  in  the  cele- 
brated case  of  Louise  Lateau.  In  many  eases  these  are  undoubtedly  fraud- 
ulent, but  if,  as  appears  credible,  such  bleeding  may  exist  in  the  hj^pnotic 
trance,  there  seems  no  reason  to  doubt  its  occurrence  in  the  trance  of  pro- 
longed religious  ecstasy. 

Joint  AJfectio7is. — To  Sir  Benjamin  Brodie  and  Sir  James  Paget  we 
owe  the  recognition  of  these  extraordinary  manifestations  of  hysteria.  Per- 
haps no  single  affection  has  brought  more  discredit  upon  the  profession, 
for  the  eases  are  very  refractory,  and  finally  fall  into  the  hands  of  a  char- 
latan or  faith-healer,  under  whose  touch  the  disease  may  disappear  at  once. 
Usually  it  affects  the  knee  or  the  hip,  and  may  follow  a  trifling  injury. 
The  joint  is  usually  fixed,  sensitive,  and  swollen.  The  surface  may  be 
cool,  but  sometimes  the  local  temperature  is  increased.  To  the  touch  it 
is  very  sensitive  and  movement  causes  great  pain.  In  protracted  cases  the 
muscles  about  the  joint  are  somewhat  wasted,  and  in  consequence  it  looks 
larger.  The  pains  are  often  nocturnal,  at  which  time  the  local  tempera- 
ture may  be  much  increased.  While,'  as  a  rule,  neuromimetic  joints  5deld 
to  proper  management,  there  are  interesting  instances  in  the  literature  in 
which  organic  change  has  succeeded  the  functional  disturbance.  In  the 
remarkable  case  reported  in  Weir  ]\Iitchell's  lectures,  the  hysterical  fea- 
tures were  pronounced,  and,  on  accoimt  of  the  chronic-it};,  the  disease  of 
the  knee-joint  was  considered  organic  by  such  an  authority  as  Billroth. 
Sands  found  the  joint  surfaces  normal,  and  the  thickening  to  be  due  to 
inflammatory  products  outside  the  capsule. 

Intermittent  hydrarthrosis  may  be  a  manifestation  of  hysteria,  occur- 
ring in  the  knee  or  other  joints,  sometimes  with  transient  paresis. 

Mental  Symptoms. — The  psychical  condition  of  an  hysterical  patient 
is  always  abnormal,  and  the  disease  occupies  the  ill-defined  territory  be- 
tween sanity  and  insanity.  In  a  large  number  of  cases  the  patients  are 
really  insane,  particularly  in  the  perversion  witnessed  in  the  moral  sphere. 
Not  the  slightest  dependence  can  be  placed  upon  their  statements,  and 
they  will  for  months  or  years  deceive  friends,  relatives,  and  physician. 
This  appears  to  result  partly,  but  not  wholly,  from  a  morbid  craving  for 
sympathy.    It  is  really  due  to  an  entire  unhinging  of  the  moral  nature. 


HYSTERIA.  1119 

Hysterical  patients  may  become  insane  and  display  persistent  hallu- 
cinations and  delirium,  alternating  perhaps  with  emotional  outbursts  of 
an  aggravated  character.  For  weeks  or  months  they  may  be  confined  to 
bed,  entirely  oblivious  to  their  surroundings,  with  a  delirium  which  may 
simulate  that  of  delirium  tremens,  particularly  in  being  associated  with 
loathsome  and  unpleasant  animals.  The  nutrition  may  be  maintained, 
but  in  these  cases  there  is  always  a  very  heavy,  foul  breath.  With  seclu- 
sion and  care  recovery  usually  takes  place  within  three  or  four  months. 
At  the  onset  of  these  attacks  and  during  convalescence  the  patients  must 
be  incessantly  watched,  as  a  suicidal  tendency  is  by  no  means  uncommon. 
I  have  been  accustomed  to  speak  of  this  condition  as  the  status  hystericus. 

Of  hysterical  manifestations  in  the  higher  centres -that  of  trance  is  the 
most  remarkable.  This  may  develop  spontaneously  without  any  convul- 
sive seizure,  but  more  frequently,  in  this  country  at  least,  it  follows  hys- 
teroid  attacks.  Catalepsy,  a  condition  in  which  the  limbs  are  plastic  and 
remain  in  any  position  in  which  they  are  placed,  may  be  present. 

The  Metabolism  in  Hysteria. — The  studies  of  Gilles  de  la  Tourette  and 
Cathelineau,  under  Charcot's  direction,  have  shown  that  in  the  ordinary 
forms  of  hysteria  the  urine  does  not  show  quantitative  or  qualitative 
changes,  but  in  the  severer  types,  characterized  by  convulsions,  etc.,  there 
are  important  modifications:  reduction  in  the  urates  and  phosphates;  the 
ratio  of  the  earthy  to  the  alkaline  phosphates,  normally  1  :  3,  is  1  :  2,  or 
even  1:1.  The  urine  is  also  reduced  in  amount.  They  think  that  these 
changes  might  sometimes  serve  to  differentiate  convulsive  hysteria  from 
epilepsy,  in  which  there  is  always  an  increase  in  the  solid  constituents  after 
a  seizure. 

Hysterical  Fever. — In  hysteria  the  temperature,  as  a  rule,  is  normal. 
The  cases  with  fever  may  be  grouped  as  follows:  (a)  Instances  in  which 
the  fever  is  the  sole  manifestation.  These  are  rare,  but  I  have  seen  at 
least  two  cases  in  which  the  chronic  course,  the  retention  of  the  nutrition, 
and  the  entirely  negative  condition  of  the  organs  left  no  other  diagnosis 
possible.  In  a  case  recently  under  observation  the  patient  has  had  for  four 
or  five  years  an  afternoon  rise  of  temperature,  reaching  usually  to  102°  or 
103°.  She  was  well  nourished  and  presented  no  pronounced  hysterical 
symptoms,  but  there  was  a  marked  neurotic  history  on  one  side  and  a  form 
of  interrupted  sighing  respiration  so  often  seen  in  hysteria. 

(&)  Cases  of  hysterical  fever  with  spurious  local  manifestations.  These 
are  very  troublesome  and  deceptive  cases.  The  patient  may  be  suddenly 
taken  ill  with  pain  in  various  regions  and  elevation  of  temperature.  The 
case  may  simulate  meningitis.  There  may  be  pain  in  the  head,  vomiting, 
contracted  pupils,  and  retraction  of  the  neck — symptoms  which  may  per- 
sist for  weeks — and  some  anoraalous  manifestation  during  convalescence 
may  alone  indicate  to  the  physician  that  he  has  had  to  deal  with  a  case  of 
hysteria,  and  has  not,  as  he  perhaps  flattered  himself,  cured  a  case  of  men- 
ingitis. Mary  Putnam  Jacobi,  in  a  recent  article  on  hysterical  fever,  men- 
tions a  case  in  the  service  of  Cornil  which  was  admitted  with  dyspnoea, 
slight  cyanosis,  and  a  temperature  of  39°  C.  The  condition  proved  to  be 
hysterical.     There  is  also  an  hysterical  pseudo-phthisis  with  pain  in  the 


1120  DISEASES  OP  THE  NERVOUS  SYSTEM. 

chest,  slight  fever,  and  the  expectoration  of  a  blood-stained  mucus.  The 
cases  of  hysterical  peritonitis  may  also  show  fever. 

(c)  Hysterical  Hyperpyrexia. — It  is  a  suggestive  fact  that  the  cases  of 
paradoxical  temperatures  reported  of  late  years,  in  which  the  thermometer 
has  registered  113°  to  120°  or  more,  have  been  in  women.  Fraud  has  been 
practised  in  some  of  these,  but  others  have  to  be  accepted,  though  their 
explanation  is  impossible  under  our  known  laws.  Jacobi  has  reported  a 
case  in  which  the  temperature  rose  to  148°  F.  (64.5°  C).  The  Omaha 
case,  in  which  the  temperature  was  recorded  at  170°  F.,  has,  I  am  informed 
on  good  authority,  proved  a  fraud. 

Diagnosis. — Inquiry  into  the  occurrence  of  previous  manifestations 
and  the  mental  conditions  may  give  important  information.  These  ques- 
tions, as  a  rule,  should  not  be  asked  the  mother,  who  of  all  others  is  least 
likely  to  give  satisfactory  information  about  the  patient's  condition.  The 
occurrence  of  the  globus  hystericus,  of  emotional  attacks,  of  weeping  and 
crying,  are  always  suggestive.  The  points  of  difference  between  the  con- 
vulsive attacks  and  true  epilepsy  were  referred  to  in  their  description, 
and  as  a  rule  little  difficulty  is  experienced  in  distinguishing  between  the 
two  conditions.  The  hysterical  paralyses  are  very  variable  and  apt  to  be 
associated  with  anesthesia.  The  contractures  may  at  times  be  very  decep- 
tive, but  the  occurrence  of  areas  of  angesthesia,  of  retraction  of  the  visual 
field,  and  the  "development  of  minor  hysterical  manifestations,  give  valua- 
ble indications.  The  contractures  disappear  under  full  auEesthesia.  Spe- 
cial care  must  be  taken  not  to  confound  the  spastic  paraplegia  of  hysteria 
with  lateral  sclerosis. 

The  visceral  manifestations  are  usually  recognized  without  much  diffi- 
culty.^ The  practitioner  has  constantly  to  bear  in  mind  the  strong  tendency 
in  hysterical  patients  to  practise  deception. 

Treatment. — The  prophylaxis  in  hysteria  may  be  gathered  from  the 
remarks  on  the  relation  of  education  to  the  disease.  The  successful  treat- 
ment of  hysteria  demands  qualities  possessed  by  few  physicians.  The  first 
element  is  a  due  appreciation  of  the  nature  of  the  disease  on  the  part  of 
the  physician  and  friends.  It  is  pitiable  to  think  of  the  misery  which  has 
been  inflicted  on  these  unhappy  victims  by  the  harsh  and  unjust  treat- 
ment which  has  resulted  from  false  views  of  the  nature  of  the  trouble; 
on  the  other  hand,  worry  and  ill-health,  often  the  wrecking  of  mind, 
body,  and  estate,  are  entailed  upon  the  near  relatives  in  the  nursing  of  a 
protracted  case  of  hysteria.  The  minor  manifestations,  attacks  of  the 
vapors,  the  crying  and  weeping  spells,  are  not  of  much  moment  and  rarely 
require  treatment.  The  physical  condition  should  be  carefully  looked  into 
and  the  mode  of  life  regulated  so  as  to  insure  system  and  order  in  every- 
thing. A  congenial  occupation  ofl'ers  the  best  remedy  for  many  of  these 
manifestations.  Any  functional  disturbance  should  be  attended  to  and  a 
course  of  tonics  prescribed.  Special  attention  should  be  paid  to  the  action 
of  the  bowels. 

Valerian  and  asafoetida  are  often  of  service.  For  the  pains  in  various 
parts,  particularly  in  the  back,  the  thermo-cautery  and  static  electricity 
will  be  found  invaluable.    Morphia  should  be  withheld.    In  the  convulsive 


HYSTERIA.  1121 

seizures,  particularly  in  the  minor  forms,  it  is  often  best,  after  settling  the 
patient  comfortably,  to  leave  her.  When  she  comes  to,  and  finds  herself 
alone  and  without  sympathy,  the  attacks  are  less  likely  to  be  repeated. 
There  is,  as  a  rule,  no  cure  for  the  hysterical  manifestations  of  women, 
otherwise  in  good  health,  who  are,  as  Mitchell  says,  "  fat  and  ruddy,  with 
sound  organs  and  good  appetites,  but  ever  complain  of  pains  and  aches, 
and  ever  liable  on  the  least  emotional  disturbance  to  exhibit  a  quaint  vari- 
ety of  hysterical  phenomena." 

To  treat  hysteria  as  a  physical  disorder  is,  after  all,  radically  wrong.  It 
is  essentially  a  mental  and  emotional  anomaly,  and  the  important  element 
in  the  treatment  is  moral  control.  At  home,  surrounded  by  loving  relatives 
who  misinterpret  entirely  the  symptoms  and  have  no  appreciation  of  the 
nature  of  the  disease,  the  severer  forms  of  hysteria  can  rarely  be  cured.  The 
necessary  control  is  impossible;  hence  the  special  value  of  the  method  in- 
troduced by  Weir  Mitchell,  which  is  particularly  applicable  to  the  advanced 
cases  which  have  become  chronic  and  bedridden.  The  treatment  consists 
in  isolation,  rest,  diet,  massage,  and  electricity.  Separation  from  friends 
and  sympathetic  relatives  must  be  absolute,  and  can  rarely,  if  ever,  be 
obtained  in  the  individual's  home.  An  essential  element  in  the  treatment 
is  an  intelligent  nnrse.  No  small  share  of  the  success  which  has  attended 
the  author  of  this  plan  has  been  due  to  the  fact  that  he  has  persistently 
chosen  as  his  allies  bright,  intelligent  women.  The  details  of  the  plan  are 
as  follows:  The  patient  is  confined  to  bed  and  not  allowed  to  get  up,  nor, 
at  first,  in  aggravated  cases,  to  read,  write,  or  even  to  feed  herself.  Massage 
is  used  daily,  at  first  for  twenty  minutes  or  half  an  hour,  subsequently  for 
a  longer  period.  It  is  essential  as  a  substitute  for  exercise.  The  induction 
current  is  applied  to  the  various  muscles  and  to  the  spine.  Its  use,  how- 
ever, is  not  so  essential  as  that  of  massage.  The  diet  may  at  first  be  entirely 
of  milk,  4  ounces  every  two  hours.  It  is  better  to  give  skimmed  milk, 
and  it  may  be  diluted  with  soda  water  or  barley  water  and,  if  necessary, 
peptonized.  After  a  week  or  ten  days  the  diet  may  be  increased,  the 
amount  of  milk  still  being  kept  up.  A  chop  may  be  given  at  midday,  a  cup 
of  coffee  or  cocoa  with  toast  or  bread  and  butter  or  a  biscuit  with  the  milk. 
The  patients  usually  fatten  rapidly  as  the  solid  food  is  added,  and  with 
the  gain  there  is,  as  a  rule,  a  diminution  or  cessation  of  the  nervous  symp- 
toms. The  milk  is  the  essential  element  in  the  diet,  and  is  in  itself  amply 
sufficient. 

The  remarkable  results  obtained  by  this  method  are  now  universally 
recognized.  The  plan  is  more  applicable  to  the  lean  than  to  fat,  flabby 
hysterical  patients.  Not  only  is  it  suitable  for  the  more  obstinate  varieties 
of  hysteria  with  bodily  manifestations,  but  in  the  cases  with  mental  symp- 
toms the  seclusion  and  separation  from  relatives  and  friends  are  particu- 
larly advantageous.  In  the  hysterical  vomiting  Debove's  method  of  forced 
feeding  may  be  used  with  benefit.  For  the  innumerable  minor  manifesta- 
tions of  hysteria  and  for  the  simulations  the  indications  for  treatment  are 
usually  clear.  Of  late,  hypnotism  has  been  extensively  used  in  the  treat- 
ment of  hysteria.  Occasionally  in  cases,  of  hysterical  contractious  or  paraly- 
sis it  is  of  benefit,  but  any  one  who  has  seen  the  development  of  this  method 
70 


1122  DISEASES   OF  THE  NERVOUS  SYSTEM. 

as  practised  at  present  in  France  must  feel  that  it  is  a  two-edged  sword  and 
that  the  constant  repetition  in  the  same  patient  is  fraught  with  danger. 
In  the  cases  in  which  we  have  tried  it  here  the  success  has  not  been  marked. 


XII.    NEURASTHENIA. 

Definition. — A  condition  of  weakness  or  exhaustion  of  the  nervous 
system,  giving  rise  to  various  forms  of  mental  and  bodily  inefhciency. 

The  term,  an  old  one,  but  first  popularized  by  Beard,  covers  an  ill-de- 
fined, motley  group  of  symptoms,  which  may  be  either  general  and  the  ex- 
pression of  derangement  of  the  entire  system,  or  local,  limited  to  certain 
organs;  hence  the  terms  cerebral,  spinal,  cardiac,  and  gastric  neurasthenia. 

Etiology. — The  causes  may  be  grouped  as  hereditary  and  acquired. 

(a)  Hereditary. — We  do  not  all  start  in  life  with  the  same  amount  of 
nerve  capital.  Parents  who  have  led  irrational  lives,  indulging  in  excesses 
of  various  kinds,  or  who  have  been  the  subjects  of  nervous  complaints  or 
of  mental  trouble,  may  transmit  to  their  children  an  organization  which  is 
defective  in  what,  for  want  of  a  better  term,  we  must  call  "  nerve  force." 
Such  individuals  start  handicapped  with  a  neuropathic  predisposition,  and 
furnish  a  considerable  proportion  of  our  neurasthenic  patients.  As  van 
Gieson  sonorously  puts  it,  "  the  potential  energies  of  the  higher  constella- 
tions of  their  association  centres  have  been  squandered  by  their  ancestors." 

Besides  such  forms  of  hereditary  neuropathy,  which  we  have  to  look 
upon  as  instances  of  injury  to  the  germ-plasm  derived  from  one  or  both 
of  the  parents,  there  have  to  be  considered  those  cases  in  which  during 
intra-uterine  life  there  have  been  conditions  which  interfered  with  the 
proper  development  and  nutrition  of  the  embryo.  So  long  as  these  indi- 
viduals are  content  to  transact  a  moderate  business  "with  their  life  capital, 
all  may  go  well,  but  there  is  no  reserve,  and  in  the  exigencies  of  modern  life 
these  small  capitalists  go  under  and  come  to  us  as  bankrupts. 

(&)  Acquired. — The  functions,  though  perverted  most  readily  in  persons 
who  have  inherited  a  feeble  organization,  may  also  be  damaged  in  persons 
with  no  neuropathic  predisposition  by  exercise  which  is  excessive  in  pro- 
portion to  the  strength — i.  e.,  by  strain.  The  cares  and  anxieties  attendant 
upon  the  gaining  of  a  livelihood  may  be  borne  without  distress,  but  in  many 
persons  the  strain  becomes  excessive  and  is  first  manifested  as  worry.  The 
individual  loses  the  distinction  between  essentials  and  non-essentials,  trifles 
cause  annoyance,  and  the  entire  organism  reacts  with  unnecessary  readiness 
to  slight  stimuli,  and  is  in  a  state  which  the  older  writers  called  irritable 
weakness.  If  such  a  condition  be  taken  early  and  the  patient  given  rest, 
the  balance  is  quickly  restored.  In  this  group  may  be  placed  a  large  pro- 
portion of  the  neurasthenics  which  we  see  in  this  country,  particularly 
among  business  men,  teachers,  and  journalists.  Neurasthenia  may  follow 
the  infectious  diseases,  particularly  influenza,  typhoid  fever,  and  syphilis. 
The  abuse  of  certain  drugs,  alcohol,  tobacco,  morphine  may  lead  to  a  high 
grade  of  neurasthenia,  though  the  drug  habit  is  more  often  a  result  rather 
than  a  cause  of  the  neurasthenia.    Other  causes  more  subtle,  yet  potent,  and 


NEURASTHENIA.  1123 

less  easily  dealt  with,  are  the  worries  attendant  upon  love  affairs,  religious 
doubts,  and  the  sexual  passion.  Sexual  excesses  have  undoubtedly  been 
exaggerated  as  a  cause  of  neurasthenia,  but  that  they  are  responsible  in  a 
number  of  instances  is  certain. 

The  traumatic  forms,  especially  those  following  upon  railway  accidents, 
will  be  separately  considered. 

Symptoms. — These  are  extremely  varied,  and  may  be  general  or 
localized;  more  often  a  combination  of  both.  The  appearance  of  the  pa- 
tient is  suggestive,  sometimes  characteristic,  but  difficult  to  describe.  Im- 
portant information  can  be  gained  by  the  physician  if  he  observe  the 
patient  closely  as  he  enters  the  room — the  way  he  is  clothed,  the  manner 
in  which  he  holds  his  body,  his  facial  expression,  and  the  humor  which  he 
is  in.  Loss  of  weight  and  slight  anaemia  may  be  present.  The  physical 
debility  may  reach  a  high  grade  and  the  patient  may  be  confined  to  bed. 
Mentally  the  patients  are  usually  low-spirited  and  despondent;  women  are 
frequently  emotional. 

The  local  symptoms  may  dominate  the  situation,  and  there  have  accord- 
ingly been  described  a  whole  series  of  types  of  the  disease — cerebral,  spinal, 
cardio-vascular,  gastric,  and  sexual.  In  all  forms  there  is  a  striking  lack  of 
accordance  between  the  symptoms  of  which  the  patient  complains  and  the 
objective  changes  discoverable  by  the  physician.  In  nearly  every  clinical  type 
of  the  disease  the  predominant  symptoms  are  referable  to  pathological  sensa- 
tions and  the  psychic  effects  of  these.  Imperfect  sleep  is  also  complained 
of  by  a  majority  of  patients,  or,  if  not  complained  of,  is  found  to  exist  on 
inquiry. 

In  the  cerebral  or  psychic  form  the  symptoms  are  chiefly  connected  with 
an  inability  to  perform  the  ordinary  mental  work.  Thus  a  row  of  figures 
cannot  be  correctly  added,  the  dictation  or  the  writing  of  a  few  letters  is  a 
source  of  the  greatest  worry,  the  transaction  of  petty  details  in  business  is 
a  painful  effort,  and  there  is  loss  of  power  of  fixed  attention.  With  this 
condition  there  may  be  no  headache,  the  appetite  may  be  good,  and  the 
patient  may  sleep  well.  As  a  rule,  however,  there  are  sensations  of  fulness 
and  weight  or  flushes,  if  not  actual  headache.  Sleeplessness  is  a  frequent 
concomitant  of  the  cerebral  form,  and  may  be  the  first  manifestation. 
Some  of  these  patients  are  good-tempered  and  cheerful,  but  a  majority  are 
moody,  irritable,  and  depressed. 

Hyperesthesia,  especially  to  sensations  of  pain,  is  one  of  the  main  char- 
acteristics of  almost  all  neurasthenic  individuals.  The  sensations  are  nearly 
always  referred  to  some  special  region  of  the  body — the  skin,  eye  muscles, 
the  joints,  the  blood-vessels,  or  the  viscera.  It  is  frequently  possible  to 
localize  a  number  of  points  painful  to  pressure  (Valleix's  points).  In  some 
patients  there  is  marked  vertigo,  occasionally  even  resembling  that  of  Meni- 
ere's disease. 

If  such  pathological  sensations  continue  for  a  long  time  the  mood  and 
character  of  the  patient  gradually  alter.  The  so-called  "  irritable  humor  " 
develops.  Many  obnoxiously  egoistic  individuals  met  with  in  daily  life  are 
in  reality  examples  of  psychic  neurasthenia.  Everything  is  complained  of. 
The  individual  demands  the  greatest  consideration  for  his  condition;  feels 


1124  DISEASES  OF  THE  NERVOUS  SYSTEM. 

that  he  has  been  deeply  insulted  if  his  desires  are  not  always  immediatel}' 
granted.  He  may  at  the  same  time  have  but  little  consideration  for  others. 
Indeed,  in  the  severer  forms  of  the  disease  he  may  show  a  malicious  pleas- 
ure in  attempting  to  make  people  who  seem  happier  than  himself  uncom- 
fortable. Such  patients  complain  frequently  that  they  are  "misunder- 
stood "  by  their  fellows. 

In  many  cases  the  so-called  "  anxiety  conditions  "  gradually  develop; 
one  scarcely  ever  sees  a  ease  of  advanced  neurasthenia  without  the  existence 
of  some  form  of  "  anxiety."  In  the  simpler  forms  of  anxiety  (nosophobic) 
there  may  be  only  a  fear  of  impending  insanity  or  of  approaching  death 
or  of  apoplexy.  More  frequently  the  anxious  feeling  is  localized  somewhere 
in  the  body — in  the  praecordial  region,  in  the  head,  in  the  abdomen,  in  the 
thorax,  or  more  rarely  in  the  extremities. 

In  some  cases  the  anxiety  becomes  intense  and  the  patients  are  restless, 
and  declare  that  they  do  not  know  what  to  do  with  themselves.  They  may 
throw  themselves  upon  a  bed,  crying  and  complaining,  and  making  con- 
vulsive movements  with  the  hands  and  feet.  Suicidal  tendencies  are  not 
uncommon  in  such  cases,  and  patients  may  in  desperation  actually  take 
their  own  lives. 

Involuntary  mental  activity  may  be  very  troublesome;  the  patient  com- 
plains that  when  he  is  overtired  thoughts  which  he  cannot  stop  or  control 
run  through  his  head  with  lightning-like  rapidity.  In  other  cases  there  is 
marked  absence  of  mind,  the  individual's  mind  being  so  filled  up  owing 
to  the  overexcitability  of  latent  memory  pictures  that  he  is  unable  to  form 
the  proper  associations  for  ideas  called  up  by  external  stimuli.  Sometimes 
a  patient  complains  that  a  definite  word,  a  name,  a  number,  a  melody,  or  a 
song  keeps  running  in  his  head  in  spite  of  all  he  can  do  to  abolish  it. 

In  the  severer  cases  of  psychic  neurasthenia  the  so-called  "  phobias  " 
are  common.  The  most  frequent  form  perhaps  is  agorapJiobia,  in  which 
patients  the  moment  they  come  into  an  open  space  are  oppressed  by  an 
exaggerated  feeling  of  anxiety.  They  seem  "  frightened  to  death,''  and 
commence  to  tremble  all  over;  they  complain  of  compression  of  the  thorax 
and  palpitation  of  the  heart.  They  may  break  into  profuse  perspiration  and 
assert  that  they  feel  as  though  chained  to  the  ground  or  that  they  cannot 
move  a  step.  It  is  remarkable  that  in  some  such  eases  the  open  space  can 
be  crossed  if  the  individual  be  accompanied  by  some  one,  even  by  a  child, 
or  if  he  carry  a  stick  or  an  umbrella!  Other  people  are  afraid  to  be  left 
alone  (monophobia),  especially  in  a  closed  compartment  (claustrophobia). 

The  fear  of  people  and  of  society  is  known  as  anthropophobia.  A  whole 
series  of  other  phobias  have  been  described — batophobia,  or  the  fear  that 
high  things  will  fall;  pathophobia,  or  fear  of  disease;  siderodromophobia, 
or  fear  of  a  railway  journey;  siderophobia  or  astrophobia,  fear  of  thunder 
and  lightning.  Occasionally  we  meet  with  individuals  who  are  afraid  of 
everything  and  every  one — victims  of  the  so-called  pantophobia. 

The  special  senses  may  be  disturbed,  particularly  vision.  An  aching  or 
weariness  of  the  eyeballs  after  reading  a  few  minutes  or  flashes  of  light  are 
common  symptoms.  The  "  irritable  eye,"  the  so-called  nervous  or  neu- 
rasthenic asthenopia,  is  familiar  to  every  family  -physician.     According  to 


NEURASTHENIA.  1125 

Binswanger,  the  essence  of  the  asthenopic  disturbance  consists  in  patho- 
logical sensations  of  fatigue  in  the  ciliary  muscles  or  the  medial  recti. 

There  may  be  acoustic  disturbances — hyperalgesia  and  even  true  hyper- 
acusia. 

One  of  the  most  common  of  all  the  symptoms  of  neurasthenia  is  the 
pressure  in  the  head  complained  of  by  these  patients.  This  symptom,  vari- 
ously described,  may  be  diffuse,  but  is  more  frequently  referred  to  some  one 
region — frontal,  temporal,  parietal,  or  occipital.* 

When  the  spinal  symptoms  predominate — spinal  irritation  or  spinal 
neurasthenia — in  addition  to  many  of  the  features  just  mentioned,  the 
patients  complain  of  weariness  on  the  least  exertion,  of  weakness,  pain  in 
the  back,  intercostal  neuralgiform  pains,  and  of  aching  pains  in  the  legs. 
There  may  be  spots  of  local  tenderness  on  the  spine.  The  rachialgia  may 
be  spontaneous,  or  may  be  noticed  only  on  pressure  or  movement.  Occa- 
sionally there  may  be  disturbances  of  sensation,  particularly  a  feeling  of 
numbness  and  tingling,  and  the  reflexes  may  be  increased.  Visceral  neural- 
gias, especially  in  connection  with  the  genital  organs,  are  frequently  met 
with.  The  aching  pain  in  the  back  or  in  the  back  of  the  neck  is  the  most 
constant  complaint  in  these  cases.  In  women  it  is  often  impossible  to  say 
whether  this  condition  is  one  of  neurasthenia  or  hysteria.  It  is  in  these 
cases  that  the  disturbances  of  muscular  activity  are  most  pronounced,  and 
in  the  French  writings  amyosthenia  particularly  plays  an  important  role. 
The  symptoms  may  be  irritative  or  paretic,  or  a  combination  of  both.  Dis- 
turbances of  coordination  are  not  uncommon  in  the  severer  forms.  These 
are  particularly  prone  to  involve  the  associated  movements  of  the  eye  mus- 
cles leading  to  asthenopic  lack  of  accommodation.  Drooping  of  one  eyelid 
is  very  common,  probably  owing  to  insufficient  innervation  on  the  part  of 
the  sympathetic  rather  than  to  paresis  of  the  nervus  oculomotorius.  Oc- 
casionally Eomberg's  symptom  may  be  present,  and  the  patient,  or  even  his 
physician,  may  fear  a  beginning  tabes.  More  rarely  there  is  disturbance  of 
such  finely  coordinated  acts  as  writing  and  articulation,  not  unlike  those 
seen  at  the  onset  of  general  paresis.  Such  symptoms  are  always  alarming, 
and  the  greatest  care  must  be  taken  in  establishing  a  diagnosis.  That  they 
may  be  the  symptoms  of  pure  neurasthenia,  however,  can  no  longer  be 
doubted. 

The  reflexes  in  neurasthenia  are  usually  increased,  the  deep  reflexes 
especially  never  being  absent.  The  condition  of  the  superficial  reflexes  is 
less  constant,  though  these,  too,  are  usually  increased.  The  pupils  are  often 
dilated,  and  the  reflexes  are  usually  normal.  There  may  be  inequality  of  the 
pupils  in  neurasthenia,  a  point  which  Pelizaeus  has  especially  empliasized. 

In  another  type  of  cases  the  muscular  weakness  is  extreme,  and  may  go 
on  even  to  complete  motor  helplessness.  Very  thorough  examination  is 
necessary  before  deciding  as  to  the  nature  of  the  affection,  since  in  some 

*  For  an  exhaustive  consirleration  of  the  mental  symptoms  of  neurasthenia,  see  the 
Shattuck  Lecture,  by  Cowles  (Boston  Medical  and  Sursjical  Journal,  1891),  as  well  as  two 
German  monographs,  that  of  Binswangcr  (1896),  and  that  of  Lowonfeld.  The  French 
treatise  of  Bouveret  (1891)  is  also  valuable.  F.  C.  Mliller's  ITandbuch  dcr  Neurasthenie 
(Leipzig,  1893)  contains  an  excellent  bibliography  of  this  subject. 


1126  DISEASES  OP  THE  NERVOUS  SYSTEM. 

instances  serious  mistakes  have  been  made.  Here  belong  the  atremia  of 
Neftel,  the  akinesia  algera  of  Mobius,  and  the  neurasthenic  form  of  astasia 
abasia  described  by  Binswanger. 

In  other  cases  the  cardio-vascular  symptoms  are  the  most  distressing, 
and  may  occur  with  only  slight  disturbance  of  the  cerebro-spinal  functions, 
though  the  conditions  are  nearly  always  combined.  Palpitation  of  the  heart, 
irregular  and  very  rapid  action  (neurasthenic  tachycardia),  and  pains  and 
oppressive  feelings  in  the  cardiac  region  are  the  most  common  symptoms. 
The  slightest  excitement  may  be  followed  by  increased  action  of  the  heart, 
sometimes  associated  with  sensations  of  dizziness  and  anxiety,  and  the  pa- 
tients frequently  have  the  idea  that  they  suffer  from  serious  disease  of  this 
organ.    Attacks  of  pseudo-angina  may  occur. 

Vaso-motor  disturbances  constitute  a  special  feature  of  many  cases. 
Flushes  of  heat,  especially  in  the  head,  and  transient  hypersBmia  of  the 
skin  may  be  very  distressing  symptoms.  Profuse  sweating  may  occur, 
either  local  or  general,  and  sometimes  nocturnal.  The  pulse  may  show  inter- 
esting features,  owing  to  the  extreme  relaxation  of  the  peripheral  arterioles. 
The  arterial  throbbing  may  be  everywhere  visible,  almost  as  much  as  in 
aortic  insufficiency.  The  pulse,  too,  may  under  these  circumstances  have 
a  somewhat  water-hammer  quality.  The  capillary  pulse  may  be  seen  in 
the  nails,  on  the  lips,  or  on  the  margins  of  a  line  drawn  upon  the  forehead, 
and  I  have  on  several  occasions  seen  pulsation  in  the  veins  of  the  back  of 
the  hand.  A  characteristic  symptom  in  some  cases  is  the  throbbing  aorta. 
This  "  preternatural  pulsation  in  the  epigastrium,"  as  Allan  Burns  calls 
it,  may  be  extremely  forcible  and  suggest  the  existence  of  abdominal  aneu- 
rism. The  subjective  sensations  associated  with  it  may  be  very  unpleasant, 
particularly  when  the  stomach  is  empty. 

In  women  especially,  and  sometimes  in  men,  the  peripheral  blood-ves- 
sels are  contracted,  the  extremities  are  cold,  the  nose  is  red  or  blue,  and  the 
face  has  a  pinched  expression.  These  patients  feel  much  more  comfortable 
when  the  cutaneous  vessels  are  distended,  and  resort  to  various  means  to 
favor  this  (wearing  of  heavy  clothing,  use  of  diffusible  stimulants). 

The  general  features  of  g astro-intestinal  neurasthenia  have  been  dealt 
with  under  the  section  of  nervous  dyspepsia.  The  connection  of  these  cases 
with  dilatation  of  the  stomach,  floating  kidney,  and  the  condition  which 
Glenard  calls  enteroptosis  has  already  been  mentioned. 

Sexual  neurasthenia  is  a  condition  in  which  there  is  an  irritable  weak- 
ness of  the  sexual  organs  manifested  by  nocturnal  emissions,  unusual  de- 
pression after  intercourse,  and  often  by  a  distressing  dread  of  impotence. 
The  mental  condition  of  these  patients  is  most  pitiable,  and  they  fall  an 
easy  prey  to  quacks  and  charlatans  of  all  kinds. 

Spermatorrhoea  is  the  bugbear  of  the  majority.  They  complain  of  con- 
tinued losses,  usually  without  accompanying  pleasurable  sensations.  After 
defecation  or  micturition  there  may  be  seminal  discharges.  Microscopic  ex- 
amination sometimes  reveals  the  presence  of  spermatozoa.  Actual  nervous 
impotence  is  not  uncommon.  The  "  painful  testicle  "  is  a  well-known  neu- 
rasthenic phenomenon. 

In  the  severer  cases,  especially  those  bearing  the  stigmata  of  degenera- 


NEURASTHENIA.  1127 

tion,  there  may  be  evidence  of  sexual  perversion.  The  "  damnable  itera- 
tion "  with  which  writers  in  our  ranks  "  dish  up  "  this  unpleasant  subject 
is  proof  positive  that  not  all  prophets  speak  to  edification. 

In  females  it  is  common  to  find  a  tender  ovary,  and  painful  or  irregular 
menstruation. 

In  all  forms  of  neurasthenia  the  condition  of  the  urine  is  important. 
Many  cases  are  complicated  with  the  symptoms  of  the  condition  known 
as  lithgemia,  and  so  marked  may  this  be  that  some  have  indeed  made  a  spe- 
cial form  of  lithgemic  neurasthenia.  Polyuria  may  be  present,  but  is  more 
common  in  hysteria.  With  disturbed  digestion  the  urates  and  oxalates 
may  be  in  excess. 

Diagnosis.' — While  in  the  majority  of  cases  the  diagnosis  can  readily 
be  made,  still  there  are  instances  in  which  it  is  very  difficult.  Neurasthenia 
overlaps  hypochondria  and  hysteria  on  the  one  hand,  and  the  psychoses  and 
degenerative  diseases  of  the  nervous  system  on  the  other.  The  term  has 
in  the  past  been  altogether  too  loosely  used.  Simple  local  disturbances 
and  temporary  general  disturbances  the  result  of  sudden  overexertion  should 
scarcely  be  diagnosed  as  neurasthenia.  Only  when  we  have  before  us  a 
clinical  picture  indicating  general  weakness  of  the  nervous  system  in  addi- 
tion to  the  local  disturbances,  no  matter  how  pronounced  they  are,  is  the 
diagnosis  justifiable.  Charcot  has  designated  as  neurasthenic  stigmata  cer- 
tain fundamental  and  typical  symptoms,  such  as  the  pain  and  pressure  in 
the  head,  the  disturbances  of  sleep,  the  rhachialgia  and  spinal  hyperses- 
thesia,  the  muscular  weakness,  the  nervous  dyspepsia,  the  disturbances  of 
the  genital  organs,  and  the  typical  mental  phenomena  (irritable  humor, 
psychic  depression,  feelings  of  anxiety,  intellectual  fatigue,  incapacity  of 
decision,  and  the  like).  In  addition  to  these  cardinal  symptoms  of  the  dis- 
ease, he  described  as  secondary  or  accessory  symptoms  the  feelings  of  dizzi- 
ness and  vertigo,  the  neurasthenic  asthenopia,  the  circulatory,  respiratory, 
secretory,  and  nutritive  disturbances,  disturbances  of  motility  and  sensa- 
tion, the  fever  of  neurasthenia,  and  neurasthenic  idiosyncrasies.  The  anxiety 
conditions  and  various  phobias,  as  well  as  the  different  varieties  of  tic  and 
the  occupation  neuroses  when  they  accompany  neurasthenia,  are  regarded 
as  complications  dependent  in  the  majority  of  instances  upon  faulty  hered- 
ity. I  must  agree  with  Binewanger  in  emphasizing  the  importance  for  the 
diagnosis  of  the  peculiar  intellectual  and  emotional  condition  of  the  patient, 
as  well  as  the  disturbances  of  sleep. 

Neurasthenia  is  a  disease  above  all  others  which  has  to  be  diagnosed 
from  the  subjective  statements  of  the  patient,  and  from  an  observation  of 
his  general  behavior  rather  than  from  the  physical  examination.  The 
physical  examination  is  of  the  highest  importance  in  excluding  other  dis- 
eases likely  to  be  confounded  with  it.  That  somatic  changes  occur  and  tliat 
physical  signs  are  often  to  be  made  out  is  very  true,  and  we  owe  to  Lowen- 
feld  especially  a  careful  discussion  of  these  points,  but  there  is  nothing 
typical  or  pathognomonic  in  these  objective  changes. 

The  hypochondriac  differs  from  the  neurasthenic  in  the  excessive  psychic 
distortion  of  the  pathological  sensations  to  which  he  is  subject.  He  is 
the  victim  of  actual  delusions  regarding  his  condition. 


1128  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  confusion  of  neurasthenia  with  hysteria  is  still  more  frequent;  in 
women  especially  a  diagnosis  of  hysteria  is  often  made  when  in  reality 
the  condition  is  one  of  neurasthenia.  In  the  absence  of  hysterical  par- 
oxysms, of  crises,  and  of  those  marked  emotional  and  intellectual  char- 
acteristics of  the  hysterical  individual  the  diagnosis  of  hysteria  should  not 
be  made.  Of  course,  in  many  of  the  cases  of  hysteria  definite  hysterical 
stigmata  (hysterical  paralyses,  convulsions,  contractures,  anesthesias, 
alterations  in  the  visual  field,  etc.)  are  present,  and  the  diagnosis  is  not 
difficult. 

Epilepsy  is  not  likely  to  be  confounded  with  neurasthenia  if  there  be 
definite  epileptic  attacks,  but  the  cases  of  petit  mal  may  be  puzzling. 

The  onset  of  exophthalmic  goitre  may  be  mistaken  for  neurasthenia, 
especially  if  there  be  no  exophthalmos  at  the  beginning.  The  emotional 
disturbances  and  the  irritability  of  the  heart  may  mislead  the  physician. 
In  pronounced  cases  of  nervous  prostration  the  differential  diagnosis  from 
the  various  psychoses  may  be  extremely  difficult. 

The  two  forms  of  organic  disease  of  the  nervous  system  with  which  neu- 
rasthenia is  most  likely  to  be  confounded  are  tabes  and  general  paresis.  The 
symptoms  of  the  spinal  form  of  neurasthenia  may  resemble  those  of  the 
former  disease,  while  the  symptoms  of  the  psychic  or  cerebral  form  of  neu- 
rasthenia may  be  very  similar  to  those  of  general  paresis.  The  diagnosis, 
as  a  rule,  presents  no  difficulty  if  the  physician  be  careful  to  make  a  thor- 
ough routine  examination.  It  is  only  the  superficial  study  of  a  case  that  is 
likely  to  lead  one  astray.  In  tabes  especially  a  consideration  of  the  sensory 
disturbances,  of  the  deep  reflexes,  and  of  the  pupillary  findings  will  always 
establish  the  presence  or  absence  of  the  disease.  In  general  paresis  there  is 
sometimes  more  difficulty.  The  onset  of  general  paresis  is  often  character- 
ized by  the  appearance  of  symptoms  quite  like  those  of  ordinary  neu- 
rasthenia, and  the  family  physician  may  entirely  overlook  the  grave  nature 
of  the  malady.  The  mistake  in  the  other  direction  is,  however,  perhaps  just 
as  common.  A  physician  who  once  or  twice  has  seen  a  case  of  general 
paresis  develop  out  of  what  appeared  to  be  one  of  pronounced  neurasthenia 
is  too  prone  afterward  to  suspect  every  neurasthenic  to  be  developing  the 
malign  affection.  The  most  marked  symptoms,  however,  of  psychic  ex- 
haustion do  not  justify  a  diagnosis  of  general*  paresis  even  when  the  his- 
tory is  suspicious,  unless  along  with  it  definite  paresis  of  the  facial  or  mus- 
cles of  articulation  or  of  the  pupils  exist.  A  history  of  syphilis  or  of  chronic 
alcoholism  or  morphinism  associated  with  severe  psychic  exhaustion  should, 
of  course,  put  one  always  on  his  guard,  and  the  physician  should  be  sharply 
on  the  lookout  for  the  appearance  of  intellectual  defects,  paraphasia,  facial 
paresis,  and  sluggishness  of  the  pupils. 

Treatment.' — Prophylaxis. — Many  patients  come  under  our  care  a 
generation  too  late  for  satisfactory  treatment,  and  it  may  be  impossible  to 
restore  the  exhausted  capital.  The  greatest  care  should  be  taken  in  the 
rearing  of  children  of  neuropathic  predisposition.  From  a  very  early  age 
they  should  be  submitted  to  a  process  of  "  psychic  hardening,"  every  effort 
being  made  to  strengthen  the  bodily  and  mental  condition.  Even  in  in- 
fancy the  child  should  not  be  pampered.     Later  on  the  greatest  care  should 


NEURASTHENIA.  1129 

be  exercised  with  regard  to  food,  sleep,  and  school  work.  Complaints  of 
children  should  not  be  too  seriously  considered. 

Much  depends  upon  the  example  set  by  the  parents.  A  restless,  emo- 
tional, constantly  complaining  mother  will  rack  the  nervous  system  of  a 
delicate  child.  In  some  instances,  for  the  welfare  of  a  developing  boy  or 
girl,  the  physician  may  find  it  necessary  to  advise  its  removal  from 
home. 

Neurotic  children  are  especially  liable  during  development  to  fits  of 
temper  and  of  emotional  disturbance.  These  should  not  be  too  lightly 
considered.  Above  all,  violent  chastisement  in  such  cases  is  to  be  avoided, 
and  loss  of  temper  on  the  part  of  the  parent  or  teacher  is  particularly  per- 
nicious for  the  nervous  system  of  the  child.  Where  possible,  in  such  in- 
stances, the  best  treatment  is  to  put  the  obstreperous  child  immediately  to 
bed,  and  if  the  excitement  and  temper  continue  a  warm  bath  followed  by 
a  cool  douch  may  be  effective.  If  he  be  put  to  bed  after  the  bath  sleep  soon 
follows. 

Special  attention  is  necessary  at  puberty  in  both  boys  and  girls.  If 
there  be  at  this  period  any  marked  tendency  to  emotional  disturbance  or  to 
intellectual  weakness  the  child  should  be  removed  from  school  and  every 
care  taken  to  avoid  unfavorable  influences. 

Personal  Hygiene. — Throughout  life  individuals  of  neuropathic  predis- 
position should  obey  scrupulously  certain  hygienic  and  prophylactic  rules. 
Intellectual  work  especially  should  be  judiciously  limited  and  should  alter- 
nate frequently  with  periods  of  repose.  Excitement  of  all  kinds  should  of 
course  be  avoided,  and  such  individuals  will  do  well  to  be  abstemious  in 
the  use  of  tobacco,  tea,  coffee,  and  alcohol,  if,  indeed,  they  be  permitted  to 
use  these  substances  at  all.  The  habit,  happily  in  this  country  becoming 
very  common,  of  taking  at  least  once  a  year  a  prolonged  holiday  away  from 
the  ordinary  environment,  in  the  woods,  in  the  mountains,  or  at  the  sea- 
shore, should  be  urgently  enjoined  upon  every  neuropathic  individual.  In 
many  instances  it  is  found  to  be  the  greatest  relief  and  rest  if  the  patient 
can  take  his  holiday  away  from  his  relatives. 

During  ordinary  life  nervous  people  should,  during  some  portion  of 
each  day,  pay  rational  attention  to  the  body.  Cold  baths,  swimming,  exer- 
cises in  the  gymnasium,  gardening,  golf,  lawn  tennis,  cricket,  hunting, 
shooting,  rowing,  sailing,  and  bicycling  are  of  value  in  maintaining  the 
general  nutrition.  Such  exercises  are,  of  course,  to  be  recommended  only 
to  individuals  physically  equal  to  them.  If  neurasthenia  be  once  well  de- 
veloped the  greatest  care  must  be  observed  in  the  ordering  of  exercise. 
Many  nervous  girls  have  been  completely  broken  down  by  following  injudi- 
cious advice  with  regard  to  long  walks. 

Treatment  of  the  Condition. — The  treatment  of  neurasthenia  when  once 
established  presents  a  varied  problem  to  the  thoughtful  physician.  Every 
ease  must  be  handled  upon  its  own  merits,  no  two,  as  a  rule,  requiring  ex- 
actly the  same  methods.  In  general  it  will  be  the  aim  of  the  medical 
adviser  to  remove  the  patient  as  far  as  possible  from  the  influences  which 
have  led  to  his  downfall,  and  to  restore  to  normal  the  nervous  mechanisms 
which  have  been  weakened  by  injurious  influences.     The  general  character 


1130  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  the  individual,  his  physical  and  social  status  must  of  course  be  consid- 
ered, and  the  therapeutic  measures  carefully  adjusted  to  these. 

Above  all,  the  physician  must  first  gain  the  confidence  of  his  patient, 
and  this  he  will  not  do  if  he  be  inattentive  to  the  complaints  of  the  individ- 
ual, especially  at  first,  or  if  he  rudely  tell  the  patient  before  he  has  care- 
fully examined  him  and  observed  him  for  some  time  that  his  troubles  are 
imaginary.  As  has  been  said,  it  is  education  more  than  medicine  that 
these  patients  need,  but  the  patients  themselves  do  not  wish  to  be  educated; 
they  come  to  the  physician  to  be  treated,  and  the  educating  process  has  to 
be  disguised. 

The  diagnosis  having  been  settled,  the  physician  may  assure  the  patient 
that  with  prolonged  treatment,  during  which  his  cooperation  with  the  physi- 
cian is  absolutely  essential,  he  may  expect  to  get  well.  He  must  be  told 
that  much  depends  upon  himself  and  that  he  must  make  a  vigorous 
effort  to  overcome  certain  of  his  tendencies,  and  that  all  his  strength 
of  will  will  be  needed  to  further  the  progress  of  the  cure.  In  the  case  of 
business  or  professional  men,  in  whom  the  condition  develops  as  a  result 
of  overwork  or  overstudy,  it  may  be  sufficient  to  enjoin  absolute  rest  with 
change  of  scene  and  diet.  A  trip  abroad,  with  a  residence  for  a  month  or 
two  in  Switzerland,  or,  if  there  are  symptoms  of  nervous  dyspepsia,  a  resi- 
dence at  one  of  the  Spas  will  usually  prove  sufficient.  The  excitement  of 
the  large  cities  abroad  should  be  avoided.  The  longer  the  disease  has 
lasted  and  the  more  intense  the  symptoms  have  been,  the  longer  the  time 
necessary  for  the  restoration  of  health.  In  cases  of  any  severity  the  patient 
must  be  told  that  at  least  six  months'  complete  absence  from  business,  under 
strict  medical  guidance,  will  be  necessary.  Shorter  periods  may  of  course 
be  of  benefit,  which,  however,  as  a  rule,  will  be  only  temporary. 

It  will  be  wise  in  very  many  cases  to  treat  the  individual  for  a  few 
weeks  at  least  in  a  hospital  or  other  institution  before  sending  him  away  on 
a  journey.  In  this  preliminary  treatment  the  greatest  tact  is  required  on 
the  part  of  the  medical  attendant  and  nurse.  The  patient  should  not  see 
the  doctor  too  often  after  the  first  careful  examination,  although  he  should 
of  course  receive  regular  visits  from  him.  The  physician  will  make  a  mis- 
take if  he  responds  to  frequent  calls  on  the  part  of  the  patient  between 
the  periods  of  his  regular  visits.  The  choice  of  a  nurse  is  by  no  means  an 
easy  matter.  That  she  should  be  healthy,  strong,  and  by  no  means 
nervous  herself  are  among  the  first  considerations.  Sallow-faced,  emo- 
tional, emaciated  women  can  only  do  harm  if  detailed  to  the  care  of  a 
nervous  patient. 

It  will  often  be  found  advisable  to  make  out  a  daily  programme,  which 
shall  occupy  almost  the  whole  time  of  the  patient.  At  first  he  need  know 
nothing  about  this,  the  case  being  given  over  entirely  to  the  nurse.  As 
improvement  advances,  moderate  physical  and  intellectual  exercises,  alter- 
nating frequently  with  rest  and  the  administration  of  food,  may  be  under- 
taken. Some  one  hour  of  the  day  may  be  left  free  for  reading,  correspond- 
ence, conversation,  and  games.  In  some  instances  the  writing  of  letters  is 
particularly  harmful  to  the  patient  and  must  be  prohibited  or  limited.  Cul- 
tured individuals  may  find  benefit  from  attention  to  drawing,  painting,  mod- 


NEURASTHENIA.  1131 

elling,  translating  from  a  foreign  language,  the  making  of  abstracts,  etc., 
for  short  periods  in  the  day. 

In  not  a  few  cases,  including  a  large  proportion  of  neurasthenic  women, 
a  systematic  Weir  Mitchell  treatment  rigidly  carried  out  should  be  tried 
(see  Hysteria).  For  obstinate  and  protracted  cases,  particularly  if  com- 
bined with  the  chloral  or  morphia  habit,  no  other  plan  is  so  satisfactory. 
The  patient  must  be  isolated  from  his  friends,  and  any  regulations  under- 
taken must  be  strictly  adhered  to,  the  consent  of  the  patient  and  his  family 
having  first  been  gained.  If  the  case  responds  well  to  the  treatment  there 
should  be  a  gain  of  from  2  to  4  pounds  per  week.  The  benefit  is  often 
extraordinary,  individuals  increasing  in  weight  as  much  as  from  50  to  80 
pounds  in  the  course  of  twelve  weeks.  The  treatment  of  the  gastric  and  in- 
testinal symptoms  so  important  in  this  condition  has  already  been  con- 
sidered. For  the  irregular  pains,  particularly  in  the  back  and  neck,  the 
thermo-cautery  is  invaluable. 

Hydrotherapy  is  indicated  in  nearly  every  case  if  it  can  be  properly 
-applied.  Much  can  be  done  at  home  or  in  an  ordinary  hospital,  but  for 
systematic  hydrotherapeutic  treatment  residence  in  a  suitable  sanitarium  is 
necessary.  I  have  found  the  wet  pack  of  especial  value.  Particularly  at 
night  in  cases  of  sleeplessness  it  is  perhaps  the  "best  remedy  against  in- 
somnia we  have.  Some  patients  gain  rapidly  in  weight  through  the  sys- 
tematic use  of  the  wet  pack.  Salt  baths  are  more  helpful  to  some  patients. 
The  various  forms  of  douches,  partial  packs,  foot  baths,  etc.,  may  be  valu- 
able in  individual  cases.  The  Scotch  douche  is  often  invigorating  in  the 
milder  cases. 

Electrotherapy  is  of  some  value,  though  only  in  combination  with  psy- 
chic treatment  and  hydrotherapy.  General  and  local  faradization,  galvanic 
electricity,  and  Franklinization  may  be  used;  in  every  case,  however,  with 
great  caution  and  only  by  skilled  operators. 

Treatment  by  drugs  should  be  avoided  as  much  as  possible.  They  are 
of  benefit  chiefly  in  the  combating  of  single  symptoms.  A  placebo  is 
sometimes  necessary  for  its  psychic  effect.  Alcohol,  morphia,  chloral,  or  co- 
caine should  never  be  given.  The  family  physician  is  often  responsible  for 
the  development  of  a  drug  habit.  I  have  been  repeatedly  shocked  by  the 
loose,  careless  way  in  which  physicians  inject  morphia  for  a  simple  head- 
ache or  a  mild  neuralgia. 

General  tonics  may  be  helpful,  especially  if  the  individual  be  anaemic. 
Arsenic  and  more  often  iron  are  then  indicated.  The  value  of  phosphorus 
has  been  exaggerated.  For  the  severer  pains  and  nervous  attacks  some 
sedative  may  occasionally  be  necessary,  especially  at  the  beginning  of  tbe 
treatment.  The  bromides,  especially  a  mixture  of  the  salts  of  ammonium, 
potassium,  and  sodium  may  here  be  given  with  advantage.  An  occasional 
dose  of  plienacetin,  antipyrin,  or  salipyrin  may  be  required,  but  the  less  of 
these  substances  we  can  get  along  with  the  better.  For  the  relief  of  sleep- 
lessness all  possible  measures  should  be  resorted  to  before  the  employment  of 
drugs.  The  wet  pack  will  usually  suffice.  If  absolutely  necessary  to  give 
a  drug,  sulphonal,  trional,  or  amylene  hydrate  may  be  employed. 

In  cases  in  which  the  anxiety  conditions  are  disturbing,  the  cautious  use 


1132 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


of  opium  in  pill  form  may  be  necessary,  since,  as  in  the  psychoses,  opium 
here  will  sometimes  yield  permanent  relief.  A  prolonged  treatment  with 
opium  is,  however,  never  necessary  in  neurasthenia. 


Xm.   THE   TRAUMATIC    NEUROSES 

{Railway  Brain  and  Railway  Spine  ;  Traumatic  Hysteria). 

Definitiou. — A  morbid  condition  following  shock  which  presents  the 
symptoms  of  neurasthenia  or  hysteria  or  of  both.  The  condition  is  known 
as  "  railway  brain  "  and  "  railway  spine." 

Erichsen  regarded  the  condition  as  the  result  of  inflammation  of  the 
meninges  and  cord,  and  gave  it  the  name  railway  spine.  Walton  and 
J.  J.  Putnam,  of  Boston,  were  the  first  to  recognize  the  hysterical  nature 
of  many  of  the  cases,  and  to  Westphal's  pupils  we  owe  the  name  traumatic 
neurosis.  For  an  excellent  discussion  of  the  whole  question  the  reader  is 
referred  to  Pearce  Baily's  recent  work.  On  Accident  and  Injury;  their  Eela- 
tion  to  Diseases  of  the  Nervous  System. 

Etiology. — The  condition  follows  an  accident,  often  in  a  railway 
train,  in  which  injury  has  been  sustained,  or  succeeds  a  shock  or  concus- 
sion, from  which  the  patient  may  apparently  not  have  suffered  in  his  body. 
A  man  may  appear  perfectly  well  for  several  days,  or  even  a  week  or 
more,  and  then  develop  the  symptoms  of  the  neurosis.  Bodily  shock  or 
concussion  is  not  necessary.  The  affection  may  follow  a  profound  mental 
impression;  thus,  an  engine-driver  ran  over  a  child,  and  received  thereby 
a  very  severe  shock,  subsequent  to  which  the  most  pronounced  symptoms 
of  neurasthenia  developed.  Severe  mental  strain  combined  with  bodily 
exposure  may  cause  it,  as  in  a  case  of  a  naval  officer  who  was  wrecked  in 
a  violent  storm  and  exposed  for  more  than  a  day  in  the  rigging  before 
he  was  rescued.  A  slight  blow,  a  fall  from  a  carriage  or  on  the  stairs  may 
suffice. 

Symptoms. — The  cases  may  be  divided  into  three  groups:  simple 
neurasthenia,  cases  with  marked  hysterical  manifestations,  and  cases  with 
severe  symptoms  indicating  or  simulating  organic  disease. 

(a)  Simple  Traumatic  Neurasthenia. — The  first  symptoms  usually  de- 
velop a  few  weeks  after  the  accident,  which  may  or  may  not  have  been 
associated  with  an  actual  trauma.  The  patient  complains  of  headache 
and  tired  feelings.  He  is  sleepless  and  finds  himself  unable  to  concentrate 
his  attention  properly  upon  his  work.  A  condition  of  nervous  irritability 
develops,  which  may  have  a  host  of  trivial  manifestations,  and  the  entire 
mental  attitude  of  the  person  may  for  a  time  be  changed.  He  dwells  con- 
stantly upon  his  condition,  gets  very  despondent  and  low-spirited,  and  in 
extreme  cases  melancholia  may  develop.  He  may  complain  of  numbness 
and  tingling  in  the  extremities,  and  in  some  cases  of  much  paki  in  the 
back.  The  bodily  functions  may  be  well  performed,  though  such  patients 
usually  have,  for  a  time  at  least,  disturbed  digestion  and  loss  in  weight. 
The  physical  examination  may  be  entirely  negative.  The  reflexes  are 
slightly  increased,  as  in  ordinary  neurasthenia.     The  pupils  may  be  un- 


THE  TRAUMATIC  NEUROSES.  1133 

equal;  the  cardio-vasciilar  changes  ah-eady  described  in  neurasthenia  may 
be  present  in  a  marked  degree.  According  as  the  symptoms  are  more 
spinal  or  more  cerebral,  the  condition  is  known  as  railway  brain  or  rail- 
way spine. 

(2)  Cases  with  Marked  Hysterical  Features. — Following  an  injury  of 
any  sort,  neurasthenic  symptoms,  like  those  described  above,  may  develop, 
and  in  addition  symptoms  regarded  as  characteristic  of  hysteria.  The 
emotional  element  is  prominent,  and  there  is  but  slight  control  over  the 
feelings.  The  patients  have  headache,  backache,  and  vertigo.  A  violent 
tremor  may  be  present,  and  indeed  constitutes  the  most  striking  feature  of 
the  ease.  I  have  recently  seen  an  engineer  who  developed  subsequent  to 
an  accident  a  series  of  nervous  phenomena,  but  the  most  marked  feature 
was  an  excessive  tremor  of  the  entire  body,  which  was  specially  manifest 
during  emotional  excitement.  The  most  pronounced  hysterical  symptoms 
are  the  sensory  disturbances.  As  first  noted  by  Putnam  and  Walton,  hemi- 
ansesthesia  may  occur  as  a  sequence  of  traumatism.  This  is  a  common 
symptom  in  France,  but  rare  in  England  and  in  this  country.  Achromatop- 
sia may  exist  on  the  anaesthetic  side.  A  second,  more  common,  manifesta- 
tion is  limitation  of  the  field  of  vision,  similar  to  that  which  occurs  in 
hysteria. 

Eemarkable  disturbances  may  develop  in  some  of  these  cases.  A  few 
months  ago  I  saw  a  man  who  had  been  struck  by  an  electric  car,  whose 
chief  symptom  was  an  extraordinary  increase  in  the  number  of  respira- 
tions. He  was  a  stout,  powerfully  built  man,  and  presented  practically  no 
other  symptom  than  dyspnoea  of  the  most  extreme  grade.  At  the  time  of 
observation  his  respirations  were  over  130  per  minute,  and  he  stated  that 
they  had  been  counted  at  over  150. 

(3)  Cases  in  which  the  Symptoms  suggest  Organic  Disease  of  the  Brain 
and  Cord. — As  a  result  of  spinal  concussion,  without  fracture  or  external 
injury,  there  may  subsequently  develop  symptoms  suggestive  of  organic 
disease,  which  may  come  on  rapidly  or  at  a  late  date.  In  a  case  reported  by 
Leyden  the  symptoms  following  the  concussion  were  at  first  slight  and  the 
patient  was  regarded  as  a  simulator,  but  finally  the  condition  became  aggra- 
vated and  death  resulted.  The  post  mortem  showed  a  chronic  pachy- 
meningitis, which  had  doubtless  resulted  from  the  accident.  The  cases 
in  this  group  about  which  there  is  so  much  discussion  are  those  which  dis- 
play marked  sensory  and  motor  changes.  Following  an  accident  in  which 
the  patient  has  not  received  external  injury  a  condition  of  excitement  may 
develop  within  a  week  or  ten  days;  he  complains  of  headache  and  backache, 
and  on  examination  sensory  disturbances  are  found,  either  hemianesthesia 
or  areas  on  the  skin  in  which  the  sensation  is  much  benumbed;  or  painful 
and  tactile  impressions  may  be  distinctly  felt  in  certain  regions,  and  the 
temperature  sense  is  absent.  The  distribution  may  be  bilateral  and  sym- 
metrical in  limited  regions  or  hemiplegie  in  type.  Limitation  of  the  field 
of  vision  is  usually  marked  in  these  cases,  and  there  may  be  disturbance 
of  the  senses  of  taste  and  smell.  The  superficial  reflexes  may  be  diminished; 
usually  the  deep  reflexes  are  exaggerated.  Tlic  pupils  may  be  unequal;  the 
motor  disturbances  are  variable.     The  French   writers  describe  cases  of 


1134  DISEASES  OF  THE  NERVOUS  SYSTEM. 

monoplegia  with  or  without  contracture,  symptoms  upon  which  Charcot  lays 
great  stress  as  a  manifestation  of  profound  hysteria.  The  combination  of 
sensory  disturbances — ansesthesia  or  hypersesthesia — with  paralysis,  particu- 
larly if  monoplegic,  and  the  occurrence  of  contractures  without  atrophy  and 
with  normal  electrical  reactions,  may  be  regarded  as  distinctive  of  hysteria. 

In  rare  cases  following  trauma  and  succeeding  to  symptoms  which  may 
have  been  regarded  as  neurasthenic  or  hysterical,  there  are  organic  changes 
which  may  prove  fatal.  That  this  sequence  occurs  is  demonstrated  clearly 
by  recent  post-mortem  examinations.  The  features  upon  which  the  greatest 
reliance  can  be  placed  as  indicating  organic  change  are  optic  atrophy,  blad- 
der symptoms,  particularly  in  combination  with  tremor,  paresis,  and  exag- 
gerated reflexes. 

The  anatomical  changes  in  this  condition  have  not  been  very  definite. 
When  death  follows  spinal  concussion  within  a  few  days  there  may  be  no 
•apparent  lesion,  but  in  some  instances  the  brain  or  cord  has  shown  punc- 
tiform  haemorrhages.  Edes  has  reported  4  cases  in  which  a  gradual  degen- 
eration in  the  pyramidal  tracts  followed  concussion  or  injury  of  the  spine; 
but  in  all  these  cases  there  was  marked  tremor  and  the  spinal  symptoms 
developed  early  or  followed  immediately  upon  the  accident.  Autopsies 
upon  cases  in  which  organic  lesions  have  supervened  upon  a  traumatic 
neurosis  are  extremely  rare.  Bernhardt  reports  an  instance  of  a  man,  aged 
thirty-three,  who  in  1886  received  a  kick  from  a  horse  on  the  epigastrium 
and  subsequently  developed  the  symptom-complex  of  neurasthenia  and  hys- 
teria with  attacks  of  vertigo  and  great  psychical  depression.  He  afterward 
had  more  marked  mental  sym|)toms  and  attacks  of  unconsciousness.  He 
committed  suicide  and  the  brain  and  cord  showed  a  beginning  multiple 
sclerosis  in  the  white  matter,  which  was  possibly  associated  with  an  ad- 
vanced grade  of  arterio-sclerosis.  In  a  second  case  a  man,  aged  forty-two, 
received  a  shock  in  a  railway  accident  in  July,  1884.  He  was  rendered 
unconscious  and  had  a  slight  injury  in  the  buttock  region.  In  a  few  weeks 
symptoms  of  traumatic  neurosis  developed,  particularly  great  depression 
of  spirits,  with  headache  and  sensory  disturbances  in  the  feet  and  hands. 
Tremor  and  great  weakness  were  complained  of  when  he  attempted  to 
work.  There  was  no  increase  in  the  reflexes.  The  case  was  regarded  as  an 
instance  of  simulation  and  a  defect  in  objective  s}Tnptoms  favored  this 
view.  Subsequently  this  judgment  was  reversed,  but  he  did  not  improve. 
He  died  in  January,  1889,  with  symptoms  of  cardiac  dyspnosa.  Macro- 
scopically  the  brain  and  cord  appeared  normal.  There  was  extreme  arterio- 
sclerosis, particularly  of  the  vessels  of  the  brain  and  cord.  In  the  latter 
there  were  scattered  areas  of  degeneration  in  the  white  substance,  and  de- 
generation in  the  sympathetic  ganglia. 

I  have  entered  somewhat  fully  into  this  question  because  of  its  extreme 
importance  and  on  account  of  the  paucity  of  the  observations  upon  cases 
which  have  subsequently  developed  symptoms  of  organic  disease.  Exam- 
ples of  it  are  extremely  rare.  So  far  as  I  know  no  case  with  autopsy  has 
been  reported  in  this  country,  nor  have  I  seen  an  instance  in  which  the 
clinical  features  pointed  to  an  organic  disease  which  had  followed  upon  a 
traumatic  neurosis. 


THE   TRAUMATIC   NEUROSES.  1135 

Diagnosis. — A  coudition  of  fright  and  excitement  following  an  acci- 
dent may  persist  for  days  or  even  weeks,  and  then  gradually  pass  away. 
The  symptoms  of  neurasthenia  or  of  hysteria  which  subsequently  develop 
present  nothing  peculiar  and  are  identical  with  those  which  occur  under 
other  circumstances.  Care  must  be  taken  to  recognize  simulation,  and,  as  in 
these  cases  the  condition  is  largely  subjective,  this  is  sometimes  extremely 
difficult.  In  a  careful  examination  a  simulator  will  often  reveal  himself 
by  exaggeration  of  certain  symptoms,  particularly  sensitiveness  of  the  spine, 
and  by  increasing  voluntarily  the  reflexes.  Maunkopff  suggests  as  a  good 
test  to  take  the  pulse-rate  before,  during,  and  after  pressure  upon  an  area 
said  to  be  painful.  If  the  rate  is  quickened,  it  is  held  to  be  proof  that  the 
pain  is  real.  This  is  not,  however,  always  the  case.  It  may  require  a  careful 
study  of  the  case  to  determine  whether  the  individual  is  honestly  suffering 
from  the  symptoms  of  which  he  complains.  A  still  more  important  ques- 
tion in  these  cases  is.  Has  the  patient  organic  disease?  The  symptoms  given 
under  the  first  two  groups  of  eases  may  exist  in  a  marked  degree  and  may 
persist  for  several  years  without  the  slightest  evidence  of  organic  change. 
Hemiansesthesia,  limitation  of  the  field  of  vision,  monoplegia  with  con- 
tracture, may  all  be  present  as  hysterical  manifestations,  from  which  recov- 
ery may  be  complete.  In  our  present  knowledge  the  diagnosis  of  an  organic 
lesion  should  be  limited  to  those  cases  in  which  optic  atrophy,  bladder 
troubles,  and  signs  of  sclerosis  of  the  cord  are  well  marked — indications 
either  of  degeneration  of  the  lateral  columns  or  of  multiple  sclerosis. 

Prognosis. — A  majority  of  patients  with  traumatic  hysteria  recover. 
In  railway  cases,  so  long  as  litigation  is  pending  and  the  patient  is  in  the 
hands  of  lawyers  the  symptoms  usually  persist.  Settlement  is  often  the 
starting-point  of  a  speedy  and  perfect  recovery.  I  have  known  return  to 
health  after  the  persistence  of  the  most  aggravated  symptoms  with  com- 
plete disability  of  from  three  to  five  years'  duration.  On  the  other  hand, 
there  are  a  few  cases  in  which  the  symptoms  persist  even  after  the  litigation 
has  been  closed;  the  patient  goes  from  bad  to  worse  and  psychoses  develop, 
such  as  melancholia,  dementia,  or  occasionally  progressive  paresis.  And, 
lastly,  in  extremely  rare  cases,  organic  lesions  may  develop  as  a  sequence 
of  the  traumatic  neurosis. 

The  function  of  the  physician  acting  as  medical  expert  in  these  cases 
consists  in  determining  (a)  the  existence  of  actual  disease,  and  (h)  its  char- 
acter, whether  simple  neurasthenia,  severe  hysteria,  or  an  organic  lesion. 
The  outlook  for  ultimate  recovery  is  good  except  in  cases  which  present  the 
more  serious  symptoms  above  mentioned.  Nevertheless,  it  must  be  borne 
in  mind  that  traumatic  hysteria  is  one  of  the  most  intractable  affections 
which  we  are  called  upon  to  treat.  In  the  treatment  of  the  traumatic 
neuroses  the  practitioner  may  be  guided  by  the  principles  laid  down  in  the 
preceding  chapter,  in  which  the  treatment  of  neurasthenia  in  general  has 
been  described. 


1136  DISEASES  OF  THE  NERVOUS  SYSTEM. 

XIV.  OTHER  FORMS  OF  FUNCTIONAL  PARALYSIS. 

I.  Periodical  Paralysis. 

The  periodical  paralysis  of  the  ocular  muscles,  which  may  recur  for 
years,  has  already  been  referred  to.  A  periodical  paralysis  involving  the 
general  muscles,  also  a  "  family  "  affection,  may  return  with  great  regu- 
larity. Goldflam  described  twelve  cases  in  one  family,  the  heredity  being 
through  the  mother.  In  this  country  E.  W.  Taylor  described  eleven  cases 
in  one  family  in  five  generations. 

The  clinical  picture  is  similar  in  all  recorded  cases.  The  paralyis  in- 
volves, as  a  rule,  the  arms  and  legs,  but  may  be  general  below  the  neck. 
It  comes  on  in  healthy  persons  without  apparent  cause,  and  often  during 
sleep.  At  first  there  may  be  weakness  of  the  limbs,  a  feeling  of  weariness 
and  sleepiness,  but  rarely  sensory  symptoms.  The  paralysis,  beginning  in 
the  legs,  to  which  it  may  be  confined,  is  usually  complete  within  the  first 
twenty-four  hours.  The  neck  muscles  are  sometimes  involved,  and  occa- 
sionally those  of  the  tongue  and  pharynx.  The  cerebral  nerves  and  the 
special  senses  are,  as  a  rule,  unaffected.  The  temperature  is  normal  or 
subnormal  and  the  pulse  slow.  The  deep  reflexes  are  diminished,  sometimes 
abolished,  and  the  skin  reflexes  may  be  enfeebled.  A  most  remarkable 
feature  is  the  extraordinary  reduction  or  complete  abolition  of  the  faradic 
excitability  both  of  muscles  and  of  nerves. 

Improvement  begins  within  a  few  hours  or  a  day  or  two,  the  paralysis 
disappearing  completely  and  the  patient  becoming  perfectly  well.  The 
attacks  usually  recur  at  intervals  of  one  to  two  weeks,  but  they  may  return 
daily.  They  generally  cease  after  the  fiftieth  year.  There  may  be  signs 
of  acute  dilatation  of  the  heart  during  the  attack.  In  the  three  cases 
reported  by  J.  K.  Mitchell,  Flexner,  and  Edsall,  a  diminished  kreatinin 
excretion  for  several  days  before  and  at  the  beginning  of  a  seizure  was  re- 
peatedly found.  There  was  a  rise  to  normal  after  the  attacks.  Potassium 
citrate  in  full  doses  either  shortened  or  aborted  the  paralyses. 

II.  Astasia;  Abasia. 

These  terms,  indicating  respectively  inability  to  stand  and  inability  to 
walk,  have  been  applied  by  Charcot  and  Blocq  to  diseased  conditions  char- 
acterized by  loss  of  the  power  of  standing  or  of  walking,  with  retention  of 
muscular  power,  coordination,  and  sensation.  Blocq's  definition  is  as  fol- 
lows: "A  morbid  state  in  which  the  impossibility  of  standing  erect  and 
walking  normally  is  in  contrast  with  the  integrity  of  sensation,  of  muscu- 
lar strength,  and  of  the  coordination  of  the  other  movements  of  the  lower 
extremities."  The  condition  forms  a  symptom  group,  not  a  morbid  entity, 
and  is  probably  a  functional  neurosis.  Knapp  in  his  monograph  analyzes 
the  50  cases  reported  in  the  literature.  Twenty-five  of  these  were  in  men, 
25  in  women.  In  21  cases  hysteria  was  present;  in  3,  chorea;  in  2,  epi- 
lepsy; and  in  4,  intention  psychoses.  As  a  rule,  the  patients,  though  able 
to  move  the  feet  and  legs  perfectly  when  in  bed,  are  either  unable  to  walk 
properly  or  cannot  stand  at  all.     The  disturbances  have  been  very  varied, 


RAYNAUD'S  DISEASE.  1137 

and  different  forms  have  been  recognized.  The  commonest,  according  to 
Ivnapp's  analysis  of  the  recorded  cases,  is  the  paralytic,  in  which  the  legs 
give  out  as  the  patient  attempts  to  walk  and  "  bend  under  him  as  if  made 
of  cotton."  "  There  is  no  rigidity,  no  spasm,  no  incoordination.  In  bed, 
sitting,  or  even  while  suspended,  the  muscular  strength  is  found  to  be  good." 
Other  cases  are  associated  with  spasm  or  ataxia;  thus  there  may  be  move- 
ments which  stiffen  the  legs  and  give  to  the  gait  a  somewhat  spastic  char- 
acter. In  other  instances  there  are  sudden  flexions  of  the  legs,  or  even  of 
the  arms,  or  a  saltatory,  spring-like  spasm.  In  a  majority  of  the  cases  it 
is  a  manifestation  of  a  neurosis  allied  to  hysteria. 

The  cases,  as  a  rule,  recover,  particularly  in  young  persons.  Eelapses 
are  not  uncommon.  The  rest  treatment  and  static  electricity  should  be 
employed. 


YIII.  YASP-MOTOR  ANT>  TEOPHIC  DISORDEES. 
I.     RAYNAUD'S    DISEASE. 

Definition. — A  vascular  disorder,  probably  dependent  upon  vaso- 
motor influences,  characterized  by  three  grades  of  intensity:  (a)  Local  syn- 
cope, (b)  local  asphyxia,  and  (c)  local  or  symmetrical  gangrene. 

Local  Syncope. — This  condition  is  seen  most  frequently  in  the  extremi- 
ties, producing  the  condition  known  as  dead  fingers  or  dead  toes.  It  is 
analogous  to  that  produced  by  great  cold.  The  entire  hand  may  be  affected 
with  the  fingers;  more  commonly  only  one  or  more  of  the  fingers.  This 
feature  of  the  disease  rarely  occurs  alone,  but  is  generally  associated  with 
local  asphyxia.  The  common  sequence  is  as  follows:  On  exposure  to  slight 
cold  or  in  consequence  of  some  emotional  disturbance  the  fingers  become 
white  and  cold,  or  both  fingers  and  toes  are  affected.  The  pallor  may  con- 
tinue for  an  indefinite  time,  though  usually  not  more  than  an  hour  or  so; 
then  gradually  a  reaction  follows  and  the  fingers  get  burning  hot  and  red. 
This  does  not  necessarily  occur  in  all  the  fingers  together;  one  finger  may 
be  as  white  as  marble,  while  the  adjacent  ones  are  of  a  deep  red  or  plum 
color. 

Local  AspJiyxia. — Chilblains  form  the  mildest  grade  of  this  condition. 
It  usually  follows  the  local  syncope,  but  it  may  come  on  independently. 
The  fingers  and  toes  are  oftenest  affected,  next  in  order  the  ears;  more 
rarely  portions  of  the  skin  on  the  arms  and  legs.  During  an  attack  the 
fingers  alone,  sometimes  the  hands,  also  swell  and  become  intensely  con- 
gested. In  the  most  extreme  grade  the  fingers  are  perfectly  livid,  and  the 
capillary  circulation  is  almost  stagnant.  The  swelling  causes  stiffness  and 
usually  pain,  not  acute,  but  due  to  the  tension  and  distention  of  the  skin. 
Sometimes  there  is  marked  anaesthesia.  Pain  of  a  most  excruciating  kind 
may  be  present.  Attacks  of  this  sort  may  recur  for  years,  and  be  brought 
on  by  the  slightest  exposure  to  cold  or  in  consequence  of  disturbances,  either 
mental  or,  in  some  instances,  gastric.  Apart  from  this  unpleasant  symp- 
71 


1138  DISEASES  OP  THE  NERVOUS  SYSTEM. 

torn  the  general  health  may  be  very  good.  The  condition  is  always  worse 
during  the  winter,  and  may  be  present  only  when  the  external  temperature 
is  low. 

Local  or  Symmetrical  Gangrene. — The  mildest  grade  of  this  condition 
follows  the  local  asphyxia,  in  the  chronic  eases  of  which  small  necrotic 
areas  are  sometimes  seen  at  the  tips  of  the  fingers.  Sometimes  the  pads 
of  the  fingers  and  of  the  toes  are  quite  cicatricial  from  repeated  slight  losses 
of  this  kind.  So  also  when  the  ears  are  affected  there  may  be  superficial 
loss  of  substance  at  the  edge.  The  severer  cases,  which  terminate  in  ex- 
tensive gangrene,  are  fortunately  rare. 

In  an  attack  the  local  asphyxia  persists  in  the  fingers.  The  terminal 
phalanges,  or  perhaps  the  end  of  only  one  finger,  become  black,  cold,  and  in- 
sensible. The  skin  begins  to  necrose  and  superficial  gangrenous  blebs  appear. 
Gradually  a  line  of  demarkation  shows  itself  and  a  portion  of  one  or  more  of 
the  fingers  sloughs  away.  The  resulting  loss  of  substance  is  much  less  than 
the  appearance  of  the  hand  or  foot  would  indicate,  and  a  condition  which 
looks  as  if  the  patient  would  lose  all  the  fingers  or  half  of  a  foot  may  result 
perhaps  in  only  a  slight  superficial  loss  in  the  phalanges.  In  severer  cases 
the  greater  portion  of  a  finger  or  the  tip  of  the  nose  may  be  lost.  Occa- 
sionally the  disease  is  not  confined  to  the  extremities,  but  affects  sym- 
metrical patches  on  the  limbs  or  trunk,  and  may  pass  on  to  rapid  gangrene. 
These  severe  types  of  cases  occur  particularly  in  young  children,  and  death 
may  result  within  three  or  four  days.  The  attacks  are  usually  very  pain- 
ful, and  the  motion  of  the  part  is  much  impaired.  In  some  cases  numbness 
and  tingling  persist  for  a  long  time. 

The  climax  of  this  series  of  neuro-vascular  changes  is  seen  in  the  re- 
markable instances  of  extensive  multiple  gangrene.  They  are  most  com- 
mon in  children,  and  may  progress  with  frightful  rapidity.  In  the  Medico- 
Chirurgical  Society's  Transactions,  vol.  xxii,  there  is  an  extraordinary  case 
reported,  in  which  the  child,  aged  three,  lost  in  this  way  both  arms  above 
the  elbow,  and  the  left  leg  below  the  knee.  There  also  had  been  a  spot 
of  local  gangrene  on  the  nose.  Spontaneous  amputation  occurred,  and  the 
child  made  a  complete  recovery.  The  cases  are  more  frequent  than  has 
been  supposed,  and  an  illustration  is  given  by  Weeks,  of  Marion,  Ohio,  in 
which  the  boy  had  rheumatic  pains  in  the  legs,  and  purpuric  blotches  de- 
veloped before  the  gangrene  began  (Medico-Surgical  Bulletin,  July  1, 
1894). 

There  are  remarkable  concomitant  symptoms  in  Eaynaud's  disease  to 
which  a  good  deal  of  attention  has  been  paid  of  late  years.  Hsemoglobi- 
nuria  may  develop  during  an  attack,  or  may  take  the  place  of  an  outbreak. 
In  such  instances  the  affection  is  usually  brought  on  by  cold  weather.  In 
a  case  reported  by  H.  M.  Thomas  from  my  clinic,  Eaynaud's  disease  occurred 
for  three  successive  winters  and  always  in  association  with  hsemoglobinuria. 
The  attacks  were  sometimes  preceded  by  a  chill.  Several  cases  of  the  kind 
are  found  in  Barlow's  appendix  to  his  translation  of  Eaynaud's  paper  for 
the  New  Sydenham  Society.  The  onset  with  a  chill,  as  in  the  case  just 
mentioned,  has  doubtless  given  rise  to  the  idea  that  the  disease  is  in  some 
way  associated  with  ague.     Cerebral  symptoms,  particularly  mental  torpor 


ERYTHROMELALGIA.  1139 

and  transient  loss  of  consciousness,  have  also  been  noticed  in  some  cases. 
The  case  just  mentioned  with  hasmoglobinuria  had  epilepsy  with  the  at- 
tacks. Exposure  on  a  cold  day  would  bring  on  an  epileptic  seizure  with 
the  local  asphyxia  and  bloody  urine.  Another  patient,  the  subject  for  years 
of  Raynaud's  disease,  has  had  many  attacks  of  transient  hemiplegia  on  one 
side  or  the  other,  when  on  the  right  side  with  aphasia.  Since  the  second 
edition  of  this  work  was  issued  she  died  in  an  attack.  Occasionally  joint 
affections  develop,  particularly  anchylosis  and  thickening  of  the  phalan- 
geal articulations.  Southey  has  reported  a  case  in  which  mania  developed, 
and  Barlow  an  instance  in  which  the  woman  had  delusions.  Peripheral 
neuritis  has  been  found  in  several  cases. 

The  pathology  of  this  remarkable  disease  is  still  obscure.  Raynaud 
suggested  that  the  local  syncope  was  produced  by  contraction  of  the  vessels, 
which  seems  likely.  The  asphyxia  is  dependent  upon  dilatation  of  the 
capillaries  and  small  veins,  probably  with  the  persistence  of  some  degree 
of  spasm  of  the  smaller  arteries.  There  are  two  totally  different  forms  of 
congestion,  which  may  be  shown  in  adjacent  fingers;  one  may  be  swollen, 
of  a  vivid  red  color,  extremely  hot,  the  capillaries  and  all  the  vessels  fully 
distended,  and  the  anaemia  produced  by  pressure  may  be  instantaneously 
obliterated;  the  adjacent  finger  may  be  equally  swollen,  absolutely  cyanotic, 
stone  cold,  and  the  anaemia  produced  by  pressure  takes  a  lohg  time  to 
disappear.  In  the  latter  case  the  arterioles  are  probably  still  in  a  condition 
of  spasm.    Monro's  monograph  may  be  consulted  for  additional  details. 

Treatment. — In  many  cases  the  attacks  recur  for  years  uninfluenced 
by  treatment.  Mild  attacks  require  no  treatment.  In  the  severer  forms 
of  local  asphyxia,  if  in  the  feet,  the  patient  should  be  kept  in  bed  with  the 
legs  elevated.  The  toes  should  be  wrapped  in  cotton-Avool.  The  pain  is 
often  very  intense  and  may  require  morphia.  Carefully  applied,  systematic 
massage  of  the  extremities  is  sometimes  of  benefit.  Galvanism  may  be  tried. 
Barlow  advises  immersing  the  affected  limb  in  salt  water  and  placing  one 
electrode  over  the  spine  and  the  other  in  the  water.  Nitroglycerin  has  been 
warmly  recommended  by  Gates. 


II.    ERYTHRO MELALGIA  {Red  Neuralgia). 

Definition. — "  A  chronic  disease  in  which  a  part  or  parts — usually  one 
or  more  extremities — suffer  with  pain,  flushing,  and  local  fever,  made  far 
worse  if  the  parts  hang  down  "  (Weir  Mitchell).  The  name  signifies  a  pain- 
ful, red  extremity. 

Symptoms.— In  1872  (Phila.  Med.  Times,  November  23d),  in  a  lec- 
ture on  certain  painful  affections  of  the  feet,  Weir  Mitchell  described  the 
case  of  a  sailor,  aged  forty,  who  after  an  African  fever  began  to  have  "  dull, 
heavy  pains,  at  first  in  the  left  and  soon  after  in  the  right  foot.  There  was 
no  swelling  at  first.  Wlien  at  rest  he  was  comfortable  and  the  feet  were 
not  painful.  After  walking  the  feet  were  swollen.  Tliey  scarcely  pitted 
on  pressure,  but  were  purple  with  congestion;  the  veins  were  everywhere 
singularly  enlarged,  and  the  arteries  were  throbbing  visibly.     The  whole 


11^40  DISEASES  OP  THE  NERVOUS  SYSTEM.  * 

foot  was  said  to  be  aching  and  burning,  but  above  the  ankle  there  was 
neither  swelling,  pain,  nor,  flushing."  As  the  weather  grew  cool  he  got 
relief.  Nothing  seemed  to  benefit  him.  This  brief  summary  of  Mitchell's 
first  case  gives  an  accurate  clinical  picture  of  the  disease.  His  second  com- 
munication. On  a  Eare  Vaso-motor  Neurosis  of  the  Extremities,  appeared 
in  the  Am.  Jour,  of  the  Medical  Sciences  for  July,  1878,  while  in  his  Clin- 
ical Lessons  on  Nervous  Diseases,  1897,  will  be  found  additional  observa- 
tions. 

The  disease  is  rare.  Eost  states  that  there  are  only  about  40  instances  in 
the  literature.  The  feet  are  much  more  often  affected  than  the  hands.  The 
pain  may  be  of  the  most  atrocious  character.  It  is  usually,  but  not  always, 
relieved  by  cool  weather;  in  one  of  my  cases  the  winter  aggravates  the  trou- 
ble. In  a  few  cases  (Eisner,  Dehio,  Eolleston)  the  affection  has  been  com- 
plicated with  Eaynaud's  disease. 

Mitchell  speaks  of  it  as  a  "  painful  nerve-end  neuritis."  Dehio  suggests 
that  there  may  be  irritation  in  the  cells  of  the  ventral  horns  of  the  cord 
at  certain  levels.  Excision  of  the  nerves  passing  to  the  parts  has  been  fol- 
lowed by  relief.  In  one  of  Mitchell's  cases  gangrene  of  the  foot  followed 
excision  of  four  inches  of  the  musculo-cutaneous  nerve  and  stretching  of  the 
posterior  tibial.    Sclerosis  of  the  arteries  was  found. 


III.    ANGIO-NEUROTIC  CEDEMA. 

Definition. — An  affection  characterized  by  the  occurrence  of  local 
oedematous  swellings,  more  or  less  limited  in  extent,  and  of  transient  dura- 
tion. Severe  colic  is  sometimes  associated  with  the  outbreak.  There  is  a 
marked  hereditary  disposition  in  the  disease. 

Symptoms. — The  oedema  appears  suddenly  and  is  visually  circum- 
scribed. It  may  appear  in  the  face;  the  eyelid  is  a  common  situation;  or 
it  may  involve  the  lips  or  cheek.  The  backs  of  the  hands,  the  legs,  or  the 
throat  may  be  attacked.  Usually  the  condition  is  transient,  associated  per- 
haps with  slight  gastro-intestinal  distress,  and  the  affection  is  of  little 
moment.  There  may  be  a  remarkable  periodicity  in  the  outbreak  of  the 
eedema.  In  Matas'  case  this  periodicity  was  very  striking;  the  attack  came 
on  every  day  at  eleven  or  twelve  o'clock.  The  disease  may  be  hereditary 
through  many  generations.  In  the  family  whose  history  I  reported,  five 
generations  had  been  affected,  including  twenty-two  members.  The  swell- 
ings appear  in  various  parts;  only  rarely  are  they  constant  in  one  locality. 
The  hands,  face,  and  genitalia  are  the  parts  most  frequently  affected.  Itch- 
ing, heat,  redness,  or  in  some  instances,  urticaria  may  precede  the  out- 
break. Sudden  oedema  of  the  larjmx  may  prove  fatal.  Two  members  of 
the  family  just  referred  to  died  of  this  complication.  In  one  member  of  this 
family,  whom  I  saw  repeatedly  in  attacks,  the  swellings  came  on  in  different 
parts;  for  example,  the  under  lip  would  be  swollen  to  such  a  degree  that 
the  mouth  could  not  be  opened.  The  hands  enlarge  suddenly,  so  that  the 
fingers  cannot  be  bent.  The  attacks  recur  every  three  or  iowr  weeks.  Ac- 
companying them  are  usually  gastro-intestinal  attacks,  severe  colic,  pain, 


FACIAL  HEMIATROPHY.  1141 

nausea,  and  sometimes  vomiting.  It  is  quite  possible  that  some  of  the  cases 
of  Leyden's  intermittent  vomiting  may  belong  to  this  group.  The  colic 
is  of  great  intensity  and  usually  requires  morphia.  Arthritis  apparently 
does  not  occur.  Periodic  attacks  of  cardialgia  have  also  been  met  with  dur- 
ing the  outbreak  of  the  oedema.  Hgemoglobinuria  has  occurred  in  several 
cases. 

The  disease  has  affinities  with  urticaria,  the  giant  form  of  which  is 
probably  the  same  disease.  There  is  a  form  of  severe  purpura,  often  with 
urticarial  manifestations,  which  is  also  associated  with  marked  gastro- 
intestinal crises,  and  it  is  interesting  to  note  that  Schlesinger  has  reported 
a  case  in  which  a  combination  of  erythromelalgia,  Eaynaud's  disease,  and 
acute  oedema  occurred.  Quincke  regards  the  condition  as  a  vaso-motor 
neurosis,  under  the  influence  of  which  the  permeability  of  the  vessels  is 
suddenly  increased.  Milroy,  of  Omaha,  has  described  cases  of  hereditary 
oedema,  twenty-two  individuals  in  six  generations,  in  which  there  existed 
from  birth  a  solid  oedema  of  one  or  of  both  legs,  without  any  special  incon- 
venience or  any  progressive  increase  of  the  disease. 

Some  years  ago  I  described  a  remarkable  vaso-motor  neurosis  charac- 
terized by  swelling  and  tumefaction  of  the  whole  arm  on  exertion.  My  patient 
was  a  man,  healthy  in  every  other  respect.  A  similar  case  has  been  ob- 
served in  Philadelphia;  on  the  supposition  that  it  might  be  due  to  pressure, 
the  axillary  vessels  were  exposed,  but  nothing  was  found. 

The  treatment  is  very  unsatisfactory.  In  the  cases  associated  with  anse- 
mia  and  general  nervousness,  tonics,  particularly  large  doses  of  strychnia, 
do  good;  but  too  often  the  disease  resists  all  treatment.  I  have  seen  great 
improvement  follow  the  prolonged  use  of  nitroglycerin. 


IV.     FACIAL    HEMIATROPHY. 

An  affection  characterized  by  progressive  wasting  of  the  bones  and  soft 
tissues  of  one  side  of  the  face.  The  atrophy  starts  in  childhood,  but  in  a 
few  cases  has  not  come  on  until  adult  life.  Perhaps  after  a  trifling  injury 
or  disease  the  process  begins,  either  diffusely  or  more  commonly  at  one  spot 
on  the  skin.  It  gradually  spreads,  involving  the  fat,  then  the  bones,  more 
particularly  the  upper  Jaw,  and  last  and  least  the  muscles.  The  wasting 
is  sharply  limited  at  the  middle  line,  and  the  appearance  of  the  patient  is 
very  remarkable,  the  face  looking  as  if  made  up  of  two  halves  from  differ- 
ent persons.  There  is  usually  change  in  the  color  of  the  skin  and  the  hair 
falls.  Owing  to  the  wasting  of  the  alveolar  processes  the  teeth  become  loose 
and  ultimately  drop  out.  The  eye  on  the  affected  side  is  sunken,  owing  to 
loss  of  orbital  fat.  There  is  usually  hemiatrophy  of  the  tongue  on  the  same 
side.  Disturbance  of  sensation  and  muscle  twitching  may  precede  or  ac- 
company the  atrophy.  In  a  majority  of  the  cases  the  atrophy  has  been 
confined  to  one  side  of  the  face,  but  there  are  instances  on  record  in  which 
the  disease  was  bilateral,  and  a  few  cases  in  which  there  were  areas  of  atro- 
phy on  the  back  and  on  the  arm  of  the  same  side.  The  disease  is  rare;  only 
about  100  cases  are  in  the  literature  (Mobius). 


1142  -     '  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Of  the  autopsies,  Mendel's  alone  is  satisfactory.  There  was  the  terminal 
stage  of  an  interstitial  neuritis  in  all  the  branches  of  the  trigeminus,  from 
its  origin  to  the  periphery,  most  marked  in  the  superior  maxillary  branch. 

The  disease  is  recognized  at  a  glance.  The  facial  asymmetry  associated 
with  congenital  wryneck  must  not  be  confounded  with  progressive  facial 
hemiatrophy.  Other  conditions  to  be  distinguished  are:  Facial  atrophy 
in  anterior  polio-myelitis,  and  more  rarely  in  the  hemiplegia  of  infants  and 
adults;  the  atrophy  following  nuclear  lesions  and  sympathetic  nerve  paraly- 
sis; acquired  facial  hemihypertrophy,  such  as  in  the  case  recorded  by  D. 
W.  Montgomery,  which  may  by  contrast  give  to  the  other  side  an  atrophic 
appearance;  and,  lastly,  scleroderma  (a  closely  related  affection),  if  confined 
to  one  side  of  the  face.  The  precise  nature  of  the  disease  is  still  doubtful, 
but  it  is  a  suggestive  fact  that  in  many  of  the  cases  the  atrophy  has  followed 
the  acute  infections.    It  is  incurable. 


V.    ACROMEGALY. 

Defiuitiou. — A  dystrophy  characterized  by  abnormal  processes  of 
growth,  chiefly  in  the  bones  of  the  face  and  extremities. 

The  term  was  introduced  by  Marie,  and  signifies  large  extremities. 

Etiology. — It  occurs  rather  more  frequently  in  women.  The  aifection 
usually  begins  about  the  twenty-fifth  year,  though  in  some  instances  as  late 
as  the  fortieth.  Eheumatism,  syphilis,  and  the  specific  fevers  have  pre- 
ceded the  development  of  the  disease,  but  probably  have  no  special  connec- 
tion with  it.    In  this  country  many  cases  have  now  been  reported. 

Symptoms. — In  a  Avell-marked  case  the  disease  presents  most  char- 
acteristic features.  The  hands  and  feet  are  greatly  enlarged,  but  are  not 
deformed,  and  can  be  used  freely.  The  hypertrophy  is  general,  involving 
all  the  tissues,  and  gives  a  curious  spade-like  character  to  the  hands.  The 
lines  on  the  palms  are  much  deepened.  The  wrists  may  be  enlarged,  but 
the  arms  are  rarely  affected.  The  feet  are  involved  like  the  hands  and  are 
uniformly  enlarged.  The  big  toe,  however,  may  be  much  larger  in  propor- 
tion. The  nails  are  usually  broad  and  large,  but  there  is  no  curbing,  and  the 
terminal  phalanges  are  not  bulbous.  The  head  increases  in  volume,  but  not 
as  much  in  proportion  as  the  face,  which  becomes  much  elongated  and  en- 
larged in  consequence  of  the  increase  in  the  size  of  the  superior  and  inferior 
maxillary  bones.  The  latter  in  particular  increases  greatly  in  size,  and  often 
projects  below  the  upper  Jaw.  The  alveolar  processes  are  widened  and  the 
teeth  separated.  The  soft  parts  also  increase  in  size,  and  the  nostrils  are 
large  and  broad.  The  eyelids  are  sometimes  greatly  thickened,  and  the 
ears  enormously  hypertrophied.  The  tongue  in  some  instances  becomes 
greatly  enlarged.  Late  in  the  disease  the  spine  may  be  affected  and  the 
back  bowed — kyphosis.  The  bones  of  the  thorax  may  slowly  and  pro- 
gressively enlarge.  "With  this  gradual  increase  in  size  the  skin  of  the  hands 
and  face  may  appear  normal.  Sometimes  it  is  slightly  altered  in  color, 
coarse,  or  flabby,  but  it  has  not  the  dry,  harsh  appearance  of  the  skin  in 
myxcedema,    The  muscles  are  sometimes  wasted.     Changes  in  the  thyroid 


ACROMEGALY.  II43 

have  been  found,  but  are  not  constant.  The  gland  has  been  normal  in 
some,  atrophied  in  others,  and  in  a  third  group  of  eases  enlarged.  Erb,  who 
has  made  an  elaborate  study  of  the  disease,  has  noticed  an  area  of  dulness 
over  the  manubrium  sterni,  which  he  thought  possibly  due  to  the  persist- 
ence or  enlargement  of  the  thymus.  Headache  is  not  uncommon.  Somno- 
lence has  been  noted  in  many  cases.  Menstrual  disturbance  may  occur 
early,  and  there  may  be  suppression.  Ocular  symptoms  are  common.  Hertel 
has  analyzed  175  recorded  cases,  92  of  which  presented  eye  complications. 
In  three  fourths  of  these  the  optic  nerves  were  affected — usually  atrophy, 
rarely  neuritis.  Bitemporal  hemianopia  is  often  an  early  sign.  The  disease 
may  persist  for  fifteen,  twenty,  or  more  years. 

Pathological  Anatomy .—l^herQ  are  263  cases  on  record  with  77  autopsies, 
in  only  4  of  which  the  pituitary  gland  Avas  not  involved  (Woods-Hutchin- 
son, April,  1902).  In  24  cases  in  which  it  was  examined  the  thyi'oid  was 
normal  in  5,  hypertrophied  in  one  half;  the  thymus  in  17  examined  was 
absent  in  7,  hypertrophied  in  3,  and  persistent  in  7  (Furnival).  In  Os- 
borne's case  the  heart  was  enormous,  weighing  2  pounds  9  ounces. 

Owing  to  the  remarkable  changes  in  the  pituitary  gland  in  acromegaly, 
it  has  been  suggested  that  the  disease  is  a  nutritional  disturbance  analogous 
to  myxoedema,  and  caused  directly  by  disturbance  in  the  function  of  this 
organ.  The  evidence  from  comparative  anatomy  and  embryology  shows 
that  the  pituitary  body  is  a  very  "  complex  organ,  consisting  of  an  anterior 
secreting  glandular  organ;  a  water-vascular  duct;  a  posterior,  sensitive, 
nervous  lobe,  of  which  the  last  two — namely,  the  duct  and  the  nervous  lobe 
— were  morphologically  well  developed  and  functioned  in  ancestral  verte- 
brates, but  have  become  obliterated  and  atrophied  in  structure  and  func- 
tion forever  above  larval  acraniates  "  (Andriezen,  British  Medical  Journal, 
1894,  i).  The  pituitary  body  continues  active,  but  the  duet  is  obliterated 
"  and  the  gland  changed  into  a  ductless  gland;  the  secretion  becomes  an 
'  internal  secretion,' "  which  is  absorbed  by  the  lymphatics.  The  extraor- 
dinary frequency  with  which  the  pituitary  is  involved  in  this  disease  lends 
weight  to  the  view  that  it  is,  in  the  words  of  Woods  Hutchinson, 
the  growth  centre,  or  at  any  rate  the  proportion  regulator  of  the  skeleton. 

It  has  been  suggested  by  Massalongo  and  others  that  gigantism  and 
acromegaly  are  one  and  the  same  disease,  both  due  to  the  superfunction 
of  the  pituitary  gland.  Certain  persons  exhibited  as  giants,  or  who  have 
been  "  strong  men  "  and  wrestlers,  have  become  acromegalic,  and  the  skulls 
of  some  notable  giants  show  enormous  enlargement  of  the  sella  turcica. 

There  is  a  congenital  progressive  hj^pertrophy  of  one  extremity  or  of  a 
part  of  it  or  of  one  side  of  the  body — the  so-called  giant  growth,  which  does 
not  appear  to  have  any  connection  with  acromegaly. 

The  treatment  does  not  appear  to  have  any  influence  upon  the  progress 
of  the  disease.  The  thyroid  extract  has  been  tried  in  many  cases,  without, 
so  far  as  my  personal  experience  goes,  any  benefit.  Extract  of  the  pituitary 
gland  has  also  been  used.  The  lung  extract  has  been  employed  in  some 
cases  of  pulmonary  osteo-arthropathy.  In  a  case  of  Caton's,  of  Liverpool, 
an  unsuccessful  attempt  was  made  to  extirpate  the  pituitary  body. 


114A  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Osteitis  Defoemans  {Paget' s  Disease). 

Definition. — A  disease  characterized  by  "  enlargement  and  forward 
projection  of  the  head,  dorso-cervical  kyphosis,  prominence  of  the  clavicles, 
spreading  of  the  base  of  the  thorax,  a  diamond-shaped  abdomen,  crossed 
by  a  deep  sulcus,  a  relative  increase  in  the  width  of  the  hips,  and  an  out- 
ward and  forward  bowing  of  the  legs." 

It  is  a  rare  disease.  I  have  seen  only  4  cases — 1  in  Philadelphia,  which 
is  figured  in  Ashhurst's  Surgery,  and  3  in  Baltimore.  Of  these,  one  is  un- 
reported; the  others  I  saw  with  Watson  (who  has  recorded  the  case,  Johns 
Hopkins  Hospital  Bulletin,  1898)  and  with  A.  D.  Atkinson.  Careful  studies 
have  been  made  recently  by  J.  C.  Wilson,  by  Elting,  and  by  Packard,  Steele, 
and  Kirkbride,  from  whose  recent  exhaustive  paper  (Am.  Jour.,  1891)  I 
have  taken  the  definition.  About  67  typical  cases  are  on  record:  41  males, 
24  females,  and  in  2  the  sex  was  not  given.  In  49  cases  the  bones  of  the 
skull  were  involved,  in  47  both  tibiae,  in  40  the  femur,  and  in  31  the  spine. 
These  figures  from  Packard's  paper  give  the  relative  frequency  with  which 
the  bones  are  attacked.  The  shortening  of  the  stature  is  remarkable;  in 
Watson's  patient  the  height  at  forty-two  was  5  feet  llf  inches,  and  at  sixty- 
two  it  was  5  feet  2-J-  inches.    The  head  had  increased  3yV  inches. 

The  etiology  of  the  disease  is  unknown;  it  is  possibly  allied  to  but  not 
identical  with  osteo-malacia,  fragilitas  ossium,  and  acromegaly.  There  is 
a  curious  relationship  between  osteitis  deformans  and  malignant  tumors, 
of  which  a  certain  number  of  the  patients  have  died. 

The  bone  structure  shows  a  mixture  of  rarefying  osteitis,  with  large 
and  irregular  Haversian  canals,  and  of  a  formative  osteitis,  with  certain 
Haversian  canals  narrowed  and  lamellge  of  recent  formation. 

The  diagnosis  is  readily  made.  The  features  given  in  the  definition 
make  up  a  most  typical  picture.  As  Marie  states,  in  Paget's  disease  the  face 
is  triangular  with  the  base  upward;  in  acromegaly  it  is  ovoid  or  egg-shaped 
with  the  large  end  downward;  while  in  mjrx oedema  it  is  round  and  full- 
moon-shaped.    Treatment  seems  to  be  of  no  avail. 

Hypeeteophic  Pulmonaey  Aetheopathy. 

Marie  has  given  the  name  hypertrophic  pulmonary  osteo-arthropathy  to 
a  remarkable  disorder,  first  recognized  by  Bamberger,  characterized  by  en- 
largement of  the  hands  and  feet,  and  of  the  ends  of  the  long  bones,  chiefly 
of  the  lower  three  fourths  of  the  forearm  and  le^s.  Unlike  acromegaly, 
the  bones  of  the  skull  and  of  the  face  are  not  involved.  The  terminal 
phalanges  are  much  spread  with  both  transverse  and  longitudinal  curves; 
the  nails,  too,  are  large  and  much  curved  over  the  ends  of  the  phalanges. 
Scoliosis  and  kyphosis  are  rarely  seen.  The  disease  is  very  chronic,  and  in 
nearly  all  cases  has  been  associated  with  some  long-standing  affection  of 
the  bronchi,  lungs,  or  pleura  (hence  the  name  pulmonary  osteo-arthropathy) ^ 
of  which  sarcoma,  chronic  bronchitis,  chronic  tuberculosis,  and  empyema 
have  been  the  most  frequent.  There  are  several  instances  in  which  the 
affection  has  developed  in  the  subjects  of  syphilis.  It  occurs  usually  in 
adults  and  in  the  male  sex.     Thayer  has  reported  4  cases  from  my  clinic 


SCLERODERMA.  II45 

and  has  collected  55  typical  cases  from  the  literature.  Forty-three  showed 
preceding  pulmonary  affection;  of  the  remaining,  3  followed  syphilis,  3 
heart-disease,  2  chronic  diarrhoea,  1  spinal  caries,  and  3  unknown  causes. 

The  essential  pathology  of  the  disease  is  very  ohscure.  Marie  suggests 
that  the  toxines  of  the  pulmonary  disease  are  absorbed  into  the  circulation 
and  exercise  an  irritant  action  on  the  bony  and  articular  structures,  caus- 
ing an  ossifying  periostitis.  Thorburn  thinks  that  it  is  a  chronic  tubercu- 
lous affection  of  a  large  number  of  bones  and  joints  of  a  benign  type. 

Leontiasis  Ossea. 

Finally,  in  a  remarkable  condition  known  as  leontiasis  ossea,  there  is 
hyperostosis  of  the  bones  of  the  cranium,  and  sometimes  those  of  the  face. 
The  description  is  largely  based  upon  the  skulls  in  museums,  but  Allen 
Starr  has  recently  reported  an  instance  in  a  woman,  who  presented  a  slowly 
progressing  increase  in  the  size  of  the  head,  face,  and  neck,  the  hard  and 
soft  tissues  both  being  affected.  He  has  applied  to  the  condition  the  term 
megalo-cephaly.  Putnam  states  that  the  disease  begins  in  early  life,  often 
as  a  result  of  injury.  There  may  be  osteophytic  growths  from  the  outer  or 
inner  tables,  which  in  the  latter  situation  may  give  the  symptoms  of  tumor. 

MiCEOMEGALY. 

A  remarkable  condition,  the  antithesis  of  acromegaly,  has  been  de- 
scribed by  Jonathan  Hutchinson  and  Hastings  Gilford  (Lancet,  1896,  ii,  p. 
1227)  as  "  mixed  premature  and  immature  development."  The  name  micro- 
megaly  is  suggested  by  Gilford,  who  describes  it  as  a  disease  of  that  part  of 
the  nervous  system  presiding  over  nutrition,  which  manifests  itself  in  a 
smallness  and  immaturity  of  some  parts  or  functions  and  a  relative  or 
actual  largeness  or  prematurity  of  others. 


VI.    SCLERODERMA. 

Definition. — A  condition  of  localized  or  diffuse  induration  of  the 
skin. 

Lewin  and  Heller  (Die  Sclerodermic,  Berlin,  1895)  have  recently  col- 
lected from  the  literature  508  cases. 

Two  forms  are  recognized:  the  circumscribed,  which  corresponds  to 
the  keloid  of  Addison,  and  to  morphcea;  and  the  diffuse,  in  which  large 
areas  are  involved. 

The  disease  affects  females  more  frequently  than  males.  The  cases 
occur  most  commonly  at  the  middle  period  of  life.  The  sclerema  neona- 
torum is  a  different  affection,  not  to  be  confounded  with  it.  The  disease  is 
more  common  in  this  country  than  statistics  indicate.  I  have  reported  8 
cases  (Jour,  of  Genito-Urinary  and  Cutaneous  Diseases,  January,  1898), 
since  which  date  I  have  seen  3  additional  cases. 

In  the  circumscribed  form  there  are  patches,  ranging  from  a  few  centi- 


1146  DISEASES  OF  THE  NERVOUS  SYSTEM. 

metres  in  diameter  to  the  size  of  the  hand  or  larger,  in  which  the  skin  has 
a  waxy  or  dead-white  appearance,  and  to  the  touch  is  brawny,  hard,  and 
inelastic.  Sometimes  there  is  a  preliminary  hypersemia  of  the  skin,  and 
subsequently  there  are  changes  in  color,  either  areas  of  pigmentation  or  of 
complete  atrophy  of  the  pigment — leucoderma.  The  sensory  changes  are 
rarely  marked.  The  secretion  of  sweat  is  diminished  or  entirely  abolished. 
The  disease  is  more  common  in  women  than  in  men,  and  is  situated  most 
frequently  about  the  breasts  and  neck,  sometimes  in  the  course  of  the 
nerves.  •  The  patches  may  develop  with  great  rapidity,  and  may  persist  ior 
months  or  years;  sometimes  they  disappear  in  a  few  weeks. 

The  diffuse  form,  though  less  common,  is  more  serious.  It  develops 
first  in  the  extremities  or  in  the  face,  and  the  patient  notices  that  the  skin 
is  unusually  hard  and  firm,  or  that  there  is  a  sense  of  stiffness  or  tension 
in  making  accustomed  movements.  Gradually  a  diffuse,  brawny  indura- 
tion develops  and  the  skin  becomes  firm  and  hard,  and  so  united  to  the 
subcutaneous  tissues  that  it  cannot  be  picked  up  or  pinched.  The  skin 
may  look  natural,  but  more  commonly  is  glossy,  drier  than  normal,  and 
unusually  smooth.  With  reference  to  the  localization,  in  66  observations 
the  disease  was  universal;  in  203,  regions  of  the  trunk  were  affected;  in 
193,  parts  of  the  head  or  face;  in  287,  portions  of  one  or  other  of  the  upper 
extremities;  and  in  122,  portions  of  the  lower  extremities.  In  80  cases 
there  were  disturbances  of  sensation.  The  disease  may  gradually  extend 
and  involve  the  skin  of  an  entire  limb.  When  universal,  the  face  is  ex- 
pressionless, the  lips  cannot  be  moved,  mastication  is  hindered,  and  it  may 
become  extremely  difficult  to  feed  the  patient.  The  hands  become  fixed  and 
the  fingers  immobile,  on  account  of  the  extreme  induration  of  the  skin 
over  the  joints.  Eemarkable  vaso-motor  disturbances  are  common,  as  ex- 
treme cyanosis  of  the  hands  and  legs.  In  one  of  my  cases  tachycardia  was 
present.  The  disease  is  chronic,  lasting  for  months  or  years.  There  are 
instances  on  record  of  its  persistence  for  more  than  twenty  years.  Eecovery 
may  occur,  or  the  disease  may  be  arrested.  The  patients  are  apt  to  suc- 
cumb to  pulmonary  complaints  or  to  nephritis.  Eheumatic  troubles  have 
been  noticed  in  some  instances;  in  others,  endocarditis.  Eaynaud's  disease 
may  be  associated  with  it,  as  in  2  cases  described  by  Stephen  Mackenzie.  I 
have  seen  an  instance  of  the  diffuse  form  in  which  the  primary  symptoms 
were  those  of  local  asphyxia  of  the  fingers,  and  in  which,  with  extensive 
scleroderma  of  the  arms  and  hands  and  face,  there  were  cyanosis  and  swell- 
ing of  the  skin  of  the  feet  without  any  brawny  induration.  The  pigmenta- 
tion of  the  skin  may  be  as  deep  as  in  Addison's  disease,  for  which  cases  have 
been  mistaken;  scleroderma  may  occur  as  a  complication  of  exophthalmic 
goitre. 

The  remarkable  dystrophy  known  as  sclerodadylie  belongs  to  this  dis- 
order. There  are  symmetrical  involvements  of  the  fingers,  which  become 
deformed,  shortened,  and  atrophied;  the  skin  becomes  thickened,  of  a 
waxy  color,  and  is  sometimes  pigmented.  Bulte  and  ulcerations  have 
been  met  with  in  some  instances,  and  a  great  deformity  of  the  nails.  The 
disease  has  usually  followed  exposure,  and  the  patients  are  much  worse 
during  the  winter,  and  are  curiously  sensitive  to  cold.     There  may  b^ 


SCLERODERMA.  II47 

changes  in  the  skin  of  the  feet,  but  the  deformity  similar  to  that  which 
occurs  in  the  hand  has  not  been  noted.  Some  of  the  cases  present  in  addi- 
tion diffuse  sclerodermatous  changes  of  the  skin  of  other  parts.  In  Lewin 
and  Heller's  monograph  there  are  35  cases  of  isolated  sclerodaetylism,  and 
106  cases  in  which  it  was  combined  with  scleroderma. 

The  pathology  of  the  disease  is  unknown.  It  is  usually  regarded  as  a 
tropho-neurosis,  probably  dependent  upon  changes  in  the  arteries  of  the 
skin  leading  to  connective-tissue  overgrowth.  The  thyroid  has  been  found 
atrophied. 

Treatment. — The  patients  require  to  be  warmly  clad  and  to  be 
guarded  against  exposure,  as  they  are  particularly  sensitive  to  changes  in 
the  weather.  Warm  baths  followed  by  frictions  with  oil  should  be  sys- 
tematically used.  I  have  tried  the  thyroid  feeding  thoroughly  in  the  dif- 
fuse form  without  success.  In  a  recent  case  of  quite  extensive  localized 
scleroderma,  after  ten  weeks'  treatment,  the  patches  are  softer  and  the  pig- 
mentation much  less  intense.  Salol  in  15-grain  doses  three  times  a  day  is 
stated  to  have  been  successful  in  several  cases. 

AiNHUM. 

Here  a  brief  reference  may  be  made  to  the  remarkable  trophic  lesion 
described  by  Da  Silva  Lima,  which  is  met  with  in  negroes  in  Brazil,  Africa, 
India,  and  occasionally  in  the  Southern  States.  It  is  confined  to  the  toes, 
usually  the  little  toe,  and  begins  as  a  furrow  on  the  line  of  the  digito- 
plantar  fold.  This  gradually  deepens,  the  end  of  the  toe  enlarges,  and, 
usually  without  inflammation  or  pain,  the  toe  falls  off.  The  process  may 
last  some  years.  Cases  have  been  reported  in  this  country  by  Hornaday, 
Pittman,  F.  J.  Shepherd,  and  Morrison. 


SECTIOl^  XL 
DISEASES   OF  THE   MUSCLES. 


I.    MYOSITIS. 

Definition.' — Inflammation  of  the  voluntary  muscles. 

A  primary  myositis  occurs  as  an  acute  or  subacute  affection,  and  is 
probably  dependent  on  some  unknown  infectious  agent.  Severgtl  charac- 
teristic cases  have  been  described  of  late  years.  That  of  E.  Wagner  may 
be  taken  as  a  typical  example.  A  tuberculous  but  well-built  woman  entered 
the  hospital,  complaining  of  stiffness  in  the  shoulders  and  a  slight  oedema 
of  the  back  of  the  hands  and  forearms.  There  was  pargesthesia,  the  arms 
became  swollen,  the  skin  tense,  and  the  muscles  felt  doughy.  Gradually 
the  thighs  became  affected.  The  disease  lasted  about  three  months.  The 
post  mortem  showed  slight  pulmonary  tuberculosis;  all  the  muscles  except 
the  glutei,  the  calf,  and  abdominal  muscles  were  stiff  and  firm,  but  fragile, 
and  there  were  serous  infiltration,  great  proliferation  of  the  interstitial 
tissue,  and  fatty  degeneration.  Similar  cases  have  been  reported  by  Un- 
verricht,  Hepp,  and  Jacoby,  of  New  York.  In  the  case  reported  by  Jacoby 
the  muscles  were  firm,  hard,  and  tender,  and  there  was  slight  oedema  of  the 
skin — dermato-myositis.  The  cases  usually  last  from  one  to  three  months, 
though  there  are  instances  in  which  it  has  been  longer.  The  swelling  and 
tenderness  of  the  muscles,  the  oedema,  and  the  pain  naturally  suggest  trichi- 
nosis, and  indeed  Hepp  speaks  of  it  as  a  pseudo-trichinosis.  The  nature  of 
the  disease  is  unknown.  Senator's  case  presented  marked  disorders  of 
sensation,  and  there  is  a  question  whether  the  peripheral  nerves  are  not 
involved  with  the  muscles.  Wagner  suggests  that  some  of  these  cases  were 
examples  of  acute  progressive  muscular  atrophy.  The  separation  from 
trichinosis  can  be  made  only  by  removing  a  portion  of  the  muscle.  It  has 
not  yet  been  determined  whether  the  eosinophilia  described  by  Brown  is 
peculiar  to  the  trichinous  myositis.  There  are  septic  cases  in  which  a  dif- 
fuse, purulent  infiltration  of  the  muscles  of  different  regions  occurs.  In- 
stances have  been  reported  in  which  this  has  been  described  as  the  primary 
affection,  the  condition  of  the  muscles  even  passing  on  to  gangrene. 
1148 


MYOTONIA.  1149 

Myositis  Ossificans  Peogeessiva. 

Of  this  rare  and  remarkable  affection  42  cases  have  been  recorded  (Mat- 
thes).  The  process  begins  within  the  neck  or  back,  usually  with  swelling 
of  tiie  affected  muscles,  redness  of  the  skin,  and  slight  fever.  After 
subsiding  an  induration  remains,  which  becomes  progressively  harder  as 
the  transformation  into  bone  takes  place.  The  disease  is  very  chronic,  and 
ultimately  may  involve  a  majority  of  the  skeletal  muscles.  Nothing  is 
known  of  the  etiology;  the  condition  has  often  been  associated  with  mal- 
formations. 

II.    MYOTONIA  (Thomsen's  Disease). 

Definition.' — An  infection  characterized  by  tonic  cramp  of  the  mus- 
cles on  attempting  voluntary  movements.  The  disease  received  its  name 
from  the  physician  who  first  described  it,  in  whose  family  it  has  existed 
for  five  generations. 

While  the  disease  is  in  a  majority  of  cases  hereditary,  hence  the  name 
myotonia  congenita,  there  are  other  forms  of  spasm  very  similar  which  may 
be  acquired,  and  others  still  which  are  quite  transitory. 

Etiology. — All  the  typical  cases  have  occurred  in  family  groups;  a 
few  isolated  instances  have  been  described  in  which  similar  symptoms  have^ 
been  present.    The  disease  is  rare  in  this  country  and  in  England;  it  seems 
,more  common  in  Germany  and  in  Scandinavia. 

Symptoms. — The  disease  comes  on  in  childhood.  It  is  noticed  that 
on  account  of  the  stiffness  the  children  are  not  able  to  take  part  in  ordi- 
nary games.  The  peculiarity  is  noticed  only  during  voluntary  movements. 
The  contraction  which  the  patient  wills  is  slowly  accomplished;  the  relaxa- 
tion which  the  patient  wills  is  also  slow.  The  contraction  often  persists  for 
a  little  time  after  he  has  dropped  an  object  which  he  has  picked  up.  In 
walking,  the  start  is  difficult;  one  leg  is  put  forward  slowly,  it  halts  from 
stiffness  for  a  second  or  two,  and  then  after  a  few  steps  the  legs  become 
limber  and  he  walks  without  any  difficulty.  The  muscles  of  the  arms  and 
legs  are  those  usually  implicated;  rarely  the  facial,  ocular,  or  laryngeal  mus- 
cles. Emotion  and  cold  aggravate  the  condition.  In  some  instances  there 
is  mental  weakness.  The  sensation  and  the  reflexes  are  normal.  G.  M. 
Hammond  has  reported  three  remarkable  cases  in  one  family,  in  which  the 
disease  began  at  the  eighth  year  and  was  confined  entirely  to  the  arms.  It 
was  accompanied  with  some  slight  mental  feebleness.  The  condition  of  the 
muscles  is  interesting.  The  patients  appear  and  are  muscular,  and  there 
is  sometimes  a  definite  hypertrophy  of  the  muscles.  The  force  is  scarcely 
proportionate  to  the  size.  Erb  has  described  a  characteristic  reaction  of 
the  nerve  and  muscle  to  the  electrical  currents — the  so-called  myotonic 
reaction,  the  chief  feature  of  which  is  that  normally  the  contractions  caused 
by  either  current  attain  their  maximum  slowly  and  relax  slowly,  and  ver- 
micular, wave-like  contractions  pass  from  the  cathode  to  the  anode. 

The  disease  is  incnra1)]e,  hnt  it  may  be  arrested  temporarily.  The  na- 
ture of  the  affection  is  unknown.    In  the  only  autopsy  made  Dejerine  and 


1150  DISEASES  OF  THE  MUSCLES. 

Sottas  have  found  hypertrophy  of  the  primitive  fibres  with  multiplication 
of  the  nuclei  of  all  the  muscles,  including  the  diaphragm,  but  not  the 
heart.  The  spinal  cord  and  the  nerves  were  intact.  From  Jacoby's  recent 
studies  it  is  doubtful  whether  these  changes  in  the  muscles  are  in  any  way 
characteristic  or  peculiar  to  the  disease.  No  treatment  for  the  condition  is 
known. 

III.    PARAMYOCLONUS    MULTIPLEX 

{Myoclonia). 

An  affection,  described  by  Friedreich,  characterized  by  clonic  contrac- 
tions, chiefly  of  the  muscles  of  the  extremities,  occurring  either  constantly 
or  in  paroxysms. 

The  cases  have  been  chiefly  in  males,  and  the  disease  has  followed  emo- 
tional disturbance,  fright,  or  straining.  The  contractions  are  usually  bilat- 
eral and  may  vary  from  fifty  to  one  hundred  and  fifty  in  the  minute.  Occa- 
sionally tonic  spasms  occur.  They  are  not  accompanied  by  any  sensory 
disturbances.  In  the  intervals  between  the  attacks  there  may  be  tremors  of 
the  muscles.  In  the  severe  spasms  the  movements  may  be  very  violent;  the 
body  is  tossed  about,  and  it  is  sometimes  difficult  to  keep  the  patient  in  bed. 
Grucci  has  described  a  family  in  which  the  affection  has  occurred  in  three 
generations. 

Weiss  has  also  noted  heredity  in  four  generations.  According  to  this 
author  the  essential  symptoms  are  continuous  or  paroxysmal  muscular  con- 
tractions, usually  symmetrical  and  rhythmical,  of  muscles  otherwise  normal, 
which  cease  during  sleep.  There  are  neither  psychical  nor  sensory  disturb- 
ances. The  condition  is  most  common  in  young  males,  and  is  unaffected 
by  treatment.  Eaymond  groups  this  disease  with  fibrillary  tremors,  electric 
chorea  (Henoch),  tic  non  douloureux  of  the  face,  and  the  convulsive  tic, 
under  the  name  of  myoclonies,  believing  that  it  is  only  one  link  in  a  chain 
of  pathological  manifestations  in  the  degenerate. 


INDEX. 


Abasia,  1126,  1136. 

Abdominal  typlius,  1. 

Abducens  nerve  (see  Sixth  Nerve),  1048. 

Aberrant,  thyroid  glands,  836;  adrenals,  896. 

Abortion,  in  relapsing  fever,  55;  in  small- 
pox,  65;   in  syphilis,  251. 

Abscess,  atheromatous,  771;  of  brain,  1025; 
in  appendicitis,  522,  526;  in  glanders,  235; 
of  kidney  (pyonephrosis);  886;  of  liver, 
577;  of  lung,  662;  of  mediastinum,  686;  of 
parotid  gland,  447;  of  tonsils,  452;  peri- 
nephric, 900;  cerebral,  1025;  pysemic,  163; 
retro-pharyngeal,  450,  971. 

Acanthocephala,  365. 

Acardia,  765. 

Acarus  scabiei,  A.  folliculorum,  376. 

Accentuated  aortic  second  sound,  in  chronic 
Bright's  disease,  881;  in  arterio-sclerosis, 
774. 

Accessory  spasm,  1064. 

Acephalocysts  (see  Hydatid  Cysts). 

Acetonsemia,  426. 

Acetone,  424;  tests  for,  424. 

Acetonuria,  864. 

Achondroplasia,  841. 

Achromatopsia  in  hysteria,  1116. 

Achylia  gastrica,  501. 

Acne,  from  bromide  of  potassium,  1101; 
rosacea,  382. 

Acromegaly,  1142;  and  gigantism,  1143. 

Actinomycosis,  235;  pulmonary,  236;  cutane- 
ous, 237;  cerebral,  237. 

Acute  bulbar  paralysis,  933. 

Acute  yellow  atrophy,  551. 

Addison's  disease,  828;  pill,  254;  keloid, 
1145. 

Ad6nie,  809. 

Adenitis  in  scarlet  fever,  81. 

Adenitis,  tuberculous,  282,  812;  malignant, 
191. 

Adenoid  growths  in  pharynx,  454. 

Adherent  pericardium,  696. 

Adhesive  pylephlebitis,  554. 

Adiposis  dolorosa,  410. 

Adrenals  in  Addison's  disease,  829. 

iT:gophony,  120.  670. 

Afferent  system,  diseases  of,  920. 

Ageusia,  1060. 


Agoraphobia,  1124. 

Agraphia,  992. 

Ague,  203. 

Ague  cake  (see  Enlarged  Spleen),  216. 

Ainhum,  1147. 

"  Air-hunger  "  in  diabetes,  426. 

Akinesia  algera,  1126. 

Akoria,  503. 

Albini,  nodules  of,  767. 

Albinism,  in  leprosy  (lepra  alba),  341;  of  the 
lung,  656. 

Albumin,  tests  for,  856. 

Albuminous  expectoration  in  pleurisy,  678. 

Albuminuria,  854,  and  life  assurance,  858; 
cyclic,  855;  febrile,  855;  functional  855;  in 
acute  Bright's  disease,  870;  in  chronic 
Bright's  disease,  880;  in  diabetes,  424;  in 
diphtheria,  150;  in  epilepsy,  1097;  in  ery- 
sipelas, 159;  in  gout,  415;  in  pneumonia, 
122;  in  scarlet  fever,  79,  80;  in  typhoid 
fever,  31;  in  variola,  64;  neurotic,  855; 
physiological,  855;  prognosis  in,  858. 

Albuminuric  retinitis,  1039. 

Albuminuric  ulceration  of  the  bowels,  513. 

Albumosuria,  857. 

Alcaptonuria,  865. 

Alcohol,  effects  of,  on  the  digestive  system, 
381;  on  the  kidneys,  382;  on  the  nervous 
system,  381;  poisonous  effects  of,  381. 

Alcoholic  neuritis,  1034. 

Alcoholism,  380;  acute,  380;  and  tuberculo- 
sis, 382;  chronic,  380. 

Alexia,  992. 

Algid  form  of  malaria,  215. 

Allantiasis,  391. 

Allocheiria.  924. 

Allorrhythmia,  756. 

Alopecia,  in  syphilis,  241. 

Alternating  paralysis  (see  Crossed  Paraly- 
sis). 

Altitude,  effects  of  high,  .S46. 

Altitude  in  tuberculosis,  2.59,  334. 

Amaurosis,  liysterical,  1040,  1116;  toxic, 
1040;  ursemic,  807,  881;  In  ha?matemesls, 
496. 

Amblyopia,  1040;  tobacco,  1040;  crossed, 
1044. 

Ambulatory  typhoid  fever,  14,  34. 
1151 


1152 


INDEX. 


Amteba  coli  (amceba  dysenteriae),  193;  in 
liver  abscess,  195,  577;  in  sputa,  201. 

Amoebic  dysentery,  195. 

Ammonisemia,  888. 

Amnesia  verbalis,  991. 

Amphoric  breathing,  309,  683. 

Amphoric  echo,  309. 

Amusia,  991. 

Amyloid  disease,  in  phthisis,  298;  in  syphilis, 
242;  of  kidney,  884;  of  liver,  586. 

Amyosthenia,  1125. 

Amyotrophic  lateral  sclerosis,  928. 

Anaemia,  789;  bothriocephalus,  367;  in  anchy- 
lostomiasis,  360;  from  Bilharzia,  352;  in 
chlorosis,  792;  from  gastric  atrophy,  469; 
from  haemorrhage,  789;  miner's,  360;  brick- 
maker's  360;  tunnel,  360;  from  inanition, 
791;  from  lead,  387;  idiopathic,  795;  in  gas- 
tric cancer,  489;  in  gastric  ulcer,  482; 
mountain,  346,  360;  in  malarial  fever,  216; 
in  rheumatism,  170;  in  syphilis,  240;  in 
typhoid  fever,  19;  primary  or  essential, 
792;  progressive  pernicious,  795;  secondary 
or  symptomatic,  789;  of  spinal  cord,  966; 
splenic,  834;  toxic,  791. 

Anaemic  murmurs  (see  H^Mic  Murmurs). 

Anaesthesia,  dolorosa,  970;  in  hemiplegia, 
1005;  in  hysteria,  1115;  in  leprosy,  342;  in 
locomotor  ataxia,  924;  in  Morvan's  dis- 
ease, 975;  paralysis,  1035;  pneumonia,  129; 
in  railway  spine,  1134;  in  unilateral  lesions 
of  the  cord,  965. 

Analgesia  in  hysteria,  1115;  in  Morvan's  dis- 
ease, 975;  in  syringo-myelia,  975. 

Anarthria,  989. 

Anasarca  (see  Dropsy). 

Anchylostomiasis,  359. 

Anchylostomum  duodenale,  359. 

Aneurism,  776;  arterio-venous,  776,  788;  cir- 
soid, 776;  congenital,  788;  cylindrical,  776; 
dissecting,  776;  embolic,  776;  false,  776; 
fusiform,  776;  mycotic,  776;  of  the  ab- 
dominal aorta,  786;  of  the  branches  of  the 
abdominal  aorta,  787;  of  the  cerebral  ar- 
teries, 1013;  of  the  cojliac  axis,  787;  of 
heart,  753;  of  the  hepatic  artery,  787;  of 
the  renal-artery,  787;  of  the  splenic  artery, 
787;  of  the  superior  mesenteric  artery,  787; 
true,  776. 

Aneurism,  of  thoracic  aorta,  777;  haemor- 
rhage in,  781;  pain  in,  781;  Tufnell's  treat- 
ment of,  784;  unilateral  sweating  in,  782. 

Aneurism,  verminous,  in  the  horse,  359,  777. 

Angina,  Ludovici,  450;  simplex,  448;  suffo- 
cativa,  138. 

Angina  pectoris,  761;  pseudo-  or  hysterical, 
763;  toxic,  764;  vaso-motoria,  764. 

Angiocholitis,  chronic  catarrhal,  557;  suppu- 
rative and  ulcerative,  557. 
Angioneurotic  oedema,  1140. 


Angio-sclerosis,  773. 

Anguillula  stercoralis,  A.  intestinalis,  364. 

Animal  lymph,  72. 

Anisocoria,  1047. 

Ankle  clonus,  in  hysterical  paraplegia,  941, 
1114;  in  spastic  paraplegia,  937;  spurious, 
1114. 

Anorexia  nervosa,  503,  1117. 

Anosmia,  1038. 

Anterior  cerebral  artery,  embolism  of,  1011. 

Anterior  crural  nerve,  paralysis  of,  1072. 

Anthomyia  canicularis,   378. 

Anthracosis,  of  lungs,  652;  of  liver,  570. 

Anthrax,  224;  bacillus,  224;  in  animals,  224; 
external,  225;  Internal,  226. 

Anthropophobia,  1124. 

Antipneumococcie  serum,  112. 

Antitoxine  of  diphtheria,  141,  155;  of  pneu- 
monia, 112;  of  tetanus,  233. 

Antityphoid  serum,  46. 

Anuria,  850;  complete,  from  stone,  850;  hys- 
terical, 851. 

Anus,  imperforate,  533. 

Aorta,  aneurism  of,  777;  dynamic  pulsation 
of,  782;  throbbing,  786,  1126;  tuberculosis 
of,  327. 

Aortic  incompetency,  709;  sudden  death  in, 
712. 

Aortic  orifice,  congenital  lesions  of,  767. 

Aortic  stenosis,  715. 

Aortic  valves,  bicuspid  condition  of,  766;  in- 
sufficiency of,  709. 

Apex  pneumonia,  126. 

Aphasia,  988;  auditory,  991;  in  infantile 
hemiplegia,  1018;  medico-legal  aspects  of, 
993;  motor,  992;  in  phthisis,  312;  prognosis 
of,  993;  sensory,  991;  subcortical-motor, 
993;  in  typhoid  fever,  30;  tests  for,  993; 
transient,  in  migraine,  1103;  visual,  992. 

Aphemia,  989. 

Aphonia,  hysterical,  1116;  in  acute  laryn- 
gitis, 615;  in  adductor  paralysis,  1061;  in 
pericardial  effusion,  692. 

Aphthae  (see  Stomatitis,  Aphthous),  441. 

Aphthous  fever,  347. 

Apoplectic  Jiabitus,  998;  stroke,  1001. 

Apoplexy,  cerebral,  997;  ingravescent,  1001; 
pulmonary,  038. 

-Appendicitis,  519;  obliterans,  520;  infective, 
521;  perforative,  520;  relapsing,  527;  ul- 
cerative, 521. 

Appendicular  colic,  520,  524. 

Appendix  vermiformis,  situation  of,  519;  per- 
foration of,  in  typhoid  fever,  10;  faecal 
concretions  in,  519;  foreign  bodies  in,  520; 
necrosis  and  sloughing  of,  521. 

Apraxia,  992. 

Aprosexia,  454,  456. 

Arachnida,  parasitic,  375. 

Arachnitis  (see  Meningitis),  954. 


\ 


INDEX. 


1153 


Aran-Duclicnne  type  of  muscular  atrophy, 
929,  941;  in  lead-poisoning,  388. 

Arch  of  aorta,   aneurism  of,   778. 

Arcus  senilis,  750. 

Argyll  Robertson  pupil,  1047;  in  ataxia,  922. 

Arithmomania,  1089. 

Arm,  peripheral  paralysis  of  (see  Paralysis 
OF  Brachial  Plexus). 

Arrhythmia,  756. 

Arsenical  neuritis,  1035. 

Arsenical  pigmentation,  390;  in  chorea,  1085. 

Arsenical  poisoning,  390;  paralysis  in,  391. 

Arteries,  diseases  of,  770;  calcification  of, 
770;  degeneration  of,  770;  tuberculosis  of, 
327. 

Arterio-capillary  fibrosis,  770. 

Arterio-sclerosis,  770;  diffuse,  772;  in  lead- 
poisoning,  389;  in  migraine,  1103;  nodular 
form,  771;  in  phthisis,  316;  senile  form, 
772. 

Arteritis  in  typhoid  fever,  12,  21;  syphilitic, 
250. 

Arthralgia  from  lead,  389. 

Arthritides,  post-febrile,  165;  in  gout,  414. 

Arthritis,  173;  acute,  in  infants,  173;  gonor- 
rhoeal,  256;  in  acute  myelitis,  977;  in 
cerebro-spinal  meningitis,  106;  in  chorea, 
1080;  in  dengue,  100;  in  dysentery,  200;  in 
haemophilia,  820;  in  Malta  fever,  220;  in 
small-pox,  65;  in  tabes  dorsalis,  925;  mul- 
tiple secondary,  173;  in  purpura,  815; 
rheumatoid,  399;  in  scarlet  fever,  80;  sep- 
tic, 173;  in  typhoid  fever,  32. 

Arthritis  deformans,  399;  as  a  chronic  infec- 
tion, 400;  in  children,  403;  general  progres- 
sive form,  402;  Heberden's  nodes  in,  401; 
partial  or  mono-articular  form,  403;  verte- 
bral form,  403. 

Arthropathies  in  tabes,  925. 

Arthropathy,  hypertrophic  pulmonary,  1144. 

Ascariasis,  352. 

Ascaris  lumbricoides,  352. 

Ascites,  605,  609;  from  cancerous  peritonitis, 
605;  from  cirrhosis  of  the  liver,  572;  from 
syphilis  of  the  liver,  249;  in  cancer  of  the 
liver,  584;  in  tuberculous  peritonitis,  287; 
physical  signs  of,  606;  treatment  of,  607. 

Ascitic  fluid,  chylous,  607;  serous,  607;  haem- 
orrhagic,  607. 

Aspergillus  in  lung,  302. 

Asphyxia,  local,  1137;  death  by,  in  phthisis, 
317. 

Aspiration,  Bowditch's  conclusions  on,  677; 
in  empyema,  678;  in  pericardial  effusion, 
695;  In  pleuritic  effusion,  677. 

Aspiration  pneumonia,  642. 

Astasla-abasia,  1126,  1136. 

Asthenic  bulbar  paralysis,  947. 

Asthenopia,  nervous,  1124. 

Asthma,  bronchial,  628;  nnsal  affoclions  in, 
73 


629;  sputum  in,  630;  cardiac,  628;  hay,  612; 
Lcyden's  crystals  in,  631;  renal,  628,  867; 
thymic,  618,  844. 

Astrophobia,  1124. 

Atavism,  in  haemophilia,  819;  in  gout,  408. 

Ataxia,  cerebellar,  987;  cerebellar-heredo, 
950;  hereditary,  949;  in  progressive  pare- 
sis, 962;  locomotor,  920;  after  small-pox, 
64. 

Ataxic  gait,  923. 

Ataxic  paraplegia,  948. 

Atelectasis,  pulmonary,  642. 

Atheroma  (see  Arterio-sclerosis  and 
Phlebo-sclerosis). 

Athetosis,  1019;  bilateral  or  double,  939. 

Athlete's  heart,  710. 

Athyrea,  837,  840. 

Atmospheric  pressure,  effects  of,  969. 

Atremia,  1126. 

Atrophy,  acute  yellow,  of  liver,  551;  of  brain, 
diffuse,  in  general  paresis,  961;  of  brain, 
unilateral,  1017;  of  muscles,  various  forms 
of,  935;  progressive  muscular,  of  central 
origin,  928;  unilateral,  of  face,  1141. 

Attitude,  in  pseudo-hypertrophic  muscular 
paralysis,  934;  in  paralysis  agitans,  1077. 

Auditory  centre,  affections  of,  1056;  nerve, 
diseases  of,  1056;  vertigo,  1058. 

Aura,  forms  of,  in  epilepsy,  1095. 

Auto-infection  in  tuberculosis,  273. 

Automatism,  in  petit  mal,  1097;  in  cerebral 
syphilis,  246. 

Autumnal  fever,  3. 

Avian  tuberculosis,  258. 

BaccelU's  sign,  670,  672. 

Bacilluria  in  typhoid  fever,  31. 

Bacillus,  anthracis,  224;  of  cholera,  175. 

Bacillus  coll  communis— distinction  from  ty- 
phoid bacillus,  4;  in  bile-passages,  558;  in 
faeces  of  sucklings,  508;  in  fat  necrosis 
with  colitis,  591;  in  peritonitis,  597. 

Bacillus  diphtheriae,  140,  451;  value  of,  in 
diagnosis,  151. 

Bacillus  gas  (B.  aerogenes  capsulatus),  in 
peritonitis,  597;  in  pneumaturia,  864;  in 
pneumopericardium,   698. 

Bacillus  icteroides,  184. 

Bacillus,  Klebs-Loefl3er,  140;  toxine  of,  141. 

Bacillus,  of  glanders,  233;  of  influenza,  96; 
of  smegma,  2.38;  in  whooping-cough,  92;  of 
leprosy,  340;  of  plague,  190;  of  syphilis, 
238;  of  tetanus,  231;  pyocyaneus,  163; 
strepto-,  in  typhus  fever,  50. 

Bacillus  malloi,  2.S3. 

Bacillus  pestis,  190. 

Bacillus  pneumoniae.  111. 

Bacillus  proteus  fluorescens,  344. 

Bacillus  smegma,  238. 

Bacillus    (uborculosis,    259,    666;    diagnostic 


1154 


i:ndex. 


value  of,  313;  distribution  of,  261;  in  spu- 
tum,  300;  methods  of  detection,  301;  out- 
side the  body,  261;  products  of  growth  of, 
260. 
Bacillus  typhosus,  3. 
Bacillus  xerosis,  141. 
Bacteraemia,  161. 
Bacteria,   proteus  group   in  diarrhoea,   509; 

relation  to  diarrhoea,  508. 
Bacterium,    coli    commune    (see    Bacillus 

CoLi  Communis);  lactis  aerogenes,  508. 
Balanitis  in  diabetes,  425. 
Balantidium  coli,  351. 
Ball-thrombus  in  left  auricle,  723. 
Ball-valve  stone  in  common  duct,  566. 
Banting's  method  in  obesity,  440. 
"  Barben  cholera,"  394. 
Barking  cough  of  puberty,  1117. 
Barlow's  disease,  825. 
Barrel-shaped  chest  in  emphysema,  658;  in 

enlarged  tonsils,  455. 
Basilar  artery,  embolism  and  thrombosis  of, 

1010. 
Baths,  cold,  in  typhoid  fever,  43;  in  hyperpy- 
rexia of  rheumatism,  175;  in  scarlet  fever, 
84. 
Batophobia,  1124. 
Beaded  ribs  in  rickets,  436. 
Bed-bug,  377. 
Bednar's  aphthae,  443. 

Bed-sores,  acute,  in  myelitis,  977,  978;  in  ty- 
phoid fever,  18. 
Beer-drinkers,   heart-disease  in,  745. 
Bell's  (Luther)  mania,  1075. 
Bell's  palsy,  1051. 
j3-oxy-butyric  acid,  426,  865. 
Beri-beri,  220;  forms  of,  222. 
Besoin  de  respirer,  346. 
Biernacki's  symptom,  963. 
"  Big-jaw  "  in  cattle,  235. 
Bile  coloring  matter,  tests  for,  549. 
Bile-ducts,  acute  catarrh  of,  555;  ascarides 
in,  560;  cancer  of,  559;  congenital  oblitera- 
tion of,  561;  stenosis  of,  560. 
Bile-passages,  diseases  of,  555. 
Bilharzia  h£ematobia,  352. 
Biliary  cirrhosis  of  liver,  570. 
Biliary  colic,  563. 
Biliary  fistulse,  567. 
Bilious  remittent  fever,  213. 
Birth  palsies,  938. 
Black  death,  190. 
Black  spit  of  miners,  654. 
Black  vomit,  186;  in  dengue,  100. 
Black-water  fever,  216. 

Bladder,  paralysis  of,  In  locomotor  ataxia, 
922;  care  of,  in  myelitis,  979;  hypertrophy 
of,  in  diabetes  insipidus,  432;  tuberculosis 
of,  325. 
"  Bleeders,"  819. 


Blood-letting,    in    arterio-sclerosis,    775;    in 
cerebral    haemorrhage,    1012;    in    emphy- 
sema, 659;  in  heart-disease,  731;  in  pneu- 
monia, 135;  in  sun-stroke,  398;  in  yellow 
fever,  189. 
Blepharospasm,  1055. 
Blindness  (see  Amaueosis). 
Blood  and  ductless  glands,  diseases  of,  789. 
Blood,  characters  of,  in  anaemia,  789;  in  can- 
cer of  the  stomach,  489;  in  chlorosis,  792; 
in  cholera,  178;  in  diabetes,  421;  in  gout, 
410;  in  haemophilia,  819;  in  leukaemia,  806; 
in    pernicious    anaemia,    797;    in    pseudo- 
leukaemia,  Hodgkin's  disease,  812;  in  pur- 
pura,   814;   in   secondary  anaemia,   790;   in 
typhoid  fever,  19. 
Blood  serum  therapy  in  diphtheria,  155;  in 
pneumonia,    112;    in    tetanus,    233;    in    ty- 
phoid fever,  46. 
Blood-vessels  of  liver,  affections  of,  553. 
"  Blue  disease,"  768. 

Blue  line  on  gums  in  lead-poisoning,  387. 
Boils,  in  diabetes,  425;  after  typhoid  fever, 

18;  after  small-pox,  65. 
Bones,    lesions   of,   in   acromegaly,    1142;    in 
congenital  syphilis,  244;  in  rickets,  434;  in 
typhoid  fever,  32. 
Borborygmi,  498,  507. 
Bothriocephalus  latus,  366;  anaemia,  367. 
Botulism,  391. 

Botyroid  liver  in  syphilis,  249. 
Bovine  tuberculosis,  258. 
Bowel,  affections  of  (see  Ixtestixes);  acute 

obstruction  of,  534;  infarction  of,  546. 
Brachial  plexus,  affections  of,  1069. 
Brachycardia     (Bradycardia),     759;     in     ty- 
phoid fever,  20. 
Brain,  diffuse  and  focal  diseases  of,  979;  ab- 
scess of,    1025;   abscess  of,   in  congenital 
heart-disease,  768;  affections  of  blood-ves- 
sels of,  994;  anaemia  of,  995;  atrophy  and 
sclerosis  of,  1017;  congestion  of,  994;  cysts 
in,  1021;  echinococcus  of,  374;  haemorrhage 
into,  997;  syphilis  of.  244,  1020;  glioma  of, 
1020;  hyperaemia  of,  994;  inflammation  of, 
1024;    oedema    of,    997;    porencephalus    of, 
1017. 
Brain-murmur  in  rickets,  437. 
Brain,  sclerosis  of,  957;  diffuse,  958;  insular, 

959;  miliary,  958;  tuberous,   959. 
Brain,  softening  of,  red,  yellow,  and  white, 

1009. 
Brain,   tubercle  of,   321.   1020. 
Brain,   tumors  of,   1020;    medical  treatment 
of,  1024;  surgical  treatment  of,  1024;  symp- 
toms, general  and  localizing,  1021. 
Brand's  method  in  typhoid  fever,  43. 
Breakbone  fever  (see  Dengue),  99. 
Breast-pang,  761. 
Breath,  odor  of,  in  diabetic  coma,  426;  foul. 


INDEX. 


1155 


in  scurvy,  823;  foetid,  in  enlarged  tonsils, 
456. 

Breathing  (see  Respiration);  mouth,  454. 

Bremer's  blood  test  in  diabetes,  427. 

Brick-maker's   anaemia,    360.  [of,    870. 

Bright's  disease,  acute,  869;  interstitial  form 

Bright's  disease,  chronic,  874;  interstitial 
form  of,  877;  causes  of,  877;  cardio-vascu- 
lar  changes  in,  880;  hereditary  influences 
in,  877;  Edebohls's  operation  in,  885; 
parenchymatous   form   of,   875. 

Briquet,  syndrome  of,  1116. 

Broadbent's  sign,  696. 

"  Broken-winded,"  742. 

Bromatotoxismus,  391. 

Bromism,  1100. 

Bronchi,  casts  of,  633;  diseases  of,  621. 

Bronchial  asthma,  628. 

Bronchial  catarrh  (bronchitis),  621. 

Bronchial  glands,  tuberculosis  of,  283;  en- 
largement in  whooping-cough,  94,  684;  sup- 
puration in,  684. 

Bronchiectasis,  626;  abscess  of  brain  in,  627; 
congenital,  626;  cylindrical,  626;  rheuma- 
toid affections  in,  627;  saccular,  626;  spu- 
tum in,  627;  universalis,  626. 

Bronchiolitis  exudativa,  628. 

Bronchitis,  621;  acute,  621;  capillary,  641. 

Bronchitis,  chronic,  623. 

Bronchitis,  fibrinous,  632. 

Bronchitis  in  measles,  87;  in  small-pox,  64; 
in  typhoid  fever,  27;  putrid,  625. 

Bronchocele  (see  Goitre),  835. 

Bronchophony,  in  pneumonia,  120. 

Broncho-pneumonia,  acute,  641;  chronic,  649; 
acute  tuberculous,  292. 

Bronchorrhagia,  637. 

Bronchorrhoea,  624;  serous,  624. 

Bronze-skin  in  phthiriasis,  377;  in  Addison's 
disease,  830;  in  Basedow's  disease,  839;  in 
diabetes,  425;  in  Hodgkin's  disease,  812. 

Brown  atrophy  of  heart,  750. 

Brown  induration  of  lung,  635. 

Brown-S6guard's  paralysis,  965. 

Bruit,  d'airain,  683;  de  cuir  neuf,  690;  de 
diable,  794;  de  pot  f6le  (see  Cracked-pot 
Sound),  309;  de  souffle,  703;  oesophageal, 
460. 

Bubo,  parotid  (see  also  Parotitis),  447. 

Bubonic  plague,  189. 

Buccal  psoriasis,  446. 

niihVs  disease,  818. 

Bulbar  paralysis,  928,  932;  acute,  933;  as- 
thenic form,  947;  of  cerebral  origin,  932; 
progressive,  928. 

Bulimia,  423,  502. 

Cachexia,  in  cancer  of  the  stomach,  489; 
malarial,  208,  210;  periosteal,  825;  satur- 
nine, .387;  struniipriva,  842;  syphilitic,  240. 


Caisson  disease,  969. 

Calcareous  concretions,  in  phthisis,  295;  in 

the  tonsils,  456. 
Calcareous  degeneration,  of  arteries,  770;  of 

heart,  750. 
Calcification,  annular,  of  arteries,  770. 
Calcification  in  tubercle,  271. 
Calculi,    biliary,    561;    "  coral,"    892;    pan- 
creatic, 595;  renal,  891;  tonsillar,  456;  uri- 
nary, 891. 
Calculous  pyelitis,  886. 
Camp  fever,  49. 

Cancer,  of  bile-passages,  559,  583;  of  bowel, 
533;    of  brain,   1020;   of  gall-bladder,   559; 
green,  809;  of  kidney,  896;  of  liver,  582;  of 
lung,  663;  of  oesophagus,  461;  of  pancreas, 
594;     of     peritonaeum,     miliary,     604;     of 
stomach,  486;  acute,  493. 
Cancrum  oris,  444;  in  measles,  87. 
Canities,  the  result  of  neuralgia,  1104. 
Canned  goods,  poisoning  by,  393. 
Capillary  pulse,  In  aortic  insuflSciency,  714; 

in  neurasthenia,  1126;  in  phthisis,  311. 
Capsule,  internal,  982;  lesions  of,  983. 
Caput  Medusae,  606. 
Caput  quadratum,  in  rickets,  436. 
Carboluria,  865. 
Carbuncle  in  diabetes,  425. 
Cardia,  spasm  of,  499;  insufficiency  of,  500. 
Cardiac,  compensation,  rupture  of,  741;  dis- 
ease (see  Disease  of  Heart). 
Cardiac  murmurs,  Jiwniic,  in  chlorosis,  794; 
in  chorea,  1084;  in  idiopathic  anaemia,  799. 
Cardiac  murmurs,  organic,  in  aortic  insuffi- 
ciency, 713;  in  aortic  stenosis,  716;  in  con- 
genital heart  affections,  769;  in  mitral  in- 
competency,  720;  in  mitral  stenosis,  723; 
in  tricuspid  valve  disease,  726. 
Cardiac  nerves,  neuralgia  of,  761. 
Cardiac  overstrain,  742. 
Cardiac  septa,  anomalies  of,  766. 
Cardialgia  (see  Gastralgia). 
Cardiocentesis,  755. 
Cardio-resplratory  murmur,  308. 
Cardlo-scierosis,  750. 
Cardio-vascular    changes    in    renal    disease, 

880. 
Carles,  vertebral,  970. 
Carlnated  abdomen,  278. 
Carotid  artery,  ligature  and  compression  of, 

In  cerebral  haemorrhage,  1012. 
Carphologia,  29. 
Carpo-pedal  spasm,  1111. 
Carreau,  288. 

Caseation  in  tubercle.  271. 
Caseous  pneumonia.  272. 

Casts,  blood,  of  bronchial  tubes  In  haemopty- 
sis,   038;    In    fibrinous    bronchitis,    033;    of 
pelvis  of  kidney  and  ureter,  897. 
Casts  of  urinary  tubules,  872;  epithelial,  871, 


1156 


INDEX. 


872;  fatty,  876;  granular,  876,  880;  hyaline, 
880. 

Casts,  tube,  in  acute  Bright's  disease,  872; 
in  chronic  Bright's  disease,  876,  880. 

Catalepsy  in  hysteria,  1119. 

Cataract,  diabetic,  427;  after  typhoid  fever, 
30. 

Catarrh,  acute  gastric,  463;  autumnal,  612; 
bronchial,  621;  chronic  gastric,  466;  dry, 
625;  nasal,  611;  simple  chronic  (nasal),  611; 
sufeocative,  645. 

Catarrhal  bronchitis,  influence  of,  in  tuber- 
culosis, 269. 

Catarrhe  sec,  625. 

Catarrhus  sestivus,  612. 

Cauda  equina,  lesions  of,  972. 

Cavernous  breathing,  309. 

Cavities,  pulmonary,  physical  signs  of,  309; 
quiescent,  297. 

Cayor  fly,  379. 

Cellulitis  of  the  neck,  450. 

Centrum  semiovale,  lesions  of,  981. 

Cephalalgia  (see  Headache). 

Cephalic  tetanus,  232. 

Cephalodynia,  407. 

Cercomonas  intestinalis,  199,  351;  C.  homi- 
nis,  351. 

Cerebellar,  ataxia,  950,  987;  heredo-ataxia, 
950;  vertigo,  9S6. 

Cerebellum,  tumors  of,  986 ;  affections  of, 
985. 

Cerebral  arteries,  aneurism  of,  1013;  arterio- 
sclerosis of,  1014;   embolism  of,   1008;   en- 

-  darteritis  of,  1014;  syphilitic  endarteritis 
of,  245,  1014;  thrombosis  of,  1008. 

Cerebral  cortex,  lesions  of,  980. 

Cerebral  haemorrhage,  997;  aneurisms,  mil- 
iary, in,  998;  convulsions  in,  1007;  forms 
of,  999. 

Cerebral  localization,  907. 

"  Cerebral  pneumonia,"  122. 

"  Cerebral  rheumatism,"  171. 

Cerebral  sinuses,  thrombosis  of,  1015. 

Cerebral  softening,  1008. 

Cerebritis  (see  Encephalitis),  1024. 

Cerebrospinal  fever,  epidemic,  100;  anom- 
alous forms  of,  105;  complications  of,  105; 
malignant  form,  103;  ordinary  form,  103. 

Cervical  pachymeningitis,  953. 

Cervical  plexus,  lesions  of.  1067. 

Cervico-brachial  neuralgia,  1105. 

Cervico-occipital  neuralgia,  1067,  1105. 

Cestodes,  disease  due  to,  365;  visceral,  368. 

Chalicosis,  652,  654. 

Chancre,  239. 

Charbon,  224. 

Charcot's  joint,  925. 

CJiarcot-Leydcn  crystals,  507,  631,  803. 

Chattering  teeth,  10.51. 

Cheek,  gangrene  of,  444. 


Cheese,  poisoning  by,  393. 

Chest  expansion,  diminution  of,  in  Graves' 
disease,  839. 

Cheyne- Stokes  breathing,  Cheyne's  original 
description  of,  751;  in  apoplexy,  1001;  in 
fatty  heart,  751;  in  sun-stroke,  397;  in 
acute  tuberculosis,  275;  in  uraemia,  867. 

Chiasma  and  tract,  affections  of,  1041. 

Chicken-breast,  436,  455. 

Chicken-pox,  74. 

Child-growing,  618. 

Children,  constipation  in,  540;  diabetes  in, 
425;  tuberculous  broncho-pneumonia  in, 
292;  pneumonia  in,  126;  tuberculosis  of 
mesentric  glands  in,  283,  288;  mortality 
from  small-pox  in,  65;  rheumatism  in,  167; 
typhoid  fever  in,  34. 

Chills  (see  Rigors),  in  typhoid  fever,  17. 

Chloasma  phthisicorum,  313. 

Chloro-ansemia  in  phthisis,  311. 

Chloroma,  809. 

Chlorosis,  792;  and  anaemia,  sinus  thrombo- 
sis in,  1015;  dilatation  of  stomach  in,  794; 
Egyptian,  360;  fever  in,  794;  heart  symp- 
toms in,  794;  menstrual  disturbance  in, 
795;  thrombosis  in,  794. 

Choked  disk,  1040. 

Cholaemia,  550. 

Cholangitis,  infective,  566;  suppurative,  567, 
578;  in  typhoid  fever,  26. 

Cholecystectomy,  569;  indications  for,  569. 

Cholecystitis  acuta,  564. 

Cholecystitis,  acute  infective,  558. 

Cholecystotomy,  569. 

Cholelithiasis,  561;  in  typhoid  fever,  27. 

Cholera,  aslatica,  175;  bacillus  of,  175;  epi- 
demics of,  175;  infantum,  509;  nostras,  180; 
sicca,  179;  typhoid,  179. 

Cholera  toxine,  176. 

Cholerine,  180. 

Cholesteraemia,  550. 

Cholesterin  in  biliary  calculi,  563. 

Choluria,  865. 

Chondrodystrophia  foetalis,  841. 

Chorea,  acute,  1079;  etiology  of,  1079;  heart 
symptoms  of,  1083;  infectious  origin  of, 
1080;  in  pregnancy,  1080;  paralysis  in, 
1083;  rheumatism  and,  1079;  school-made, 
1081. 

Chorea,  canine,  1080;  chronic,  1090. 

Chorea,  habit  or  spasm,  1088. 

Chorea,  Huntingdon's  or  hereditary,  1090. 

Chorea,  insaniens,  1083,  1085;  paralytic  form 
of,  1083;  major,  1088:  pandemic,  10S8:  post- 
hemiplegic, 1019;  prehemiplegie,  1001; 
rhythmic  or  hysterical,  1091;  senile,  1090; 
spastica,  939,  1086;   Sydenham's,  1079. 

Choroid  plexuses,  sclerosis  of,  1029. 

Choroid,  tubercles  in,  279. 

Choroiditis  in  syphilis,  241. 


INDEX. 


1157 


Chovstek's  symptom  In  tetany,  1110. 

Chylangiomata,  547. 

Chyle  vessels,  disorders  of,  547. 

Cliylo-pericardium,  G9S. 

Chyluria,  non-parasitic,  859;  parasitic,  361. 

Cicatricial  stenosis  of  bowel,  533. 

Ciliary  muscle,  paralysis  of,  1047. 

Ciliata,  parasitic,  351. 

Cimex  lectularius,  377. 

Circulatory  system,  diseases  of,  688. 

Circumcision,  inoculation  of  tuberculosis  by, 
264;  in  hsemophilia,  820. 

Circumflex  nerve,  affections  of,  1070. 

Cirrhosis,  of  kidney,  877;  of  liver,  569;  of 
lung,  649;  ventriculi,  467. 

Claudication,  intermittent,  763. 

Claustrophobia,  1124. 

Clavlceps  purpurea,  poisoning  by,  394. 

Clavus  hystericus,  1116. 

Claw-hand  (main  en  griffe),  930,  953. 

Climate,  influence  of,  in  asthma,  632;  in 
chronic  Bright's  disease,  882;  in  tubercu- 
losis, 333. 

Clonus  (see  Ankle  Clonus);  jaw,  931. 

Clownism  in  hysteria,  1113. 

Cnethocampa,  379. 

Cobalt  miners,  cancer  of  lung  in,  664. 

Coccidium  oviforme,  349. 

Coccydynia,  1106. 

Cochin-China  diarrhoea,  365. 

Coeliac  affection  in  children,  511. 

Cog-wheel  respiration,  308. 

Coin-sound,  683. 

Cold  pack,  method  of  giving,  84. 

Colic,  biliary,  563;  in  appendicitis,  520,  524; 
in  angio-neurotic  oedema,  1140;  in  purpura, 
816;  lead,  388;  mucous,  544;  renal,  893. 

Colica  Pictonum,  386. 

Colitis,  diphtheritic,  512;  mucous,  544; 
simple  ulcerative,  513. 

Colles's  law,  239. 

Colloid  cancer,  of  lung,  663;  of  peritonaeum, 
604;  of  stomach,  487. 

Colon,  cancer  of,  533;  dilatation  of,  545. 

Coloptosis,  543. 

Coma,  diabetic,  425;  epileptic,  1096;  from 
heat-stroke,  396;  from  muscular  exertion, 
869;  in  acute  encephalitis,  1025;  in  acute 
yellow  atrophy,  552;  in  alcoholic  poisoning, 
380;  In  apoplexy,  1001;  In  cerebral  syphilis, 
246;  in  general  paresis,  962;  in  multiple 
sclerosis,  960;  in  pernicious  malaria,  215; 
in  thrombosis  of  cerebral  sinuses,  1015;  in 
typhoid  fever,  29;  uracmic,  867. 

Coma  vigil.  29. 

Comatose  form  of  malaria,  215. 

Comma  bacillus,  175. 

Common  bile-duct,  obstruction  of,  566. 

Compensation  in  valve  lesions,  708;  periods 
in.  740;  rupture  of,  741. 


Composite  portraiture  in  tuberculosis,  268. 

Compressed  air  disease,  969. 

Compression  and  traction  of  the  bowel, 
533. 

Compression  paraplegia,  970. 

Concretions  (see  Calcareous). 

Concussion  of  spinal  cord,  1133. 

Confusional  insanity,  30. 

Congenital  heart  affections,  765. 

Congenital  stenosis  of  pylorus,  494. 

Congenital  stricture  of  the  bowel,  533. 

Congenital  syphilis,  242. 

Conjugate  deviation  in  brain  tumor,  1023;  in 
apoplexy,  1002;  in  tuberculous  meningitis, 
279. 

Conjunctiva,  diphtheria  of,  149. 

Consecutive  nephritis,  886. 

Constipation,  538;  in  adults,  538;  in  infants, 
540;  spasmodic,  539;  treatment  of,  540. 

Constitutional  diseases,  399. 

Consumption  (see  Tuberculosis). 

Contracted  kidneys,  877. 

Contracture,  hysterical,  1114;  in  hemiplegia, 
1005;  of  nursing  women,  1110. 

Contusion  pneumonia,   109. 

Conus  arteriosus,  stenosis  of,  767. 

Conus  meduilaris,  lesions  of,  972. 

Convalescence,  fever  of,  16;  from  typhoid 
fever,  management  of,  47. 

Convulsions,  epileptic,  1096;  hysterical,  1112; 
in  acute  yellow  atrophy,  552;  in  alcoholism, 
380;  in  aspiration  of  pleural  effusion,  678; 
in  cerebral  haemorrhage,  1001;  in  cerebral 
syphilis,  246,  1099;  in  cerebral  tumors, 
1021;  in  chronic  Bright's  disease,  876. 

Convulsions,  infantile,  1091;  relation  to 
rickets,  438. 

Convulsions,  in  general  paralysis,  962;  in  he- 
patic colic,  564;  in  infantile  hemiplegia, 
1019;  in  lead-poisoning,  389;  in  meningitis, 
955;  in  sun-stroke,  397;  in  typhoid  fever, 
29;  in  uraemia,  866;  Jacksonian,  1098. 

Convulsive  tic,  1088. 

Coordination,  .disturbance  of,  in  tabes,  923. 

Copaiba  eruption,  88. 

Copper  test  for  sugar,  423. 

Copraemia,  539,  792. 

Coprolalia,  1089. 

Cor  adiposum,  749. 

Cor  blloculare,  766. 

Cor  bovlnum,  711. 

Cor  villosum,  689. 

Coronar.v  arteries,  in  angina  pectoris,  762, 
763;  obliteration  of,  747. 

Corpora  quadrigemlna,  tumors  in,  1023; 
lesions  of,  984. 

Corpulence,  439. 

Corpus  callosum,  lesions  of,  981. 

Cnrrignn'a  disease.  709. 

Corrignn  pulse,  714. 


1158 


INDEX. 


Coryza,  acute,  610;  fcetida,  612;  from  the  io- 
dides, 254. 

Costiveness,  538. 

Cough,  barliing,  of  puberty,  1117;  hysterical, 
1116;  in  acute  bronchitis,  622;  in  chronic 
bronchitis,  624;  in  pertussis,  93;  in 
phthisis,  300;  during  aspiration  of  pleural 
effusion,  677;  in  pneumonia,  118;  paroxys- 
mal, in  bronchiectasis,  627;  paroxysmal,  in 
fibroid  phthisis,  314;  stomach,  469. 

Coup  de  soleil,  395. 

Cow-pox,  68. 

Cracked-pot  sound,  309. 

Cramp,  writer's,  1107. 

Cramps,  in  cholera,  180;  in  gout,  415;  in 
chronic  Bright's  disease,  882. 

Cranio-sclerosis,  437. 

Cranio-tabes,  relation  to  congenital  syphilis, 
436;  in  rickets,  436. 

Craw-craw,  361. 

Creophila,  378. 

Cretinism,  endemic,  840;  sporadic,  840. 

Cretinoid  change,  840. 

Crises,  gastro-intestinal,  in  angio-neurotic 
eedema,  1140;  in  locomotor  ataxia,  924;  in 
purpura,  816;  nasal,  in  tabes,  925. 

Crisis,  in  pneumonia,  117;  in  relapsing  fever, 
54;  in  typhus  fever,  51. 

Crossed  or  alternating  paralysis,  984,  1004. 

Crossed  sensory  paralysis,  985. 

Croup,  membranous,  148;  spasmodic,  617. 

Croupous  enteritis,  512. 

Croupous  pneumonia,  108. 

Crura  cerebri,  lesions  of,  983,  1004. 

Crutch  paralysis,  1070. 

CruveilMer's  palsy,  929. 

Cry,  epileptic,  1096;  hydrocephalic,  278;  hys- 
terical, 1116;  in  congenital  syphilis,  243. 

Cryptogenetic  septicaemia,   162. 

Curschmann's  spirals,  631,  633. 

Cyanosis,  in  acute  tuberculosis,  276;  in  con- 
genital heart-disease,  768;  in  emphysema, 
657;  chronic,  769. 

Cycloplegia,  1047. 

Cynanche  maligna,  138. 

Cynobex  hebetica,  1117. 

Cystic  disease,  of  kidney,  898;  of  liver,  584. 

Cystic  duct,  obstruction  of,  565. 

Cysticercus  cellulosse,  368;  ocular,  369;  sub- 
cutaneous, 369;  general,  369;  cerebro- 
spinal, 369. 

Cystine  calculi,  862,  892. 

Cystinuria,  861. 

Cystitis,  in  locomotor  ataxia,  925;  in  trans- 
verse myelitis,  978;  tuberculous,  326. 
Cytozoa,  .349. 

Cysts,  chylous,  of  mesentery,  547;  in  kid- 
neys, 898;  of  brain,  1021;  porencephalic, 
1017;  of  brain,  thrombotic,  1009;  pan- 
creatic, 592. 


Dacryoadenitis  (see  Lachhtmal  Glands). 

Dancing  mania,  1088. 

Dandy  fever  (dengue),  99. 

Davainea  Madagascariensis,  366. 

Day-blindness,  1040;  in  scurvy,  824. 

Deaf-mutism  after  cerebro-spinal  fever,  106. 

Deafness,  in  cerebral  tumor,  1023;  in  cere- 
bro-spinal meningitis,  106;  in  hysteria, 
1116;  in  Meniere's  disease,  1058;  in  scarlet 
fever,  81;  in  tabes  dorsalis,  924;  nervous, 
1057. 

Death,  modes  of,  in  tuberculosis,  317;  sud- 
den, in  angina  pectoris,  762;  in  aortic  in- 
sufficiency, 712;  in  typhoid  fever,  40;  in 
pleural  effusion,  671. 

Debility,  nervous  (see  Neurasthenia),  1122. 

Decubitus,  acute,  1002;  (bed-sores)  in  trans- 
verse myelitis,  978. 

Degeneration,  reaction  of,  914;  in  neuritis, 
1036;  in  facial  paralysis,  1054. 

Deglutition,  difficult  (see  Dysphagia). 

Deglutition  pneumonia,  642. 

Delayed  resolution  in  pneumonia,  129. 

Delayed  sensation  in  tabes,  924. 

Delirium,  acute,  1075;  acute,  in  lead-poison- 
ing, 389;  cordis,  40,  755,  757;  expansive, 
962;  in  acute  rheumatism,  171;  in  pneu- 
monia, 122;  in  typhoid  fever,  28;  in  typhus 
fever,  52;  tremens,  382. 

Deltoid,  paralysis  of,  1070. 

Delusional  insanity  after  pneumonia,  123. 

Delusions  of  grandeur,  962. 

Dementia  paralytica,  960;  alcohol  as  a  fac- 
tor in,  381;  syphilis  and,  242,  246,  961. 

Demodex  folliculorum,  376. 

Dengue,  99. 

Dentition,  in  congenital  syphilis,  243;  in 
mercurial  stomatitis,  445;  in  rickets,  437. 

Dercum's  disease,  440. 

Dermacentor  americanus,  376. 

Dermatitis,  exfoliative  form,  82. 

Dermatobia,  378. 

Dermato-myositis,  1148. 

Dermatose  parasitaire,  361. 

Desquamation,  in  measles,  87;  in  rubella,  89; 
in  scarlet  fever,  79;  in  small-pox,  62;  in 
typhoid  fever,  17. 

Deviation,  secondary,  1048. 

Devonshire  colic,  386. 

Dextrocardia,  765. 

Diabetes  insipidus,  432;  heredity  in,  432;  in 
abdominal  tumor,  432;  in  tuberculous  peri- 
tonitis, 432. 

Diabetes  mellitus,  418;  acute  form,  422; 
bronzing  in,  425:  chronic  form,  422;  coma 
in,  425:  diet  in.  428:  dietetic  form,  422: 
gangrene  in,  425:  hereditary  influences  in, 
418;  in  obesity,  419:  in  children,  425;  lipo- 
genic  form,  422;  neurotic  form,  422: 
pancreas   in,    421;    pancreatic    form,    422; 


INDEX. 


1159 


paraplegia  in,  427;  perforating  ulcer  in, 
425;  theories  of,  420;  urine  in,  423. 

Diabetes,  pliosphatic,  862. 

Diabetic,  centre  in  medulla,  419;  cirrhosis, 
421;  coma,  425;  phthisis,  421;  tabes,  426. 

Dlacetic  acid,  864. 

Diaphragm,  paralj'sis  of,  1068;  degeneration 
of  muscle  of,  1068. 

Diarrhoea,  505;  acute  dyspeptic,  509;  alba, 
511;  bacteria  in,  508;  chronic  treatment  of, 
514;  chylosa,  511;  endemic,  of  hot  coun- 
tries, 364;  from  anchylostomiasis,  360;  in 
children,  treatment  of,  516;  in  cholera,  179; 
in  dysentery,  198,  200;  in  hysteria,  1117; 
in  phthisis,  311;  in  typhoid  fever,  23;  in 
ursemia,  867;  nervous,  506;  of  Cochin- 
Chiua,  365;  tubular,  544;  lienteric,  507. 

Diathesis,  gouty,  408,  414;  hsemorrhagic, 
814;  lithic  acid,  859;  tuberculous  or  scrofu- 
lous, 268;  uric  acid,  860. 

Diazo-reaction  in  typhoid  fever,  30. 

Dicrotism  of  pulse  in  typhoid  fever,  13,  19. 

Diet,  in  chronic  dyspepsia,  470;  in  constipa- 
tion, 540;  in  convalescence  from  typhoid 
fever,  47;  in  diabetes,  428;  in  gout,  416;  in 
infantile  diarrhoea,  516;  in  obesity,  439;  in 
scurvy,  822;  in  tuberculosis,  335;  in  ty- 
phoid fever,  42. 

Dietl's  crises,  848. 

Digestive  system,  diseases  of,  441. 

Dioctophyme  gigas,  364. 

Diphtheria,  138;  atypical  forms  of,  146;  of 
auditory  meatus,  149;  of  conjunctiva,  149; 
and  croup,  144;  bacillus  of,  140;  contagious- 
ness of,  138;  hemiplegia  in,  150;  immunity 
from,  141;  in  animals,  139;  laryngeal,  148; 
latent,  147;  nephritis  in,  150;  neuritis  in, 
151;  nasal,  147;  pharyngeal,  146;  of  skin, 
149;  symptoms  of,  146;  systemic  infection, 
147;  antitoxine  treatment  of,  155;  of 
wounds,  149. 

Diphtheritic,  colitis,  512;  membrane,  his- 
tology of,  144;  processes  in  pneumonia, 
115;  processes  in  typhoid  fever,  33. 

Diphtheritis,  142. 

Diphtheroid  inflammations,  142. 

Diplegia,  facial,  1053;  in  children,  938. 

Diplococcus  intracellularis  meningitidis,  102. 

Diplococcus  pneumoniae  (micrococcus  lanceo- 
latus,  pneumococcus),  110,  in  empyema, 
671;  in  endocarditis,  702;  in  peritonitis,  597. 

Diplopia  (see  Double  Vision),  1049. 

Dipsomania,  380. 

Dipylldium  caninum,  366. 

Disinfection,  in  diphtheria,  153;  in  typhoid 
fever,  40. 

Dissecting  aneurism,  776. 

Distomiasis,  351. 

Distomum  lanceolatnm,  351;  D.  buski,  351; 
D.  endemlcum,  351;  D.  perniciosum,  351; 


D.  sinense,  351;  D.  felineum,  351;  D.  wes- 
termannl,  638,  352. 

Dittrich's  plugs,  625. 

Diuresis,  432. 

Diver's  paralysis,  969. 

Diverticula  of  oesophagus,  462. 

Dochmius  duodenalis,  359. 

Dorsodynia,  407. 

Dothignenterite,  1. 

Double  heart,  765. 

Double  vision,  1049;  in  ataxia,  922;  in 
chronic  Bright's  disease,  881. 

Dracontiasis,  362. 

Dracunculus  medinensis,  362. 

Drainage  and  diphtheria,  138;  and  scarlet 
fever,  76;  and  tonsillitis,  451;  and  typhoid 
fever,  5. 

Dreamy  state  in  epilepsy,  1097. 

Dropsy,  cardiac,  treatment  of,  733;  in 
anaemia  (oedema),  797;  in  acute  Bright's 
disease,  870;  in  aortic  insufficiency,  712; 
in  aortic  stenosis,  717;  in  cancer  of 
stomach,  490;  in  chronic  Bright's  disease, 
876;  in  mitral  insufficiency,  720;  in  mitral 
stenosis,  725;  in  phthisis,  312;  in  scarlet 
fever,  80. 

Drug-rashes,  83,  814. 

Drunkenness,  diagnosis  from  apoplexy,  380, 
1007. 

Dry  mouth,  447. 

Dulness,  movable,  in  pleural  effusion,  669; 
in  pneumothorax,  683. 

Dumb  ague,  217. 

Duodenal  ulcer,. 478;  diagnosis  of,  from  gas- 
tric, 484. 

Duodenum,  defect  of,  533;  ulcer  of,  478. 

Dura  mater,  diseases  of,  951;  hsematoma  of, 
952. 

Durande's  mixture,  568. 

Duroeiez's  murmur,  714. 

Dust,  diseases  due  to,  650,  652;  tubercle 
bacilli  in,  261. 

Dysacusis,  1057. 

Dysentery,  193;  abscess  of  liver  in,  196,  200; 
acute  catarrhal,  198;  acute  specific,  193; 
amoeba  coll  in,  195;  chronic,  199;  diph- 
theritic, 199;  treatment  of,  201;  tropical  or 
amoebic,  195. 

Dyspepsia,  acute,  463;  chronic,  466;  nervous, 
497. 

Dysphagia,  hysterical,  1117;  in  cancer  of  the 
oesophagus,  461;  in  hydrophobia,  228;  in 
cesophagismus,  459;  in  oesophagitis,  458;  in 
pericardial  effusion,  692;  in  thoracic  aneu- 
rism, 781;  in  tuberculous  laryngitis,  619. 

Dyspnoea,  cardiac,  treatment  of,  733;  from 
aneurism,  781;  hysterical,  1116,  1133;  in 
acute  tuberculosis,  275;  in  aortic  Insuffl- 
cloncy,  712;  in  cardiac  dilatation,  744;  In 
chlorosis,    792;   in  diabetic  coma,   426;   In 


1160 


INDEX. 


mitral  insufficiency,  719;  in  mitral  steno- 
sis, 725;  in  pericardial  effusion,  692;  in 
pneumonia,  117;  in  phthisis,  304;  in 
oedema  of  the  glottis,  617;  in  spasmodic 
laryngitis,  618;  uraemic,  867. 
Dystrophies,  muscular,  933;  clinical  forms 
of,  934. 

Ear,  complications  of  scarlet  fever,  81;  affec- 
tions of,  in  syphilis,  241,  244;  symptoms 
simulating  meningitis,  955,  1027. 

Ebstein's  method  in  obesity,  439. 

Echinococcus  cyst,  fluid  of,  371,  373. 

Echinococcus  disease,  370. 

Echinococcus,  endogenous,  371;  exogenous, 
371;  multilocular,  371,  374. 

Echinorhynchus,  gigas,  E.  moniliformis,  365. 

Echokinesis,  1089. 

Bcholalia,  1089. 

Eclampsia,  1091;  nutans,  1089. 

Ectopia  cordis,  765. 

Eczema  of  the  tongue,  445;  in  diabetes,  425; 
in  gout,  414. 

Efferent  tract,  diseases  of,  928. 

Ehrlich's  reaction  in  typhoid  fever,  30. 

Elastic  tissue  in  sputum,  301. 

Electrical  reactions,  in  exophthalmic  goitre, 
839;  in  facial  palsy,  1054;  in  Landry's 
paralysis,  947;  in  multiple  neuritis,  1036; 
in  periodical  paralysis,  1136;  in  polio- 
myelitis anterior,  944;  in  Thomsen's  dis- 
ease, 1149. 

Electrolysis  in  aneurism,  785. 

Elephantiasis,  362. 

Emaciation,  in  anorexia  nervosa,  1117;  in 
gastric  cancer,  489;  in  oesophageal  cancer, 
461;  in  phthisis,  306. 

Embolic  abscesses,  164. 

Embolism,  and  aneurism,  776;  in  chorea, 
1082;  in  typhoid  fever,  21;  of  cerebral  ar- 
teries, 1008. 

Embryocardia,  757;  in  pneumonia,  120;  in 
typhoid  fever,  20. 

Emphysema,  654;  acute  vesicular,  660; 
atrophic,  659;  compensatory,  655;  hyper- 
trophic, 655;  interstitial,  660. 

Emphysema,  subcutaneous,  after  trache- 
otomy, 687;  after  aspiration  of  the  pleura, 
677;  in  gastric  ulcer,  479;  in  phthisis,  313; 
of  the  mediastinum,  687. 

Emprosthptonos  in  tetanus,  232. 

Empyema,  671;  bacteriology  of,  671;  necessi- 
tatis, 237,  672,  783;  perforation  of  lung  in, 
673. 

Encephalitis,  acute,  1024;  meningo-,  chronic 
diffuse,  960;  meningo-,  foetal,  938;  polio-, 
of  Striimpell,  1018;  suppurative,  1025; 
syphilitic,  245. 

Encephalopathy,  lead,  388. 

Enchondroma  of  lung,  663. 


Endarteritis  of  spinal  cord,  967. 

Endocarditis,  acute,  698;  chronic,  705; 
chronic  vegetative,  701;  diphtheritic,  699; 
in  chorea,  699,  1084;  infectious,  699;  in  the 
foetus,  707,  767;  gonorrhoeal,  256;  in  pneu- 
monia, 700;  in  puerperal  fever,  700;  in 
rheumatism,  170,  699;  in  septicaemia,  700; 
in  typhoid  fever,  12,  21;  in  tuberculosis, 
298,  700;  malignant,  699;  meningitis  in, 
700;  micro-organisms  in,  702;  mural,  701; 
recurring,  699;  sclerotic,  707;  simple  or 
verrucose,  699,  syphilitic,  250;  ulcerative, 
699. 

Endophlebitis,  774. 

Enteric  fever  (see  Typhoid  Fevee),  1. 

Enteritis,  catarrhal,  505;  croupous,  512, 
diphtheritic,  512;  in  children,  508;  phleg- 
monous, 512;  membranous  or  tubular,  544; 
ulcerative,  512. 

Entero-colitis,  acute,  510. 

Enteroclysis  in  cholera,  181. 

Enteroliths,  519,  534;  as  a  cause  of  appendi- 
citis, 519;  in  sacculi  of  colon,  539. 

Enteroptosis,  541,  847,  1126. 

Entozoa  (see  Animal  Parasites),  349. 

Eosinophilia  in  leuksemia,  806;  in  trichinosis, 
357. 

Ependymitis,  purulent,  277. 

Ephemeral  fever,  342. 

Epidemic  haemoglobinuria,  818,  853. 

Epidemic  roseola,  89. 

Epidemic  stomatitis,  347. 

Epididymitis  (see  Orchitis),  251,  326. 

Epilepsia,  larvata,  1098;  nutans,  1066. 

Epilepsy,  1093;  and  alcoholism,  1095;  and 
syphilis,  1095,  1099;  heredity  in,  1094;  in 
chronic  ergotism,  394;  in  general  paresis, 
962;  in  lead-poisoning,  389;  in  Raynaud's 
disease,  1139;  Jacksonian,  917,  1098; 
masked,  1098;  post-epileptic  symptoms  of, 
1097;  procursive,  1096;  reflex,  1095;  rota- 
tory, 1096;  spinal,  937;  surgical  treatment 
of,  1101. 

Epileptic  fits,  stages  of,  1096. 

Epistaxis,  614;  in  haemophilia,  820;  in 
scurvy,  823;  in  typhoid  fever,  27;  "  renal," 
852;  vicarious,  614. 

Erb-Goldflam's  symptom-complex,  947. 

Erb's  syphilitic  spinal  paralysis,  940. 

Ergotism,  394;  convulsive,  394;  gangrenous, 
394. 

Erosion  of  teeth,  445. 

Eructations,  nervous,  498. 

Eruptions  (see  Rashes). 

Erysipelas,  157;  abscess  in,  159;  after  vacci- 
nation, 71;  facial,  158;  in  typhoid  fever,  33; 
migrans,  159;  puerperal,  157. 

Erythema,  exudativum,  815;  in  pellagra, 
395;  in  typhoid  fever,  17;  in  tonsillitis,  452. 

Erythromelalgia,  1106,  1139. 


INDEX. 


1161 


Eschar,  sloughing,  In  hemiplegia,  1002. 

Eustrougylns  gigas,  364. 

Exaltation  of  ideas  in  general  paresis,  962. 

Exanthematous  typhus,  49. 

Exfoliative  dermatitis,  82. 

Exophthalmic  goitre,  836;  acute  form,  837; 
diminution  of  electrical  resistance  in,  839; 
pigmentation  in,  839;  tremor  in,  839;  urti- 
caria in,  839. 

Eye,  motor  nerves  of,  paralysis  of,  1046; 
spasm  of,  1047. 

Eye-strain  in  migraine,  1102. 

Eyes,  conjugate  deviation  of,  in  brain  tumor, 
1023;  in  apoplexy,  1002;  in  tuberculous 
meningitis,  279. 

Facial,  asymmetry,  1064,  1141;  diplegia, 
1053;  hemiatrophy,  1141;  hemihypertrophy, 
1142;  nerve,  paralysis  of,  1051;  paralysis 
from  cold,  1053;  paralysis  from  lesion  of 
trunk  of  nerve,  1052;  paralysis  from  lesion 
of  cortex,  1052;  paralysis,  symptoms  of, 
1053. 

Facial  spasm,  1055. 

Fades,  Hippocratic,  598;  leontina,  in  leprosy, 
341;  in  mouth-breathers,  455;  Parkin- 
S07iian,  1077;  syphilitic,  243;  in  typhoid 
fever,  14. 

Faecal,  accumulation,  534,  539;  concretions, 
519,  539;  vomiting,  534. 

Faeces,  bacteria  in,  508;  in  jaundice,  549. 

Fallo.pian  tubes,  tuberculosis  of,  326. 

Famine  fever  (see  Relapsing  Fevek),  53. 

Farcy,  233;  acute,  234;  chronic,  235. 

Farcy-buds,  234. 

Farre's  tubercles,  583. 

Fasciola  hepatica,  351. 

Fat  embolism  in  diabetes,  426. 

Fat  necrosis,  591;  of  pancreas,  in  diabetes, 
422. 

Fatty  degeneration,  of  arteries,  770;  of  kid- 
neys, 874;  of  liver,  585;  of  the  new-born 
{Buhl's  disease),  818. 

Fatty  degeneration  of  heart,  749;  in  anaemia, 
796. 

Fatty  stools,  590. 

Febricula,  342. 

Febris,  carnis,  48;  recurrens,  53. 

Fehling's  test  for  sugar,  423. 

Fermentation,  test  for  sugar,  424. 

Fetid  stomatitis,  442. 

Fever,  aphthous,  347;  in  cholera,  179;  entero- 
mescnteric,  1;  ephemeral,  342;  gastric,  463; 
glandular,  .345;  hysterical,  1119;  pernicious 
malarial,  215;  in  pneumonia,  116;  in  acute 
pneumonic  phthisis,  290,  293;  in  acute 
miliary  tuberculosis,  274;  in  primary  mul- 
tiple neuritis,  1033;  in  menlngltlc  tuber- 
culosis, 278;  in  pulmonary  tuberculosis, 
304;  in  pyaemia,  104;  in  pylephlohltis,  sup- 


purative, 580;  in  intermittent  fever,  212; 
in  relapsing  fever,  54;  in  remittent  fever, 
213;  in  scarlet  fever,  77;  in  septicaemia, 
162;  in  small-pox,  59;  in  sun-stroke,  396; 
in  appendicitis,  524;  in  secondary  syphilis, 
240;  in  typhoid  fever,  14;  in  yellow  fever, 
185;  lung,  108;  Malta,  219;  Mediterranean, 
219;  mountain,  346;  Neapolitan,  219;  putrid 
malignant,  1;  relapsing,  53;  rock,  219;  ship, 
49;  slow  nervous,  1;  splenic,  224;  spotted, 
49,  101;  typhoid,  1;  typho-malarial,  39,  214; 
typhus,  49;  undulant,  219;  yellow,  182. 

Fever,  idiopathic  intermittent,  163. 

Fever,  intermittent,  in  abscess  of  liver,  579; 
in  ague,  212;  in  chronic  obstruction  of  bile- 
passages  by  gall-stones,  566;  in  Hodgkin's 
disease,  812;  in  pyaemia,  164;  in  pyelitis, 
888;  in  septicaemia,  163;  in  secondary 
syphilis,  240;  in  tuberculosis,  299,  305. 

Fibrinous,  bronchitis,  632;  pneumonia,  108. 

Fibroid  disease  of  heart,  747. 

Fibrosis,    arterio-capillary,   770. 

Fievre,  inflammatoire,  397;  typho'ide  a  forme 
renalc,  31. 

Fifth  nerve,  paralysis  of,  1050;  gustatory 
branch,  1051;  trophic  changes  in  paralysis 
of,  1050. 

Filaria  hominis  sanguinis,  F.  bancrofti,  F. 
diurna,  F.  perstans,  360;  F.  medinensis, 
362. 

Filaria  loa,  F.  lentis,  F.  labialis,  F.  hominis 
oris,  F.  bronchialis,  F.  immitis,  364. 

Filariasis,  360. 

Fish,  poisoning  by,  393. 

Fisher's  brain  murmur,  437. 

Fistula  in  ano  in  tuberculosis,  315,  320. 

Fistula,  oesophago-pleuro-cutaneous,  462. 

Flatulence,  in  hysteria,  1117;  in  nervous  dys- 
pepsia, 500;  treatment  of,  473. 

Flea,  bite  of,  378. 

Flint's  murmur,  713,  724. 

Floating  kidney,  542,  846. 

Florida  fever,  397. 

Fluke,  bronchial,  352;  blood,  352;  liver, 
351. 

Flukes,  diseases  caused  by,  351. 

Foetal  heart-rhythm,  757. 

Foetus,  endocarditis  in,  767;  syphilis  in,  242; 
tuberculosis  in,  262;  white  pneumonia  of, 
247;  typhoid  fever  in,  35. 

Folic  Brightiquc,  866. 

Follicular  tonsillitis,  451. 

Food  (see  Diet). 

Food  poisoning,  391. 

Foot  and  mouth  disease,  347. 

Foreign  bodies  in  intestines,  534. 

"  Fourth  disease,"  90. 

Fourth  nerve,  1047;  paralysis  of,  1047. 

Fremitus,  vocal,  119,  307;  hydatid,  .372. 

Friction,  mediastinal,  687;  pericardial,  690; 


1162 


INDEX. 


peritoneal,   604;  pleural,  308,  670;  pleuro- 

pericardial,  308. 
Friedreich's  ataxia,  949. 
Friedreich's   sign   in   adherent   pericardium, 

697. 
Frontal  convolutions,  lesions  of,  1022. 
E'rontal  sinuses,  pentastomes  in,  375. 
Funnel  breast,  307,  455. 

Gait,  ataxic,  923;  in  paralysis  agitans,  1077; 
in  pseudo-hypertrophic  muscular  paraly- 
sis, 934;  in  spastic  paraplegia,  937;  pseudo- 
tabetic,  426,  1034;  steppage,  in  peripheral 
neuritis,  1034;  in  diabetic  tabes,  426. 

Galactotoxismus,  393. 

Gall-bladder,  diseases  of,  555;  atrophy  of, 
566;  calcification  of,  565;  dilatation  of,  565; 
empyema  of,  565;  forming  abdominal 
tumor,  565;  phlegmonous  inflammation  of, 
565. 

Gallop-rhythm,  757. 

Galloping  consumption,  292. 

Gall-stone  crepitus,  565. 

Gall-stones,  561. 

Game-birds,  poisoning  by,  393. 

Ganglia,  basal,  tumors  of,  1022. 

Gangrene,  in  diabetes,  425;  in  ergotism,  394; 
in  pneumonia,  130;  in  typhoid  fever,  12, 
22;  in  typhus,  52;  local  or  symmetrical, 
1138;  multiple,  1138;  of  lung,  660;  of 
mouth,  444. 

Gangrenous  stomatitis,  444. 

Oarrod's  thread  test  for  uric  acid,  410. 

Gas-bacillus  (see  Bacillus  aerogenes  cap- 

SULATUS). 

Gastralgia,  501. 

Gastrectasls,  474. 

Gastric  catarrh,  acute,  463. 

Gastric,  crises,  484,  501,  924;  fever,  463. 

Gastric  juice,  hyperacidity  of,  484,  500;  sub- 
acidity  of,  501. 

Gastric  spasm,  congenital,  495. 

Gastric  ulcer,  478;  clinical  forms  of,  482. 

Gastritis,  acute,  463;  acute  suppurative,  464; 
chronic,  466;  diphtheritic,  465;  membra- 
nous, 465;  mycotic,  466;  parasitic,  466; 
phlegmonous,  464;  polyposa,  467;  sclerotic, 
467;  simple,  463;  simple  chronic,  466;  toxic, 
465. 

Gastrodynia,  501. 

Gastrorrhagia,  495. 

Gastrotomy,  462. 

Gastroxynsis,  500. 

General  paralysis  of  the  insane  (general  par- 
esis), 960;  diagnosis  of,  from  syphilis,  246, 
963;  influence  of  syphilis  in,  242,  246,  961. 

Genito-urinary  system,  tuberculosis  of,  322. 

Gentles,  379. 

Geographical  tongue,  445. 

Oerlier's  disease,  1059. 


German  measles,  89. 

Giant  growth,  1143. 

Giants  and  gigantism,  1143. 

Gigantism  and  acromegaly,  1143. 

Gigantoblasts,  799. 

Gigantorhynchus  gigas,  365. 

Oilles  de  la  Tourette's  disease,  1089. 

Gin-drinker's  liver  (see  Cirrhosis  of  Liver), 
569. 

Glanders,  233;  acute,  234;  chronic,  234;  diag- 
nosis from  small-pox,  66. 

Glandular  fever,  345. 

Olenard's  disease,  541. 

Glioma  of  brain,  1020. 

Gliosis,  975. 

Globulin  in  urine,  857. 

Globus  hystericus,  1112. 

Glomerulo-nephritis,  870. 

Glosso-labio-laryngeal  paralysis,  932. 

Glosso-pharyngeal  nerve,  affections  of,  1059. 

Glossy  skin  in  arthritis  deformans,  402. 

Glottis,  cedema  of,  617;  in  Bright's  disease, 
881;  in  small-pox,  64;  in  typhoid  fever,  11. 

Gluteal  nerve,  affections  of,  1072. 

Glycogen,  formation  of,  420. 

Glycogenic  function  of  liver,  420. 

Glycosuria,  420,  865;  gouty,  415;  lipogenic, 
422. 

Omelin's  test,  549.  ^^ 

Goitre,  835;  exophthalmic,  836;  sudden 
death  in,  836. 

Gonorrhoea!  arthritis,  256;  endocarditis,  256; 
septicaemia  and  pyaemia,  255. 

Gonorrhoeal  infection,  255;  systemic,  255. 

Gout,  407;  acute,  411;  chronic,  413;  Ehstein's 
theory  of,  409;  hereditary  influence  in,  408; 
influence  of  alcohol  in,  408;  influence  of 
food  in,  408;  influence  of  lead  in,  408;  ir- 
regular, 414;  nervous  theory  of,  409;  retro- 
cedent  or  suppressed,  413. 

Gouty  kidney,  877. 

von  Graefe's  sign,  838. 

Grain,  poisoning  by,  394. 

Grandeur,  delusions  of,  962. 

Grand  mal,  1094,  1095. 

Granular  kidney,  877. 

Granulomata,  infectious,  of  brain,  1020. 

Gravel,  renal,  892. 

Graves'  disease,  836. 

Green  cancer,  809. 

Green-sickness  (see  Chlorosis),  792. 

Green-stick  fracture  in  rickets,  437. 

Gregarinidse,  parasitic,  349. 

Grinder's  rot,  652. 

Grippe,  la,  95. 

Gruebler's  tumor,  388. 

Guinea-worm  disease,  362. 

Gull's  disease,  841. 

Gummata,  239;  in  acquired  syphilis,  241;  In 
congenital  syphilis,  244;  of  brain  and  spinal 


INDEX. 


1163 


cord,  244;  of  heart,  250;  of  kidneys,  250;  of 
liver,  248;  of  lungs,  247;  of  rectum,  249;  of 
testis,  251;  structure  of,  239. 

Gummatous  periarteritis,  250. 

Gums,  black  line  on,  in  miners,  387;  blue  line 
on,  in  lead-poisoning,  387;  in  scurvj',  823; 
in  stomatitis,  442;  red  line  on,  in  pul- 
monary tuberculosis,  311. 

Gustatory  paralysis,  1051. 

Habit  spasm,  1088;  in  mouth-breathers,  456. 

Habitus,  apoplectic,  998;  phthisicus,  268. 

Hsematemesis,  495;  causes  of,  495;  in  cir- 
rhosis of  liver,  572;  diagnosis  from  hae- 
moptysis, 497;  in  enlarged  spleen,  216,  495; 
in  scurvy,  823;  in  typhoid  fever,  23. 

Haemato-chyluria,  non-parasitic,  859;  para- 
sitic, 361. 

Hsematoma  of  dura,  of  brain,  952;  of  cord, 
953;  of  mesentery,  546. 

Hsematomyelia,  968. 

Hsematoporphyrin,  865. 

Hsematorrhachis,  967. 

Hsematuria,  851;  endemic,  of  Egypt,  352;  in 
acute  nephritis,  870;  in  chronic  phthisis, 
312;  in  psorospermiasis,  350;  in  renal  cal- 
culus, 894;  in  renal  cancer,  897;  in  tuber- 
culosis of  kidney,  325;  malaria,  216. 

Hsemochromatosis,  421. 

Hsemocytozoa  of  malaria,  204. 

Haemoglobin,  reduction  of,  in  chlorosis,  793. 

Haemoglobinaemia,  854. 

Hsemoglobinuria,  852;  epidemic,  in  infants, 
243,  818,  853;  in  Raynaud's  disease,  1138; 
paroxysmal,  853;  toxic,  853. 

Hsemoglobinuric  fever,  216. 

Hsemo-pericardium,  698. 

Hsemo-peritoneum,  588. 

Haemophilia,  819. 

Haemoptysis,  causes  of,  637;  hysterical,  1117; 
at  onset  of  phthisis,  299;  in  acute  broncho- 
pneumonic  phthisis,  293;  in  acute  miliary 
tuberculosis,  275;  in  aneurism,  637,  781;  in 
aortic  insufficiency,  712;  in  arthritic  sub- 
jects, 638;  in  bronchiectasis,  627;  in  cir- 
rhosis of  lung,  651;  in  emphysema,  659; 
in  mitral  insuflSciency,  720;  in  mitral  ste- 
nosis, 725;  in  pneumonia,  118;  in  pulmo- 
nary gangrene,  662;  in  scurvy,  823;  spuri- 
ous, 1117;  symptoms  of,  638;  treatment  of, 
639;  in  typhoid  fever,  28;  relation  to  tuber- 
culosis, 637;  parasitic,  352;  periodic,  637; 
vicarious,  637. 

Haemorrhage,  broncho-pulmonary,  637;  cere- 
bral, 997;  from  mesentery,  546;  from  the 
stomach,  495;  in  acute  yellow  atrophy,  552; 
in  anaemia,  799;  in  cirrhosis  of  the  liver, 
572;  In  contracted  kidney,  882;  in  gastric 
cancer,  490;  in  gastric  ulcer,  481;  in 
haemophilia,  820;   in  hysteria,   1117,  1118; 


in  intussusception,  537;  in  leukaemia,  805; 
in  malaria,  216;  in  nephrolithiasis,  894;  In 
the  new-born,  818;  in  purpura  haemor- 
rhagica,  816;  in  scarlet  fever,  79;  in  scurvy, 
823;  in  small-pox,  62;  in  splenic  enlarge- 
ment, 216,  495;  into  pancreas,  588;  into 
spinal  cord,  968;  into  spinal  membranes, 
967;  in  tuberculous  pyelitis,  325;  in  tuber- 
culosis of  bowels,  319;  into  ventricles  of 
brain,  999;  in  typhoid  fever,  10,  23;  in  yel- 
low fever,  186;  pulmonary,  302,  637. 

Haemorrhagic  diathesis,  814. 

Haemorrhagic  diseases  of  the  new-born,  818. 

Haemorrhagic  typhoid  fever,  34. 

Haemothorax,  674. 

Hair  tumors  in  stomach,  494. 

Hallucinations  in  hysteria,  1119. 

Harrison's  groove  in  rickets,  436;  in  en- 
larged tonsils,  455. 

Harvest-bug,  376. 

Haj'-asthma  (hay- fever),  612. 

Haygarth's  nodosities,  401. 

Headache,  from  cerbral  tumor,  1021;  in  cere- 
bral syphilis,  246;  in  mouth-breathers,  456; 
in  typhoid  fever,  13,  14,  28;  in  uraemia,  867; 
sick,  1102. 

Head-cheese,  poisoning  by,  391. 

Head-shaking  in  infants,  1066. 

Heart,  diseases  of,  698;  diseases  of,  Oertel's 
treatment  of,  752;  amyloid  degeneration  of, 
750;  aneurism  of,  753;  athlete's,  710;  brown 
atrophy  of,  750;  calcareous  degeneration 
of,  750;  congenital  affections  of,  765;  dila- 
tation of,  741;  displacement  In  pleuritic 
effusion,  667;  displacement  in  pneumo- 
thorax, 682;  fatty  disease  of,  749;  foreign 
bodies  in,  754;  fragmentation  of  fibres  of, 
748;  hydatids  of,  754;  hypertrophy  of,  735; 
hypertrophy  of,  in  Bright's  disease,  880;  in 
exophthalmic  goitre,  838;  Irritable,  745, 
756;  new  growths  in,  754;  neuroses  of,  755; 
palpitation  of,  755;  parenchymatous  de- 
generation of,  748;  rupture  of,  753;  tubercle 
of,  754;  tumors  of,  754;  valvular  diseases 
of,  707;  wounds  of,  754. 

Heart-muscle  in  fevers,  748. 

Heart-sounds,  weakness  of,  744;  increased 
loudness  of,  739;  audible  at  distance,  724, 
838. 

Heart-valves,  congenital  anomalies  and 
lesions  of,  766;  rupture  of,  711. 

Heat,  exhaustion,  395;  stroke,  395. 

Ilchcrdcn's  nodes,  401. 

Hectic  fever,  306. 

Heel,  painful,  1106. 

Heller's  test,  856. 

Ueluiinthiasis  (see  Animal  Parasites),  349. 

Hemcralopla,  1040;  in  scurvy,  824. 

Hemialbumose,  857. 

Hemianaesthesia,    in    cerebral    haemorrhage, 


1164 


INDEX. 


1005;  in  hysteria,  1115;  in  lesions  of  inter- 
nal capsule,  983;  in  unilateral  cord  lesions, 
965. 

Hemianopia,  heteronymous,  1042;  homony- 
mous, 1042;  in  migraine,  1102;  lateral, 
1042;  nasal,  1042;  significance  of,  1045; 
temporal,  1042. 

Hemicrania,  1102. 

Hemiopic  pupillary  inaction,  1044. 

Hemiplegia,  1002;  crossed,  984,  1004. 

Hemiplegia,  infantile,  1017;  aphasia  in,  1018; 
in  diphtheria,  150;  epilepsy  in,  1019;  in  hys- 
teria, 1114;  mental  defects  in,  1018;  post- 
hemiplegic movements  in,  lOl^i  spastica 
cerebralis,  1018;  in  typhoid  fever,  30. 

Hgmiplegie  flasque,  1006. 

Henoch's  purpura,  816. 

Hepatic  abscess,  577;  artery,  enlargement 
of,  555;  colic,  563;  intermittent  fever,  566; 
vein,  affections  of,  555. 

Hepatitis,  diffuse  syphilitic,  248;  interstitial 
(see  Cirrhosis),  569;  suppurative,  577. 

Hepatization,  of  lung,  113;  white,  of  foetus, 
247. 

Hereditary  form  of  oedema,  1141. 

Heredity,  in  Bright's  disease,  877;  in  dia- 
betes insipidus,  432;  in  Friedreich's  ataxia, 
949;  in  gout,  408;  in  haemophilia,  819;  in 
paramyoclonus  multiplex,  1150;  in  spastic 
paraplegia,  940;  in  syphilis,  238;  in  tuber- 
culosis, 262. 

Herpes,  in  trifacial  neuralgia,  1105;  in 
cerebro-spinal  meningitis,  104;  in  febric- 
ula,  343;  in  malaria,  212;  in  pneumonia, 
122;  in  typhoid  fever,  17;  zoster,  1106. 

Hiccough,  1068;  causes  of,  1068;  treatment 
of,  1069;  hysterical,  1116. 

High-tension  pulse,  characters  of,  774,  880. 

Hippocratic  fades,  598;  fingers,  313;  succus- 
sion,  683. 

Hippus,  1102. 

Eodgkin's  disease,  809;  intermittent  fever  in, 
812. 

Homalomyia  scalaris,  378. 

Horn-pox,  63. 

Hospital  fever,  49. 

Huntingdon's  chorea,  1090. 

Husband  and  wife,  diabetes  in,  418;  tuber- 
culosis in,  266. 

Hutchinson's  teeth,  243. 

Hyaline  casts  in  urine,  871,  876,  880. 

Hybrid  measles,  89. 

Hydatid  disease  (see  Echinococcus).    . 

Hydatid  thrill  or  fremitus,  372. 

Hydrarthrosis,  chronic,  257;  intermittent, 
1118. 

"  Hydrencephaloid  condition,"  510,  996. 

Hydriatic  treatment  (see  Hydrotherapy). 

Hydrocephalus,  1028;  acquired  chronic,  1029; 
acute,     276,     1028;     angio-neurotic,     1028; 


chronic,  after  cerebro-spinal  meningitis, 
106;  congenital,  1029;  idiopathic  internal, 
1028;  spurious,  510. 

Hydromyelus,  953,  975. 

Hydronephrosis,  889;  congenital,  889;  inter- 
mittent, 848,  890. 

Hydropericardium,  697. 

Hydroperitonseum,  605. 

Hydrophobia,  227. 

Hydro-pneumothorax,  681. 

Hydrops  vesicae  fellse,  565. 

Hydrothorax,  680. 

Hymenolepsis  diminuta;  H.  nana,  366. 

Hyperacidity,  500. 

Hyperacusis,  1057. 

Hyperaesthesia,  in  ataxia,  924;  in  hysteria, 
1115;  in  rickets,  435;  in  unilateral  cord 
lesions,  965. 

Hyperchlorhydria,  500. 

Hyperosmia,  1038. 

Hyperpyrexia,  hysterical,  1120;  in  rheumatic 
fever,  170;  in  scarlet  fever,  78;  in  sun- 
stroke, 396;  in  tetanus,  232. 

Hyperthyrea,  837. 

Hyperthyroidism,  836. 

Hypertrophic  cirrhosis  of  liver,  574. 

Hypnotism  in  hysteria,  1121. 

Hypodermic  syringe  in  diagnosis  of  pleural 
effusion,  675. 

Hypoglossal  nerve,  diseases  of,  1066;  paraly- 
sis of,  1066;  spasm  of,  1067. 

Hypophysis,  enlargement  of,  1143. 

Hypostatic  congestion,' of  lungs,  635;  in  ty- 
phoid fever,  28. 

Hypotonia,  924. 

Hysteria,  1111;  and  disseminated  sclerosis, 
960;  contractures  and  spasms  in,  1114;  con- 
vulsive forms  of,  1112;  cries  in,  1116;  dis- 
orders of  sensation  in,  1115;  forms  of  fever 
in,  1119;  haemoptysis  in,  1117;  insanity  in, 
1119;  joint  affections  in,  1118;  mental 
symptoms  of,  1118;  metabolism  in,  1119; 
metallotherapy  in,  1115;  needle-swallowing 
in,  755;  non-convulsive  forms  of,  1113; 
paralysis  in,  1113;  special  senses  in,  1116; 
stigmata  in,  815,  1118;  traumatic,  1132; 
visceral  manifestations  of,  1116. 

Hysterical  angina  pectoris,  763. 

Hystero-epilepsy,  1098,  1113. 

Hysterogenic  points,  1116. 

Ice-cream,  poisoning  by,  393. 
Ice,  typhoid  bacillus  in,  5. 
Ichthyosis  lingualse,  446. 
Ichthyotoxlsmus,  393. 
Icterus  (see  Jaundice). 

Idiocy,  in  infantile  hemiplegia,  1019;  amau- 
rotic, 940. 
Idiopathic  anaemia  of  Addison,  795. 
Idiopathic  intermittent  fever,  163. 


INDEX. 


1165 


Ileo-caecal  region,  in  typhoid  fever,  25;  in  ap- 
pendicitis, 525;  in  primary  tuberculosis  of 
bowel,  320. 

Ileus  (see  Strangulation  of  Bowel),  531. 

Imbecility  in  infantile  hemiplegia,  1019. 

Imitation  in  chorea,  1081. 

Impetigo,  contagious,  and  ulcerative  stoma- 
titis, 442. 

Impotence,  in  diabetes,  427;  in  locomotor 
ataxia,  922. 

Impulsive  tic,  1089. 

Incarceration  of  bowel,  531. 

Incoordination,  of  arms,  923;  of  legs,  923. 

Indians,  American,  chorea  in,  1079;  con- 
sumption In,  259;   small-pox  among,  56. 

Indlcanuria,  863. 

Indigestion,  463. 

Infantile,  convulsions,  1091;  paralysis,  942; 
scurvy,  825. 

Infantilism,  243,  841. 

Infection,  definition,  160. 

Infectious  diseases,  1;  of  doubtful  nature, 
342. 

Inflation  of  bowel  in  intussusception,  538. 

Influenza,  95;  complications  of,  97. 

Infusoria,  parasitic,  351. 

Inhalation  pneumonia  (see  Aspiration 
Pneumonia),  642. 

Inoculation,  against  small-pox,  56,  63;  pro- 
tective, in  cholera,  176;  preventive,  in 
hydrophobia,  229;  preventive,  in  plague, 
192;  preventive,  in  pneumonia,  112;  pre- 
ventive, in  yellow  fever,  189;  preventive,  in 
typhoid  fever,  41;  tuberculosis  transmitted 
by,  264. 

Insanity,  post-febrile,  30;  in  small-pox,  64. 

Insanity,  relation  of  drink  to,  381;  relations 
of  chronic  phthisis  to,  312;  relation  of 
heart-disease  to,  713. 

Insects,  parasitic,  376. 

Insolation,  395. 

Insular  sclerosis,  959. 

Intention  tremor  (see  Volitional  Tremor). 

Intermittent  claudication,  763,  775. 

Intermittent  fever,  209;  forms  of  (see 
Fever). 

Intermittent  hepatic  fever,  566. 

Intermittent  hydrarthrosis,  1118. 

Internal  capsule,  lesions  of,  982,  983. 

Internal  carotid  artery,  blocking  of,  1011. 

Intestinal  casts,  544;  sand,  546. 

Intestinal  coils,  tumor  formed  by,  288. 

Intestinal  obstruction,  531. 

Intestines,  diseases  of,  505;  actinomycosis 
of,  236;  dilatation  of,  545. 

Intestines,  haemorrhage  from,  in  typhoid 
fever,  10,  23;  In  dysentery,  198,  200;  in 
tuberculosis  of  bowel,  319;  in  intussuscep- 
tion of,  537;  in  ulceration  of,  513. 

Intestines,    Infarction  of,   546;    intussuscep- 


tion of,  532,  537;  invagination  of,  532;  mis- 
cellaneous affections  of,  544;  new  growths 
in,  533. 

Intestines,  obstruction  of,  531,  599;  acute, 
534;  by  enteroliths,  534;  by  foreign  bodies, 
534;  by  gall-stones,  534,  568. 

Intestines,  perforation  of,  in  typhoid  fever, 
10,  25. 

Intestines,  primary  tuberculosis  of,  207,  319; 
strangulation  of,  531,  536;  strictures  and 
tumors  of,  533;  twists  and  knots  in,  533; 
ulcers  of,  512. 

Intoxication,  definition  of,  161. 

Intoxications,  380. 

Intussusception,  532,  537. 

Invagination,  532;  post-mortem,  532. 

Inverse  type  of  temperature,  in  acute  tuber- 
culosis, 274;  in  typhoid  fever,  16. 

Iodide  eruptions,  254. 

Iridoplegia,  1047;  accommodative,  1047;  re- 
flex, 1047. 

Iritis,  syphilitic,  241,  244. 

Itch  insect,  376. 

Itching,  of  feet  in  gout,  415;  of  eyeballs  in 
gout,  415;  of  skin  in  Bright's  disease,  882; 
of  skin  in  jaundice,  549;  in  diabetes,  425; 
in  exophthalmic  goitre,  839. 

Ixodes  ricinus,  376. 

Jacksonian  epilepsy,  917,  1098. 

Jail  fever,  49. 

Jaundice,  548;  black,  549;  catarrhal,  555; 
choluria  in,  549;  from  cirrhosis  of  liver, 
572,  575;  epidemic  form  of,  344,  550;  feb- 
rile, 344;  from  acute  yellow  atrophy,  551; 
from  cancer  of  liver,  584;  in  diphtheria, 
150;  from  gall-stones,  564,  566;  in  influenza, 
97;  in  pneumonia,  125;  and  purpura,  814, 
549;  in  Weil's  disease,  344;  malignant,  551; 
of  the  new-born,  551;  obstructive,  548; 
toxsemic,  550;  xanthelasma  in,  549;  in  yel- 
low fever,  185. 

Jaw  clonus,  931. 

Jigger,  378. 

Joints  (see  Arthritis). 

Jumpers,  1089. 

"  June  cold,"  612. 

Kahler's  disease,  albumosuria  in,  857. 

Kakke,  221. 

Kfila-azar,  203. 

Keloid  of  Addison,  1145. 

Keratitis,  In  small-pox,  65;  interstitial,  of  In- 
herlted  syphilis,  244. 

Keratosis  follicularis,  .350. 

Keratosis  mucosae  oris,  446. 

Kidney,  diseases  of,  846;  amyloid  or  larda- 
ceous  disease  of,  884;  cancer  of,  896;  car- 
diac, 850;  circulatory  disturbance  in.  849; 
cirrhosis   of,    877;    congenital   cystic,    898; 


1166 


INDEX. 


congestion  of,  849;  contracted,  877;  cya- 
notic induration  of,  850;  cystic  disease  of, 
898;  echinococcus  of,  374;  floating,  846; 
fused,  846;  gouty,  877;  granular,  877;  tiorse- 
slioe,  846;  large  white,  874;  malformations 
of,  846;  movable,  846;  palpable,  846. 

Kidney,  rhabdo-myoma  of,  896;  sarcoma  of, 
896;  scrofulous,  325,  887;  small  white  kid- 
ney, 874;  surgical  kidney,  887;  syphilis  of, 
250;  tuberculosis  of,  324;  tumors  of,  896; 
unsymmetrical,  846. 

Klebs-Loeffler  bacillus,  140. 

Knee-jerk,  loss  of,  in  ataxia,  924;  in  diph- 
theria, 151. 

Koch  treatment  of  tuberculosis,  335. 

Kopftetanus  of  Rose,  232. 

Koplik's  sign,  87. 

Kreotoxismus,  391. 

Kubisagari,  1059. 

Labyrinthine  disease,  1058. 

Lachrymal  gland  in  mumps,  91;  in  Mikulicz's 
disease,  448. 

"  Lacing  "  liver,  587. 

Lacunar  tonsillitis,  451. 

La  grippe,  95. 

Lamblia  intestinalis,  351. 

Landry's  paralysis,  946. 

Laparotomy  in  typhoid  fever,  47. 

Larvae  of  flies,  diseases  caused  by  (myiasis), 
378. 

Laryngeal  crises,  925. 

Laryngismus  stridulus,  617;  from  pressure 
of  enlarged  thymus,  844. 

Laryngitis,  acute,  catarrhal,  615;  chronic, 
616;  cedematous,  617;  spasmodic,  617; 
syphilitic,  620;  tuberculous,  619. 

Larynx,  diseases  of,  615;  adductor  paralysis 
of,  1061;  anaesthesia  of,  1062;  hyperses- 
thesia  of,  1062;  paralysis  of  abductors  of, 
1061;  spasm  of  the  muscles  of,  1062;  uni- 
lateral abductor  paralysis  of,  1061. 

Latah,  1089. 

Lateral  sclerosis,  primary,  937;  amyotrophic, 
928. 

Lateritious  deposit,  860. 

Lathyrism,  394. 

Lead,  colic,  388;  in  the  urine,  387. 

Lead-palsy,  388;  localized  forms  of,  388. 

Lead-poisoning,     386;     acute,     387;     arterio- 
sclerosis   in,    389;    cerebral    symptoms    in, 
389;   chronic,   387;   convulsions  from,    389; 
gouty  deposits  in,  389;  treatment  of,  389. 
Lead-workers,  prevalence  of  gout  in,  408. 
Leichen-tubercle,  264. 
Leontlasis  ossea,  1145. 
Lepra  alba,  341;  mutilans,  341. 
Leprosy,  338;  anaesthetic,  342;  bacillus  leprae 
in,    340;    contagiousness   of,    340;    macular 
form  of,  341;  tubercular,  341. 


Leptomeningitis,   acute  cerebro-spinal,  954; 

chronic,  957;  infantum,  957. 
Leptothrix  in  mouth,  236. 
Leptus  autumnalis,  376. 
Leucin,  552. 

Leucocytes,  relation  to  uric  acid,  409. 
Leucocytosis,  in  anaemia,  791,  799;  chlorosis, 
794;   cerebro-spinal  meningitis,   104;   diph- 
theria, 147;  empyema,  672;  erysipelas,  159; 
Eodgkin's     disease,     812;     leukaemia,    806; 
malaria,    217;    measles,    88;    pyaemia,    165; 
pneumonia,    120;   pleurisy,   670;   rheumatic 
fever,  170;  scarlet  fever,  79;  stomach  can- 
cer, 489;  in  trichinosis,  357;  in  tuberculosis 
(acute),  275;   in  tuberculosis  (chronic  pul- 
monary),   311;    typhoid    fever,    19,    37;    in 
whooping-cough,  94. 
Leucoderma,  839,  1146. 
Leucomata,  241. 

Leukaemia,  802;  acute,  808;  lymphatic,  808; 
blood  in,  806;  congenital,  803;  definition  of, 
802;  heredity  in,  802;  in  animals,   803;  in 
pregnancy,   802;   morbid  anatomy  of,   803; 
myelogenous,     802;      prognosis     in,      809; 
pseudo-,  809;  spleno-meduUary,  805. 
Leukoplakia  buccalis,  446. 
Leyden's  crystals,  631,  633. 
Lienteric  diarrhoea,  507. 
Life  assurance   and   albuminuria,   858;   and 

syphilis,  255. 
Lightning  pains  in  ataxia,  922. 
Lineae  atrophicae,  18. 
Lingual  corns,  446. 
Lipaciduria,  864. 
Lipaemia,  421,  426. 
Lipothymia,  599. 

Lips,  tuberculosis  of,  317;  chancre  of,  238. 
Lipuria,  425,  864. 
Lithffimia,  859,  860. 
Lithic-acid  diathesis,  859. 
Lithuria,  859. 
Little's  disease,  938. 

Liver,  abscess  of,  577;  actinomycosis  of,  236; 
acute  yellow  atrophy  of,  551;  amyloid,  586; 
anaemia  of,  553;  angioma  of,  584;  cardiac, 
554;  anomalies  in  form  and  position  of,  587. 
Liver,  cirrhosis  of,  569;  alcoholic,  570; 
ascites  in,  572;  atrophic,  571;  capsular 
form,  575;  in  diabetes,  421;  fatty,  571; 
haemorrhage  from  stomach  in,  572;  hyper- 
trophic, 574;  syphilitic,  575;  in  tubercu- 
losis, 320;  in  children,  570;  jaundice  in,  572; 
toxic  symptoms  in,  573;  with  cancer,  583. 
Liver,  cysts  of,  584;  fatty,  585;  gummata  of, 
248;  hepato-phlebotomy  in  congestion  of, 
554;  hydatids  of,  372;  hyperaemia  of,  553; 
infarction  of,  554;  melano-sarcoma  of,  583; 
new  growths  in,  582;  nutmeg,  553;  passive 
congestion  of,  553;  periodical  enlargement 
of,  553;  primary  cancer  of,  582;  psorosper 


INDEX. 


1167 


miasis  of,  349;  pulsation  of,  554;  sarcoma 
of,  583;  secoudary  cancer  of,  583;  syphilis 
of,  248;  tuberculosis  of,  320;  in  typhoid 
fever,  11,  26. 

Liver,  diseases  of,  548. 

Liver  dulness,  obliteration  of,  in  perforative 
peritonitis,  26,  598. 

Liver,  movable,  542,  587. 

Living  skeletons,  930. 

Lobar  pneumonia,  108. 

Lobstein's  cancer,  897. 

Localization,  cerebral,  907;  spinal,  905. 

Localized  peritonitis,  522,  600. 

Lock-javr,  230. 

Lock-spasm,  1108. 

Locomotor  ataxia,  920;  bladder  symptoms 
in,  922;  gastric  crises  in,  924;  hemiplegia 
in,  925;  nasal  crises  in,  925;  paresis  in,  925; 
rectal  crises  in,  924;  relation  of  syphilis  to, 
920;  reputed  cures  of,  927. 

Long  thoracic  nerve,  affections  of,  1070. 

Loose  shoulders,  934. 

Lucilia  macellaria,  378. 

Ludwig's  angina,  450. 

Lues  venerea  (syphilis),  238. 

Lumbago,  406. 

Lumbar  plexus,  lesions  of,  1072. 

Lumbar  puncture  of  Quincke,  107,  956,  1030. 

Lung,  abscess  of,  662;  embolic,  662. 

Lung,  actinomycosis  of,  236;  albinism  of, 
656;  brown  Induration  of,  635;  cancer  of, 
acute,  664;  carnification  of,  643;  cirrhosis 
of,  649. 

Lung,  diseases  of,  634;  stones,  296. 

Lung  fever,  108. 

Lungs,  congestion  of,  634;  hypostatic,  635. 

Lungs,  echinococcus  of,  373. 

Lungs,  gangrene  of,  660;  abscess  of  brain  in, 
661. 

Lungs,  new  growths  in,  663;  in  cobalt- 
miners,  664. 

Lungs,  haemorrhagic  infarction  of,  639; 
cedema  of,  636;  splenization  of,  635,  643; 
syphilis  of,  247;  tuberculosis  of,  289. 

Lupinosis,  394. 

Lymphadenitis,  general  tuberculous,  282; 
local  tuberculous,  282;  simple,  684;  suppu- 
rative,  684. 

Lymphadenoma,  general,  809. 

Lymphatic  state,  826. 

Lymphatism,  826. 

Lymph-scrotum,  362. 

Lymph,  vaccine,  72. 

Lymph  vessels,  dilatation  of,  362. 

Lyssa,  227. 

Lyssophobia,  230. 

Maculae  ceruleae,  18. 
Macular  syphllides,  240. 
Maidlsmus,  895. 


Main  en  griffe,  930,  953. 

Maize,  poisoning  by  (pellagra),  395. 

Malarial  cachexia,  208,  210. 

Malarial  fever,  203;  accidental  and  late 
lesions  of,  209;  aestivo-autumnal,  213;  algid 
form  of,  215;  comatose  form  of,  215;  con- 
tinued and  remittent  form  of,  213;  descrip- 
tion of  the  paroxysm  in,  209;  geographical 
distribution  of,  203;  haemorrhagic  form  of, 
216;  intermittent,  209;  pernicious,  208,  215; 
pneumonia  In,  209;  quartan,  213;  quotidian, 
213;  season  in,  203;  specific  germ  of,  204; 
tertian,  212. 

Malarial  haemogloblnuria,  216. 

Malarial  nephritis,  209. 

Malignant  jaundice,  551. 

Malignant  purpuric  fever,  101. 

Malignant  pustule,  225. 

Mallein,  234. 

Malta  fever,  219. 

Mammary  glands,  hypertrophy  in  tubercu- 
losis, 312;  tuberculosis  of,  327. 

Mania  a  potu,  382. 

Mania,  Bell's,  1075. 

Marriage,  question  of,  in  haemophilia,  821; 
in  syphilis,  254;  In  tabes  dorsalis,  927;  in 
tuberculosis,  329. 

Marrow  of  bones,  In  small-pox,  58;  In  leukae- 
mia, 803;  in  pernicious  anaemia,  797. 

Masque  des  femmes  enqeintes,  831. 

Massai  disease,  363. 

Mastication,  spasm  of  the  muscles  of,  1051. 
,  Mastitis  in  enteric,   31;    chronic,   312. 

McBurncy's  tender  point,  525. 

Measles,  85;  buccal  spots  in,  87;  complica- 
tions and  sequelae  of,  87;  contagiousness 
of,  85;  desquamation  in,  87;  eruption  in, 
86;  German,  89;  period  of  incubation  in,  86. 

Measly  meat,  examination  of,  367. 

Meat,  poisoning  by,  391;  tuberculous  infec- 
tion by,  267;  inspection  of,  for  trichinae, 
355. 

Meckel's  diverticulum,  532. 

Median  nerve,  affections  of,  1071. 

Mediastinal  friction,  087. 

Mediastino-perlcarditis,  indurative,  687. 

Mediastinum,  affections  of,  684;  abscess  of, 
686;  tumors  of,  685;  cancer  of,  685;  emphy- 
sema of,  687;  pleural  effusion  in,  686; 
sarcoma  of,  685. 

Mediterranean  fever,  219. 

Medulla  oblongata,  lesions  of,  984;  tumors 
of,  1023. 

Megalo-cephaly,  1145. 

Megalocytes,  798. 

Megastric,  475. 

Mclacna,  in  duodenal  ulcer,  481;  In  typhoid 
fever,  23;  in  tuberculosis  of  bowels,  319; 
neonatorum,  818. 

Melano-sarcoma  of  liver,  583. 


1168 


INDEX. 


Melanuria,  863. 

Melasma  suprarenale,  831. 

Meniere's  disease,  1058. 

Meningeal  hsemorrhage,  999;  in  birth  palsies, 
938. 

Meninges,  affection  of,  951. 

Meningitis,  acute  cerebro-spinal,  954;  epi- 
demic cerebro-spinal,  100;  in  erysipelas, 
158,  159;  in  gout,  415;  in  typhoid  fever,  12, 
14,  28;  simple,  of  infants,  957;  pseudo,  955; 
serosa,  1028;  syphilitic,  245;  tuberculous, 
276. 

Meningococcus,  102. 

Menlngo-encephalitis,  chronic  diffuse,  960; 
tuberculous,  277. 

Mercurial,  tremor,  1079;  stomatitis,  444. 

Merycismus,  499. 

Mesenteric  artery,  aneurism  of,  546;  embo- 
lism of,  546;  thrombosis  of,  546. 

Mesenteric  glands,  tuberculosis  of,  283; 
tuberculous  tumors  of,  288;  in  typhoid 
fever,  10. 

Mesenteric  veins,  diseases  of,  547. 

Mesentery,  chylous  cysts  of,  547;  affections 
of,  546. 

Metallic  echo,  683;  tinkling,  309,  683. 

Metallotherapy,  1115. 

Metastatic  abscesses,  164. 

Metasyphilitic  affections,  242. 

Metatarsalgia,  1106. 

Meteoriem  in  typhoid  fever,  24;  treatment 
of,  46. 

Micrococci,  in  dengue,  99;  in  Malta  fever, 
219;  in  vaccine  virus,  70. 

Micrococcus  lanceolatus,  108,  110,  644,  702. 

Micrococcus  melitensis,  219. 

Microcytes,  798. 

Micromegaly,  1145. 

Micromelia,  841. 

Middle  cerebral  artery,  embolism  and  throm- 
bosis of,  1011. 

Migraine,  1102;  treatment  of,  1103. 

Miliary  abscesses  in  typhoid  fever,  11. 

Miliary  aneurism,  998. 

Miliary  fever,  346;  epidemics  of,  347. 

Miliary  tubercle,  270;  tuberculosis,  acute, 
273;  tuberculosis,   chronic,  295. 

Milk  and  scarlet  fever,  76;  and  typhoid 
fever,  6;  products,  poisoning  by,  393;  sick- 
ness, 344;  tuberculous  infection  by,  267. 

Mind-blindness,  992. 

Mind-deafness,  992. 

Miner's,  anaemia  or  cachexia,  360;  lung,  652; 
nystagmus,   1047;  cancer  of  lung,  664. 

Mitchell,  Weir,  treatment  in  hysteria,  1121. 

Mitral  incompetency,  717. 

Mitral  stenosis,  721;  chorea  and,  721;  paraly- 
sis of  recurrent  laryngeal  in,  725:  presys- 
tolic murmur  in,  723;  rheumatism  and,  721. 

Moist  sounds,  308. 


Molluseum  contagiosum,  parasites  in,  350. 

Monophobia,  1124. 

Monoplegia,  cerebral,  916,  980;  facial,  1052; 
in  hysteria,  1114;  in  traumatic  neuroses, 
1134. 

Montaigne  on  renal  colic,  893. 

Montreal  General  Hospital,  autopsies  in 
diphtheria,  144;  in  typhoid  fever,  8;  sta- 
tistics, of  apex  lesions  in  1,000  autopsies, 
332;  of  haemorrhagic  small-pox,  62;  of 
pneumonia,  131;  of  rheumatic  fever,  167; 
of  typhoid  fever,  3. 

Montreal  small-pox  epidemic  1885-'86,  65,  73. 

Morbilli  hsemorrhagici,  87. 

Morbus,  cseruleus,  768. 

Morbus,  coxse  senilis,  401,  403;  errorum,  377; 
maculosus,  814. 

Morbus  maculosus  neonatorum,  818. 

Morphia  habit,  384;  treatment  of,  385. 

Morphinism,  384. 

Morphinomania,  384. 

Morphoea,  1145. 

Mortality,  in  cerebro-spinal  meningitis,  107; 
in  pneumonia,  131;  in  typhoid  fever,  89;  in 
whooping-cough,  94;  in  yellow  fever,  188. 

Morton's  painful  foot,  1106. 

Morvan's  disease,  975. 

Mosquitoes,  relation  of,  to  fllaria  disease, 
361. 

Motor  tract,  diseases  of,  928. 

Mountain,  anaemia,  346,  360;  fever,  346; 
sickness,  346. 

Mouth-breathing,  454. 

Mouth,  diseases  of,  441;  dry,  447;  putrid 
sore,  442. 

Movable  kidney,  542,  846;  dilatation  of 
stomach  in,  848. 

Movable  liver,  542,  587. 

Mucous  colitis,  544. 

Mucous  patches,  241. 

Muguet,  443. 

Multiple  gangrene,   1138. 

Multiple  sclerosis,   959. 

Mumps,  90,  447. 

Munich,  reduction  of  typhoid  mortality  in, 
40. 

Murmur,  in  aneurism,  780;  brain,  437;  cardio- 
respiratory, 308;  in  chlorosis,  794;  in  con- 
genital heart-disease,  769;  Flint's,  713;  in 
endocarditis,  703;  in  lung  cavity,  309;  in 
subclavian  artery  in  phthisis,  308:  in  val- 
vular disease,  713,  716,  720,  723,  726,  727. 

Musca  domestica,  378;  M.  vomitoria,  378. 

Muscle  callus  in  sterno-mastoid  in  infants, 
1064. 

Muscle,  diseases  of.  1148;  degeneration  of,  in 
typhoid  fever,  12,  32. 

Muscular  atrophy,  forms  of,  934;  heredity 
in,  933;  atrophic  and  hypertrophic  varie- 
ties,   935;    infantile    form,    935;    juvenile 


/ 


INDEX. 


1160 


type,  935;  progressive  neural  form,  933; 
peroneal  type,  933. 

Muscular  atrophy,  progressive  central,  928, 
941;  hereditary  Influence  in,  929. 

Muscular  contractures  in  hysteria,  1114. 

Muscular  dystrophies,  933. 

Muscular  exertion,  coma  after,  869. 

Muscular  exertion  in  heart-disease,  710,  745. 

Muscular  rheumatism,  406. 

Muscle-sense,  992. 

Musculo-spiral  paralysis,   1070. 

Musical  faculty,  loss  of,  in  aphasia,  991. 

Musical  murmurs,  716,  769. 

Mussel  poisoning,  393. 

Myalgia,  406. 

Myasthenia  gravis,  947. 

Myasthenic  reaction,  947. 

Mycosis  intestinalis,  226;  pulmonum,  226. 

Mycotic  gastritis,  466. 

Myelsemia,  802. 

Myelitis,  acute,  976;  acute  diffuse,  977;  acute 
transverse,  978;  compression,  970;  in 
measles,  88;  reflexes  in,  978;  transverse,  of 
cervical  region,  979;  syphilitic,  245,  246. 

Myelocytes,  806. 

Myelogenous  leukaemia,  802. 

Myiasis,  378;  of  nostrils  and  of  ears,  378;  of 
vagina,  378;  cutaneous,  378;  interna,  378. 

Myocarditis,  748;  acute  interstitial,  748; 
fibrous,  747;  in  rheumatism,  171;  segment- 
ing, 21,  748;  in  typhoid  fever,  12,  21. 

Myocardium,  diseases  of,  746;  lesions  of,  due 
to  disease  of  coronary  arteries,  746. 

Myoclonia,  1150. 

Myoclonies,  1150. 

Myoidema,  308. 

Myopathies,  the  primary,  933. 

Myositis,  1148;  ossificans  progressiva,  1149. 

Myotonia,  1149;  congenita,  1149. 

Myotonic  reaction  of  Erb,  1149. 

Myriachit,  1089. 

Mytilotoxin,  393. 

Mytilotoxismus,  393. 

Myxa^dema,  840;  acute,  842;  congenital  form, 
840;  operative,  842. 

Nails,  in  typhoid  fever,  18;  in  phthisis,  313. 

Na.sal  diphtheria,  147. 

Naso-pharyngeal  obstruction,  454. 

Neapolitan  fever,  219. 

Neck,  cellulitis  of,  450. 

Necrosis,    acute,    of   bone,    173;    in   typhoid 

fever,  32. 
Necrosis  in  tubercle,  271. 
Needle-swallowing  in  hysteria,  755. 
Nematodes,  diseases  caused  by,  .352. 
Nephralgia,  1106. 
Nephritis,  869;  acute,  869;  after  diphtheria, 

1.50;    chronic,    874;    chronic    haemorrhaglc, 

875. 

73 


Nephritis,  chronic  interstitial,  877;  haemor- 
rhages In,  882;  increased  tension  in,  880; 
malarial,  209;  relation  of  heart  hyper- 
trophy to,  879;  syphilitic,  250;  urine  in, 
880;  vomiting  in,  881. 

Nephritis,  chronic  parenchymatous,  875; 
consecutive,  886;  in  erysipelas,  159;  in  ma- 
laria, 209;  in  scarlet  fever,  80;  in  typhoid 
fever,  31. 

Nephritis,  lymphomatous,  31;  suppurative, 
887. 

Nephrolithiasis,  891. 

Nephro-phthlsls  (see  Kidney,  Tuberculosis 

OF). 

Nephroptosis,  542,  846. 

Nephrorrhaphy,  849. 

Nephrotomy,  889. 

Nephro-typhus,  31. 

Nerve-fibres,  inflammation  of,  1031. 

Nerve-root  symptoms,  970. 

"  Nerve-storms,"  1103. 

Nerves,  diseases  of  peripheral,  1031;  dis- 
eases of  cerebral,  1038;  diseases  of  spinal, 
1067. 

Nerves,  lesions  of  anterior  crural,  1072;  cir- 
cumflex, 1070;  external  popliteal,  1072; 
gluteal,  1072;  internal  popliteal,  1072;  long 
thoracic,  1070;  median,  1071;  musculo- 
spiral,  1070;  obturator,  1072;  sciatic,  1072; 
small  sciatic,  1072;  uluar,  1071. 

Nervous  diarrhcea,  506,  1117. 

Nervous  dyspepsia,  497. 

Nervous  system,  diseases  of,  901;  diffuse, 
951. 

Nettle  rash  (see  Urticahia). 

Neuralgia,  1104;  causes  of,  1104;  cervlco- 
brachial,  1105;  cervlco-occlpltal,  1007,  1105; 
influence  of  malaria  in,  1104;  intercostal, 
1105;  lumbar,  1106;  of  nerves  of  feet,  1106; 
phrenic,  1105;  plantar,  1106;  red,  1139;  re- 
flex Irritation  in,  1104;  treatment  of,  1107; 
trifacial,  1105;  visceral,  1106. 

Neurasthenia,  1122;  sexual,  1126;  traumatic, 
1132. 

Neuritis,  1031;  arsenical,  1035;  from  beer, 
1035;  fascians,  1032;  Interstitial,  1031;  of 
infants,  progressive  interstitial  hyper- 
trophic, 951;  llporaatous,  1031;  localized, 
1031,  1032;  parenchymatous,  1031;  multi- 
ple, 1031,  1033;  alcoholic,  1034;  endemic, 
220,  1035;  In  diphtheria,  151;  In  chronic 
phthisis,  312;  In  the  Infectious  diseases, 
10.34;  in  typhoid  fever,  29;  recurring,  10.33; 
saturnine,  1035;  traumatic,  1032;  optic, 
1040;  from  zinc,  1035. 

Neuroglloma,  1020. 

Neuroma,  plexlform,  1037. 

Neuromata,  1037. 

Neuroses,  occupation,  1107;  traumatic,  1132. 

Neutrophlles,  800. 


IITO 


INDEX. 


New-born,  hsemorrhagic  diseases  of,  818. 
New  growths  in  the  bowel,  533. 
Night-blindness,  1040;  in  scurvy,  824. 
Night-sweats  in  phthisis,  306;  treatment  of, 

337. 
Night-terrors,  455. 
Nipple,  Paget's  disease  of,  350. 
Nits,  377. 

Nodding  spasm,  1066. 
Nodes,  Heierden's,  401. 
Nodes,  symmetrical,  in  congenital  syphilis, 

244. 
Nodules,  rheumatic,  172. 
Noma,  444;  in  scarlet  fever,  82;  in  typhoid 

fever,  33,  35. 
Normoblasts,  794,  799. 
Nose,  bleeding  from  (see  Epistaxis),  614. 
Nose,  diseases  of,  610. 
Nummular  sputa  in  phthisis,  300. 
Nurse's  contracture  of  Trousseau,  1110. 
Nutmeg  liver,  553. 
Nyctalopia,  1040;  in  scurvy,  824. 
Nystagmus,  1047;  in  Friedreich's  ataxia,  950; 

in  insular  sclerosis,  959;  of  miners,  1047. 

Obesity,  439. 

Obsession,  1089. 

Obstruction  of  bowels,  531;  acute,  534; 
chronic,  535. 

Obturator  nerve,  affections  of,  1072. 

Occipital  lobes,  tumors  of,  1022. 

Occipito-cervical  neuralgia,  1067,  1105. 

Occupation  neuroses,  1107. 

Ocular  palsies,  treatment  of,  1050. 

Oculo-motor  paralysis,  recurring,  1046. 

Odor,  in  small-pox,  68;  in  typhoid  fever,  18. 

CBdema,  angio-neurotic,  1140;  febrile  pur- 
puric, 815;  hereditary,  1141;  of  lungs,  636; 
of  brain,  997;  in  uraemia,  866,  997. 

CEdematous  laryngitis,  617. 

Oertel's  method  in  obesity,  440,  752. 

CEsophageal  iruit,  461. 

CEsophago-pleuro-cutaneous  fistula,  462. 

CEsophagismus,  459. 

Oesophagitis,  acute,  458;  chronic,  459. 

OSsophago-malacia,  462. 

(Esophagus,  diseases  of,  458;  cancer  of,  461 
dilatations  of,  462;  diverticula  of,  462 
haemorrhage  from,  in  cirrhosis  of  liver,  572 
paralysis  of,  459;  post-mortem  digestion 
of,  462;  rupture  of,  462;  spasm  of,  459; 
stricture  of,  460;  syphilis  of,  249;  tubercu- 
losis of,  318;  ulceration  of,  459;  varices  of 
veins,  in  cirrhosis  of  liver,  572. 

Oidium  albicans,  443. 

Olfactory    nerves    and   tracts,    diseases    of, 

1038. 
Omentum,  tuberculous  tumor  of,  287;  tumor 

of.  In  cancer  of  the  peritonaeum,  605. 
Omodynia,  407. 


Onomatomania,  1089. 

Onychia,    in    arthritis    deformans,    402;    in 

locomotor  ataxia,  925;  syphilitic,  241,  243. 
Operation  per  se,  effects  of,  in  epilepsy,  1101. 
Operation,  tuberculosis  after,  270. 
Ophthalmia,  gonorrhcsal,  with  arthritis,  173. 
Ophthalmoplegia,   942,   1049;    externa,   1049; 

interna,  1049. 
Opisthotonos,    cervical,    in    infants,    957;    in 

tetanus,  232. 
Opium,    poisoning,    diagnosis   from   uraemia, 

868;  habit,  384;  smoking,  effects  of,  384. 
Optic  nerve  atrophy,  1041;  hereditary,  1041; 

primary,   1041;   secondary,   1041;   in  tabes, 

922. 
Optic  nerve  and  tract,  diseases  of,  1039. 
Optic    neuritis,    1040;    in    abscess    of   brain, 

1026;  in  brain-tumor,  1021;  in  tuberculous 

meningitis,  278. 
Orchitis,  in  malaria,  216;  in  mumps,  91;  in- 
terstitial, in  syphilis,  251;  in  typhoid  fever, 

31;  in  variola,  58;  parotidea,  91;  tubercu-- 

lous,  326;  value  of,  in  diagnosis,  326. 
Orthotonos,  in  tetanus,  232. 
Osteitis  deformans,  1144. 
Osteo-arthropathy,  hypertrophic  pulmonary, 

1144. 
Osteo-myelitis  simulating  acute  rheumatism, 

173. 
Otitis-media,  in  typhoid  fever,  30;  in  scarlet 

fever,    81;    in   meningitis,    106;   meningitic 

symptoms  in,  955. 
Ovaries,   tuberculosis  of,  326. 
Over-exertion,  heart  affections  due  to,  745. 
Oxalate-of-lime  calculus,  892. 
Oxaluria,  861. 
Oxygen,    inhalations   of,    in    diabetic    coma, 

431;  in  pneumonia,  137. 
Oxyuris  vermicularis,  353. 
Oysters,    poisoning    by,    393;    and    typhoid 

fever,  6. 
Ozaena,  612. 

Pachymeningitis,  951. 

Pachymeningitis     cervicalis    hypertrophica, 

953. 
Pachymeningitis  haemorrhagica,  of  cerebral 

dura,  952;  of  spinal  dura,  953. 
Palate,   paralysis  of,   in  diphtheria,  150;   in 

facial    paralysis,    1053;    perforation   of,    in 

scarlet  fever,  82. 
Palate,  tuberculosis  of,  318. 
Palpable  kidney,  846. 
Palpitation  of  heart,  755. 
Palsies,  cerebral,  of  children,  938,  1017. 
Palsy,  lead,  388. 

Paludism  (see  Malarial  Fever),  203. 
Pancreas,   cancer  of,   594;   in  diabetes,  421; 

cysts     of,     592;     haemorrhage     into,     588; 

tumors  of,  594. 


INDEX. 


IIYI 


Pancreas,  diseases  of,  588. 

Pancreatic  abscess,  590;  diabetes,  422;  cal- 
culi, 595. 

Pancreatitis,  acute  hisemorrliagic,  589; 
chronic,  592;  fat  necrosis  in,  591;  gangre- 
nous, 590;  suppurative,  590. 

Pantophobia,  1124. 

Papillitis,  1040. 

Parsesthesia  (numbness  and  tingling),  in 
neuritis,  1032;  in  locomotor  ataxia,  924;  in 
tumor  of  brain,  1022;  In  primary  combined 
sclerosis,  949. 

Parageusis,  1060. 

Paralysis,  acute  ascending,  946;  acute  spinal, 
of  adults,  946;  acute,  of  infants,  942; 
agitans,  1076;  alcoholic,  1034;  anaesthesia, 
1035;  asthenic  bulbar,  947;  atrophic  spinal, 
942;  Bell's,  1051;  bulbar,  acute,  933; 
chronic,  933;  of  bladder,  in  myelitis,  977; 
of  brachial  plexus,  1069;  in  chorea,  1083; 
of  circumflex  nerve,  1070;  crossed  or  alter- 
nate, 984,  1004;  "  crutch,"  1070;  Cruveil- 
hier's,  929;  diver's,  969;  of  diaphragm, 
1068;  after  diphtheria,  150;  following  epi- 
lepsy, 1097;  of  facial  nerve,  1051;  of  fifth 
nerve,  1050;  of  fourth  nerve,  1047;  general, 
of  the  insane,  960;  of  hypoglossal  nerve, 
1060;  hysterical,  1113;  infantile,  942; 
labioglossal-laryngeal,  932;  Landry's,  946; 
of  laryngeal  abductors,  1061;  of  adductors, 
1061;  in  lateral  sclerosis,  937;  from  lead, 
388;  in  locomotor  ataxia,  925;  of  long 
thoracic  nerve,  1070;  in  meningitis,  278, 
950;  of  median  nerve,  1071;  of  musculo- 
spiral  nerve,  1070;  of  oculo-motor  nerves, 
1046;  of  olfactory  nerve,  1038;  periodical, 
1136;  in  progressive  muscular  atrophy,  930; 
radial,  1070;  of  rectum,  in  myelitis,  977; 
of  recurrent  laryngeal  nerve,  1061;  sec- 
ondary to  visceral  disease,  1032;  of  sixth 
nerve,  1048;  of  third  nerve,  1046;  of  ulnar 
nerve,  1071;  of  vocal  cords,  1061. 

Paramyoclonus  multiplex,   1150. 

Paraphasia,  991. 
Paraplegia  flasque,  941. 

Paraplegia,  from  alcohol,  1034;  ataxic,  948; 
from    anaemia    of    spinal    cord,    966;    from 
compression    of    cord,    970;    diabetic,    427; 
from   hiemorrhage   into  cord,   9G8;   hered- 
itary  form  of,   940;  hy.sterical,   941,   1114; 
in  lathy rism,   .394;   from   myelitis,   977;   in 
pellagra,   395;   spastic,   937;   spastica  cere- 
bralis,  938;  syphilitic,  940;  from  tnmor  of 
the  cord,  974;  in  tabes,  925. 
Parasites,  diseases  due  to  animal,  349. 
Parasitic  gastritis,  460. 
Parasitic  stomatitis,  44,3. 
Parasyphilitic  affections,  242,  961. 
"  Parchment  cracljling  "  in  ricltets,  435. 
Parenchymatous  nephritis,  875. 


Parieto-occipital  region,  brain  tumors  in, 
1022. 

"  Paris  green,"  poisoning  by,  390. 

Parkinson's  disease,  1076. 

Parosmia,  1038. 

Parotid  bubo,  447. 

Parotitis,  epidemic,  90;  deafness  in,  91;  de- 
lirium in,  91;  chronic,  447;  orchitis  in,  91; 
specific,  447. 

Parotitis,  symptomatic,  447;  after  abdomin.il 
section,  447;  in  pneumonia,  125;  in  typhuid 
fever,  22;  in  typhus  fever,  52. 

Paroxysmal  haemoglobinuria,  853. 

Parrot's  ulcers,  443. 

Parry's  disease,  836. 

Patellar-tendon  reflex  (see  Knee-jerk). 

Pathophobia,  1124. 

Pectoriloquy,  309. 

Pediculi,  376;  relations  of,  to  tache  bleuatre, 
18,  377. 

Pediculosis,  376. 

Pediculus  capitis,  376;  P.  corporis,  377. 

Peliomata,  18. 

Poliosis  rheumatica,  815;  in  chorea,  1085. 

Pellagra,  395. 

Pelvis  of  kidney,  affections  of  (see  Pye- 
litis). 

Pemphigoid  purpura,  815. 

Pemphigus  neonatorum,  242. 

Pentastomes,  375. 

Peptic  ulcer,  478;  dyspepsia  in,  481;  haemor- 
rhage in,  481;  pain  in,  481;  tenderness  on 
pressure  in,  482. 

Peptones  in  the  urine,  857. 

Perforating  ulcer  of  foot  In  tabes,  925;  in 
diabetes,  426. 

Perforation  of  bowel,  in  dysentery,  200;  in 
typhoid  fever,  10,  25. 

Periarteritis,   gummatous,  250;  nodosa,   788. 

Pericardial  friction,  690. 

Pericarditis,  688;  acute  plastic,  689;  aphonia 
in,  692;  chronic  adhesive,  696;  delirium  in, 
692;  dysphagia  in,  692;  epidemics  of,  689; 
epilepsy  in,  693;  from  extension  of  disease, 
689;  from  foreign  body.  688;  in  chorea, 
1084;  in  foetus,  689;  in  gout,  415;  in  rheuma- 
tism, 171;  haemorrhagic,  692;  hyperpyrexia 
in,  690,  692;  mental  symptoms  in,  692;  pri- 
mary, 688;  pulsus  paradoxus  in,  692; 
secondary.  688;  tulierculous,  285:  with 
effusion,  691;  In  typhoid  fever,  12,  20. 

Pericardium,  adherent,  696;  Frirdrrich's  sign 

in,  697;    calcified,    698. 
Pericardium,   diseases  of,   688;   tuberculosis 

of,  285;  air  in,  698. 
Perichondritis,   laryngeal,   in  typhoid   fever, 

11,  27;  in  tul)erculosls,  619. 
Perihepatitis.  575,  603. 
PeriiU'i)hric  abscess.  900. 
Pcrlnucl(Mr  liasdphilir  ;,M';inules,  410. 


1172 


INDEX. 


Periodical  paralysis,  1136. 

Periosteal  cachexia,  825. 

Peripheral  neuritis,  1031. 

Peristaltic  unrest,  498,  1117. 

Peritonaeum,  diseases  of,  596. 

Peritonaeum,  fluid  in,  605,  609;  cancer  of, 
604;  new  growths  in,  604. 

Peritonaeum,  tuberculosis  of,  2S6. 

Peritonaeum,  tumor  formations  in  tubercu- 
losis of,  287. 

Peritonitis,  acute  general,  522,  526,  596;  ap- 
pendicular, 526,  602;  chronic,  602;  chronic 
haemorrhagic,  604;  diffuse  adhesive,  603; 
hysterical,  599;  idiopathic,  596;  in  infants, 
600;  in  typhoid  fever,  25;  leuksemic,  805; 
local  adhesive,  602;  localized,  522,  600;  pel- 
vie,  602;  perforative,  596;  primary,  596; 
proliferative,  603;  pysemic,  596;  rheumatic, 
596;  secondary,  596;  septic,  596;  sub- 
phrenic, 600;  tuberculous,  286,  604. 

Peritonitis,  tuberculous,  effects  of  operation 
on,  609. 

Perityphlitis,  519. 

"  Perles  "  of  Laennec,  630. 

Pernicious  anaemia,  795. 

Pernicious  malaria,  208,  215. 

Peroneal  type  of  muscular  atrophy,  933. 

Pertussis  Csee  Whooping-cough),  92. 

Pesta  magna,  56. 

Pestis  minor,  191. 

Petechiee  in  epilepsy,  1097;  in  relapsing 
fever,  54;  in  scurvy,  823;  in  small-pox,  62; 
in  typhoid  fever,  17;  in  typhus  fever,  51. 

Petechial  fever,  101. 

Petit  mal,  1094,  1097;  in  general  paresis,  962. 

Peyer's  patches  in  typhoid  fever,  8;  in 
measles,  86;  in  tuberculosis,  319. 

Phagocytosis  in  erysipelas,  158;  in  tubercu- 
losis, 271. 

Pharyngitis,  448;  acute,  448;  chronic,  449; 
sicca,  449. 

Pharynx,  acute  infectious  phlegmon  of,  450; 
haemorrhage  into,  448;  hypersemia  of,  448; 
cedema  of,  448;  paralysis  of,  1060;  spasm 
of,  1061;  tuberculosis  of,  318;  ulceration 
of,  449. 

Pharynx,  diseases  of,  448. 

Philadelphia  Hospital,  relapsing  fever  at,  in 
1844,  53;  statistics  of  cerebro-spinal  fever, 
104;  of  delirium  tremens  in,  383. 

Philadelphia    Infirmary    for    Nervous    Dis- 
eases,   statistics   of   chorea,    1079;    of   epi- 
lepsy, 1094. 
Philadelphia,    tuberculosis    in    city    wards, 
266;    yellow-fever    epidemic    in   1793,    182; 
typhus  epidemic  in  1883,  49. 
Phlebitis  of  portal  vein,  577. 
Phlebo-sclerosis,  773. 
Phosphates,  alkaline,  862;   earthy,  862. 
Phosphatic  calculi,  892. 


Phosphaturia,  862. 

Phosphorus   poisoning,    similarity   of   acute 

yellow  atrophy  to,  553. 
Phrenic  nerve,  affections  of,  1068. 
Phthiriasis,  376. 
Phthirius  pubis,  377. 
Phthisical    frame,    Hippocrates'    description 

of,  268. 
Phthisis,  289;  chronic  ulcerative,  294;  acute 
pneumonic,    289;    arterio-sclerosis   in,   316; 
basic  form  of,  295;  Bright's  disease  in,  312; 
of  coal-miners,  269,   652;   chronic  arthritis 
in,  316;  cough  in,  300;  endocarditis  in,  298,. 
310;    diagnosis    of,    313;    distribution    of 
lesions    in,    294;    erysipelas   in,    315;    fatal 
haemorrhage  in,   317;  fever  in,  304;  forms 
of  cavities   in,   296;   gastric  symptoms  of, 
311;  haemoptysis  in,  302;  modes  of  death 
in,  317;  modes  of  onset  in,  298;  physical 
signs  of,  306;  pneumonia  in,  315;  relation  of 
fistula  in  ano  to,  320;  sputum  in,  300;  sum- 
mary of  lesions  in,  295;  typhoid  fever  in, 
315;  vomiting  in,  311. 
Phthisis,     fibroid,     314,     649;     florida,     292; 
renum,    324;    syphilitic,   247;   of  stone-cut- 
ters, 269,  652;  unity  of,  272;  ventriculi,  467. 
Physiological  albuminuria,  855. 
Pia  mater,  diseases  of,  954. 
Picric-acid  test  for  albumin,  857. 
Pigeon-breast,    in    rickets,    436;    in    month- 
breathers,  455. 
Pigmentation  of  skin,  from  arsenic,  390;  in 
Basedow's   disease,    839;    from   phtliiriasis, 
377;   in  Addisoti's  disease,   830;  in  chronic 
pulmonary  tuberculosis,  313;  in  melanosis, 
831;    in    peritoneal    tuberculosis,    287;    in 
scleroderma,  1146. 
Pigmentation  of  viscera  in  pellagra,  395. 
Pigs,  tuberculosis  in,  258. 
Pin-worms,  353. 

Pitting  in  small-pox,   61;  measures  to  pre- 
vent, 67. 
Pituitary  body  in  acromegaly,  1143;  in  gigan- 
tism, 1143. 
Pityriasis  versicolor,  813. 
Plague,  189;  bubonic,  191;  septicsemic,  191; 

pneumonic,  191. 
Plague  spots,  191. 
Plaques  jaunes,  1009. 
Plastic  bronchitis,  633. 
Pleura,  diseases  of,  665. 
Pleura,  echinococous  of,  373;  tuberculosis  of, 

284. 
Pleural  effusion,  BacceUi's  sign  in,  670,  672; 
compression  of  lung  in,  667;  haemorrhagic, 
673;  in  scarlet  fever,  81;  position  of  heart 
in,  668;  pseudo-cavernous  signs  in,  670; 
purulent,  671;  serous  effusion,  constituents 
of,  667;  sudden  death  in,  671. 
Pleural  membranes,  calcification  of,  679. 


INDEX. 


1173 


Pleurisj-,  acute,  665;  diaphragmatic,  674;  en- 
cysted, 674;  fibrinous,  665;  interlobar,  674; 
in  typhoid  fever,  28;  pain  in  side  in,  668; 
plastic,  665;  pleural  friction  in,  670;  pulsat- 
ing, 672;  purulent,  671;  sero-fibrinous,  666; 
tuberculous,  284,  666,  073. 

Pleurisy,  chronic,  678;  dry,  679;  primitive 
dry,  679;  vaso-motor  phenomena  in,  680; 
with  effusion,  678. 

Pleurodynia,  407. 

Pleuro-peritoneal  tuberculosis,  284. 

Pleurothotonos  in  tetanus,  232. 

Plexiform  neuroma,  1037. 

Plica  polonica,  377. 

Plumbism,  386:  and  gout,  408;  as  a  cause  of 
renal  cirrhosis,  877;  paralysis  in,  388. 

Plymouth,  epidemic  of  typhoid  fever  at,  5. 

Pneumatosis,  499. 

Pneumaturia,  424,  864. 

Pneumococcus,  110. 

Pneumogastrie  aurae,  1096. 

Pneumogastric  nerve,  affections  of,  1060; 
cardiac  branches  of,  1062;  gastric  and 
cjesophageal  branches  of,  1063;  laryngeal 
branches  of,  1061;  pharyngeal  branches  of, 
1060;  pulmonary  branches  of,  1063. 

Pneumonia,  acute  croupous,  108;  abscess  in, 
130;  acute  delirium  in,  123;  anaesthesia, 
129;  antipneumonic  serum  in,  135;  bleeding 
in,  135;  clinical  varieties  of,  126;  colitis, 
croupous,  in,  115;  complications  of,  123; 
crisis  in,  117;  delayed  resolution  in,  129; 
diagnosis  from  acute  pneumonic  phthisis, 
291;  diplococcus  pneumoniae,  110;  endocar- 
ditis in,  115;  engorgement  of  lung  in,  113; 
epidemics  of,  112:  fever  of,  116;  gangrene 
In,  130;  gray  hepatization  in,  113;  herpes 
in,  122;  immunity  from,  112;  in  diabetes, 
127;  in  infants,  126;  in  influenza,  128;  in 
old  age,  126;  meningitis  in,  115;  mortality 
of,  131;  pericarditis  in,  115;  pseudo-crisis 
in,  117;  purulent  infiltration  in,  113;  re- 
currence of,  125;  red  hepatization  in,  113; 
relapse  in,  125;  resolution  of,  113;  serum 
therapy  in,  112;  toxaemia  in,  132;  trauma 
in,  109. 

Pneumonia,  acute  syphilitic,  248;  apex  pneu- 
monia, 126;  aspiration  or  deglutition,  642; 
asthenic,  127;  central,  126;  "  cerebral," 
122;  chronic  interstitial,  649;  chronic 
pleurogenous,  680;  contusion,  109;  double, 
126;  ether,  129;  epidemic,  127;  fibrinous, 
108;  hypostatic,  6.35;  in  malaria,  209;  inter- 
stitial, of  the  root,  in  syphilis,  247;  In  ty- 
phoid fever,  27;  larval,  127;  lobar,  108; 
massive,  126;  migratory,  126;  pleuroge- 
nous Interstitial,  649;  post-operation,  128; 
secondary,  127;  toxic,  127;  typhoid  pneu- 
monia, 127;  white,  of  the  foetus,  247. 

Pneumonitis,  108, 


Pneumonokoniosis,  652. 
Pneumo-pericardium,  698. 
Pneumo-peritonaeum,  598. 
Pneumorrhagia,  637. 
Pneumothorax,  681;  after  tracheotomy,  687; 

chronic,    683;    Hippocratic    succussion    in, 

683;  in  phthisis,  297;  from  muscular  effort, 

681. 
Pneumo-typhus,  11,  27. 
Podagra,  407. 
Pododynia,  1106. 
Poikilocytosis,  794,  799. 
Poisoning,  by  arsenic,  390;  by  food,  391;  by 

lead,  386;  by  meat,  391;  by  sewer-gas,  343. 
"  Poker-back,"  40.3. 
Polio-myelitis,  acute  and  subacute,  in  adults, 

946. 
Polio-myelitis  anterior,  acute,  942;  epidemics 

of,  942;  etiology  of,  942. 
Polio-myelitis  anterior  chronica,  928,  941. 
Polyadenomata,  494. 
Polyaemia,  803. 
Polyneuritis,  acute  febrile,  1033;  recurrens, 

1033. 
Polyorrhomenitis,  284,  604. 
Polyphagia,  423. 
Polyserositis,  284,  604. 
Polyuria  (see  Diabetes  Insipidus),  432. 
Polyuria,     in    abdominal     tumors,     432;     in 

hysteria,  432,  1112. 
Pons,  lesions  of,  984;  tumors  of,  1023. 
Popliteal    nerve,    external,    1072;    internal, 

1072. 
Porencephalus,  1017. 
Portal  vein,  diseases  of,  554;  thrombosis  of, 

554;  suppuration  in,  578. 
Post-epileptic  symptoms,  1097. 
Post-hemiplegic  chorea,  1019:  epilepsy.  1019, 

1098;  movements,  1019. 
Post-mortem  movements  in  cholera   bodies, 

178. 
Post-pharyngeal  abscess,  450. 
Post-typhoid,  anaemia,  19;  variations  of  tem- 
perature, 16. 
PotVs  disease,  970. 
Pregnancy,  and  acute  yellow  atrophy,  551; 

and  chorea,   1080;  and  heart-disease,  729; 

and  phthisis,  329;  and  typhoid  fever,  35. 
Presystolic  murmur,  723. 
Priapism  in  leukaemia,  806. 
Prickly  heat  (see  Urticaria). 
Procession  caterpillar,  effects  of,  379. 
Professional  spasms,  1107. 
Proglottis  of  taenia,  305. 
Progressive  muscular  atrophy,  928. 
Progressive   pernicious  anaemia,    795;    blood 

in,  797. 
Prophylaxis,    against   cholera,    180;    against 

scurvy,    824;    against    tuberculosis,     330; 

against  taenia,  367;  against  trichina,  358; 


llTi 


INDEX. 


against  typhoid  fever,  40;   against  yellow 
fever,  188. 
Prosopalgia,  1105. 
Prostate,  tuberculosis  of,  326. 
Protozoa,  diseases  caused  by,  349;  parasitic, 

349. 
Prune-juice  expectoration,  664. 
Prurigo,  in  Eodgkin's  disease,  812. 
Pruritus  in  diabetes,  425;  in  uraemia,  867;  in 
obstructive  jaundice,  549;  in  gout,  415;  in 
Graves'  disease,  839. 
Pseudo-angina  pectoris,  763,  1118. 
Pseudo-apoplectic    seizures    in    fatty    heart, 

751;  with  slow  pulse,  760. 
Pseudo-biliary  colic,  564. 
Pseudo-bulbar  paralysis,  932. 
Pseudo-cavernous  signs,  309,  670,  675. 
Pseudo-cyesis,  1114. 
Pseudo-diphtheria,  142. 
Pseudo-hydrophobia,  230. 
Pseudo-leuksemia,  809. 
Pseudo-lipoma,  supraclavicular,  841. 
Pseudoptosis,  1046. 
Pseudo-sclerose  en  plaques,  960. 
Pseudo-tuberculosis    hominis    streptothrica, 

262. 
Psilosis,  511. 
Psoriasis,  buccal,  446. 
Psorosperniiasis,  349. 
Ptosis,   forms  of,   1046;   hysterical,   1046;   in 

ataxia,  922;  psendo-,  1046. 
Ptyalism,  444,  446. 
Puberty,  barking  cough  of,  1117. 
Pulex,  irritans,  377;  penetrans,  378. 
Pulmonal-cerebral  abscesses,  1025. 
Pulmonary  (see  LrxGs). 
Pulmonary  apoplexy,  638. 
Pulmonary  artery,  sclerosis  of,  773;  perfora- 
tion of,  782. 
Pulmonary  haemorrhage,  637. 
Pulmonary  orifice,  congenital  lesions  of,  767; 
tuberculosis  in,  316,  767;  valve  lesions  of, 
727. 
Pulmonary  osteo-arthropathy,  hypertrophic, 

1144. 
Pulsating  pleurisy,  672. 
Pulsation,  dynamic,  of  aorta,  782. 
Pulse,     alternate,     757;     anastomotic,     774; 
dicrotic,   13,   19;   under  influence   of   digi- 
talis, 732;  intermittent,  757;  irregular,  757; 
bigeminal,  757:  recurrent,  774;  trigeminal, 
757. 
Pulse,   capillary  (see  Capillaet);  Corrigan, 

714;  water-hammer,  714. 
Pulse,  slow,  in  tuberculous  meningitis,  279; 
in  jaundice.  549  (see  Brachtcardia,  759). 
Pulsus  paradoxus,  692,  697,  756. 
Pupil,  Aryyll  Robertson,  962,  1047. 
Pupillary  inaction,  hemiopic,  1044. 
Pupils,  unequal,  1047;  in  general  paresis,  962. 


Purpura,  814;  arthritic,  815;  cachetic,  814; 
fulminans,  817;  Henoch's,  816;  infectious, 
814;  mechanical,  815;  neurotic,  815;  pelio- 
sis  rheumatica  in,  815;  haemorrhagica,  816; 
pemphigoid,  815;  simplex,  815;  sympto- 
matic, 814;  toxic,  814;  urticans,  815;  vario- 
losa, 62. 

Purpuric  oedema,  febrile,  815. 

Pustule,  malignant,  225. 

Putrid  sore  mouth,  442. 

Pyaemia,  163;  arterial,  705;  idiopathic,  163; 
post-typhoid,  32. 

Pysemic  abscess  of  liver,  579,  580. 

Pyelitis,  886;  intermittent  fever  in,  888; 
pyuria  in,  887;  in  typhoid  fever,  31. 

Pyelonephritis,  886. 

Pylephlebitis  adhesiva,  5-54. 

Pylephlebitis,  in  dysentery,  200:  in  pyaemia, 
'164;  suppurative,  555,  578. 

Pylorus,  hypertrophic  stenosis  of,  494;  con- 
genital hypertrophy  of,  494;  insufficiency 
of,  500:  spasm  of,  499. 

Pyonephrosis,  886. 

Pyo-pneumothorax,  285,  681. 

Pyo-pneumothorax  subphrenicus,  479,  601, 
683. 

Pyuria,  858;  in  typhoid  fever,  31. 

Quarantine     against     yellow     fever,      188; 

against  cholera,  180. 
Quartan  ague,  213. 
Quincke's  lumbar  puncture,  107,  956. 
Quinine  ^ash,  77,  83. 

Quinsy  (see  Tonsillitis,  Sijppueative). 
Quotidian  ague,  213. 

Rabies,  227. 

Rachitic  bones,  434. 

Radial  paralysis,  1070. 

Rag-picker's  disease,  226. 

Railway  brain,  1132. 

Railway  spine,  1132. 

Rainey's  tubes,  349. 

Rapid  heart,  758. 

Rashes,  from  drugs,  83,  814:  in  glanders,  234; 
in  measles,  86;  in  relapsing  fever,  54;  in 
rubella,  89;  in  scarlet  fever,  77;  in  small- 
pox, 59,  60;  in  syphilis,  240;  in  typhoid 
fever,  17;  in  typhus  fever,  51;  in  pyaemia, 
164;  in  vaccination,  71;  in  varicella,  74. 

Raspberry  tongue  in  scarlet  fever,  78. 

Ray-fungus  (actinomyces),  235. 

Raynaud's  disease,  1137;  aphasia  in,  1139; 
and  scleroderma,  1146;  epilepsy  in,  1139; 
haemogloblnuria  in,  1138. 

Reaction  of  degeneration.  914,  1036,  1054. 

Recrudescence  of  fever  in  typhoid  fever,  16. 

Rectal  crises  In  tabes,  924. 

Rectum,  irritable,  1118;  stricture  of,  249; 
syphilis  of,  249;  tuberculosis  of,  320. 


INDEX. 


1175 


Recurrent  laryngeal  nerve,  paralysis  of, 
1061. 

Recurrent  pulse,  774. 

Recurring  multiple  neuritis,  1033. 

Red  softening  of  brain,  1009. 

Reduplication  of  heart-sounds,  757. 

Redux  crepitus,  120. 

Reflex  epilepsy,  1095. 

Reflexes  in  ascending  paralysis,  946;  in  cere- 
bral hismorrhage,  1005,  1006;  in  locomotor 
ataxia,  924;  in  polio-myelitis  acuta,  944;  in 
spastic  paraplegia,  937;  in  hysterical  para- 
plegia, 941,  1114;  in  progressive  muscular 
atrophy,  931. 

Regurgitation,  tricuspid,  725. 

Reichmann's  disease,  500. 

Relapse  in  typhoid  fever,  35. 

Relapsing  fever,  53;  spirillum  of,  54. 

Remittent  fever,  213. 

Renal  calculus,  891. 

Renal,  colic,  893;  epistaxis,  852;  sand,  892; 
syphilis,  250;  sclerosis,  877. 

Rcndu's  type  of  tremor,  1115. 

Ren  mobilis,  846. 

Resolution  in  pneumonia,  129. 

Resonance,  amphoric,  309,  682;  tympanitic, 
309,  669,  682. 

Respiratory  system,  diseases  of,  610. 

Rest  treatment,  1121;  in  aneurism,  784. 

Retina,  lesions  of,  1039. 

Retinal  hypersesthesia,  1040. 

Retinitis,  albuminuric,  1039;  in  ansemia, 
1039;  in  malaria,  1039;  leuksemic,  1040; 
■pigmentosa,  10-39;  syphilitic,  241,  10.39. 

Retraction  of  head  in  meningitis,  278,  955; 
in  otitis  media,  955;  in  typhoid  fever,  28. 

Retro-collic  spasm,  1065. 

Retroperitoneal  abscess,  522. 

Retroperitonseum,  haemorrhage  into,  58. 

Retro-pharyngeal  abscess,  450. 

Retropulsion  in  paralysis  agitans,  1078. 

Revaccination,  71. 

Rhabditis  niellyi,  361. 

Rhabdomyoma  of  kidney,  896. 

Rhabdonema  intestinale,  364. 

Rhachitis,  434. 

Rhagades,  243. 

Rheumatic  fever,  166;  cerebral  complications 
of,  171;  endocarditis  in,  170;  fibrous 
nodules  in,  172;  germ  theory  of,  168; 
heredity  in,  167;  hyperpyrexia  in,  170; 
metabolic  theory  of,  168;  nervous  theory 
of,  168;  pericarditis  in,  171;  purpura  in, 
172;  sudden  death  in,  172. 

Rheumatic  gout  (see  Arthritis  Defor- 
mans). 

Rheumatic  nodules,  172. 

Rheumatism,  chronic,  405. 

Rheumatism,  muscular,  406. 

Rheumatism,  subacute,  170. 


Rheumatoid  arthritis  (see  Arthritis  De- 
formans). 

Rhinitis,  611;  atrophica,  611;  flbrinosa,  147; 
hypertrophica.  Oil;  syphilitic,  242. 

Ribs,  resection  of,  in  empyema,  678. 

Rice-water  stools,  179. 

Rickets,  434;  acute,  438,  825;  foetal,  841. 

Riga's  disease,  442. 

Rigidity,  early,  in  hemiplegia,  1002. 

Rigidity,  late,  in  hemiplegia,  1005. 

Rigors,  in  abscess  of  brain,  1026;  in  abscess 
of  liver,  579;  in  ague,  209;  in  pneumonia, 
115;  in  pyaemia,  164;  in  pyelitis,  887;  in 
tuberculosis,  299;  in  typhoid  fever,  17. 

Risus  sardonicus,  232. 

Rock-fever,  219. 

Romberg's  symptom,  923. 

Root-nerve  symptoms  in  compression  para- 
plegia, 970. 

Rosary,  rickety,  436. 

Roseola  (see  Rose  Rash  of  Typhoid),  17; 
epidemic,  89. 

"  Rose  cold,"  612. 

Rose  rash  in  typhoid  fever,  17. 

Rotation  in  epilepsy,  1096. 

Rotatory  spasm  in  hysteria,  1115. 

Rotheln,  89. 

"  Rough-on-rats,"  poisoning  by,  390. 

Round-worms,  352. 

Rub  (see  Friction). 

Rubella,  89. 

Rubeola  notha,  89. 

Rumination,  499. 

Running  pulse  in  typhoid  fever,  19. 

Russian  fever,  95. 

Sable  intestinal,  546. 

Saccharomyces  albicans,  443. 

Sacral  plexus,  lesions  of,  1072. 

St.  Vitus's  dance,  1079. 

Salaam  convulsions,  1091,  1115. 

Saline  injections,  intravenous,  in  diabetic 
coma,  431;  subcutaneous,  in  cholera,  181. 

Saliva,  arrest  of,  447;  supersecretion  of,  446. 

Salivary  glands,  diseases  of,  446;  inflamma- 
tion of,  447. 

Salivation  (see  Ptvaxism),  444,  446;  in  small- 
pox, 61;  in  bulbar  paralysis,  932. 

Salpingitis,  tuberculous,  326. 

Saltatory  spasm,  1089. 

Sanatoria,  treatment  of  tuberculosis  in,  333. 

Sand-flea,  378. 

Saprseniia,  161. 

Saranac  Sanitarium,  333. 

Sarcina,  ventriculi,  475;  In  lung  cavities,  302. 

Sarcocystls  Mlescheri,  349;  S.  homlnis, 
.349. 

Sarcoma,  of  brain,  1020;  of  kidney,  896;  of 
liver,  583;  of  lung,  6G3;  mediastinal,  685; 
melanotic,  of  liver,  583. 


1176 


INDEX. 


Sarcoptes  scabiei,  376. 

Saturnine  neuritis,  1035. 

Saturnism,  386. 

Sausage  poisoning,  391. 

Scapulodynia,  407. 

Scarlatina  miliaris,  78. 

Scarlatina  sine  eruptione,  79. 

Scarlatinal  nephritis,  80. 

Scarlet  fever,  75;  anginose  form,  80;  atactic 
form,  79;  complications  and  sequelae,  80; 
contagiousness  of,  76;  desquamation  in, 
79:  eruption  in,  77;  hsemorrhagic  form,  79; 
incubation  of,  77;  invasion  in,  77;  malig- 
nant, 79;  puerperal,  76;  surgical,  76. 

Schistosoma  haematobium,  352. 

Schonlein' s  disease,  815. 

School-made  chorea,  1081. 

Schott  treatment  in  myocardial  disease, 
752. 

Sciatica,  1073. 

Sciatic  nerve,  affections  of,  1072. 

Scirrhous  cancer  of  stomach,  487,  488. 

Sclerema  in  cholera  infantum,  510. 

Sclerema  neonatorum,  1145. 

Sclerodactylie,  1146. 

Scleroderma,  1145. 

Sclerose  en  plaques,  959. 

Scleroses  of  the  brain,  957. 

Sclerosis,  cerebro-spinal,  957;  degenerative, 
957;  developmental,  958;  inflammatory, 
958;  of  scurvy,  823;  syphilis  as  a  cause  of, 
242. 

Sclerosis,  primary,  lateral,  937;  insular,  959; 
multiple,  959. 

Sclerosis,  posterior  spinal  (see  Locomotoe 
Ataxia),  920;  in  chronic  ergotism,  394. 

Sclerosis,  primary  combined,  949. 

Sclerosis  in  tubercles,  271. 

Sclerosis,  renal,  877. 

Sclerosis,  toxic  combined,  951. 

Sclerostomum  duodenale,  359;  S.  equinum, 
359.  I 

Sclerotic  gastritis,  467. 

Scolices  of  echinococcus,  371. 

Scorbutus,  821. 

Scrivener's  palsy,  1107. 

Scrofula,  280;  alleged  protective  inoculation 
by,  281. 

Scrofulous  pneumonia,  272. 

Scurvy,  821;  infantile,  825;  prophylaxis  of, 
824:  sclerosis,  823. 

Scybala,  539. 

Seasonal  relations,  of  chorea,  1079;  of  ma- 
laria, 203;  of  pneumonia,  110;  of  rheuma- 
tism, 167. 

Secondary  contracture  in  hemiplegia,  1005. 

Secondary  deviation,  1048. 

Secondary  fever  of  small-pox,  60. 

Self-limitation  in  tuberculosis,  328. 

Semilunar  space  of  Traube,  669. 


Semilunar  valves,  aortic,  incompetency  of, 
709. 

Senile  emphysema,  659. 

Sensation,  painful,  loss  of,  in  syringomyelia, 
975. 

Sensation,  retardation  of,  in  ataxia,  924. 

Sensory  system,  diseases  of,  920. 

Septicaemia,  160;  cryptogenetic,  162;  general, 
162;  gonorrhceal,  255;  progressive,  162; 
post-typhoid,  32. 

Septico-pyaemia,  163. 

Serratus  palsy,  1070. 

Seven-day  fever,  53. 

Sewer-gas  and  tonsillitis,  451. 

Sewer-gas  poisoning,  effects  of,  343. 

Sex,  influence  of,  in  heart-disease,  729. 

Sexes,  proportion  of,  affected  with  acute 
yellow  atrophy,  551;  in  chlorosis,  792;  in 
chorea,  1079;  in  exophthalmic  goitre,  837: 
in  general  paresis,  960;  in  haemophilia,  819. 

Shaking  palsy,  1076. 

Shell-fish,  poisoning  by,  393. 

Ship-fever,  49. 

Shock  as  a  cause  of  traumatic  neuroses, 
1132. 

Shock,  death  from,  in  acute  obstruction, 
535. 

Sick  headache,  1102. 

Sickness,  sleeping,  361. 

Siderodromophobia,  1124. 

Siderophobla,  1124. 

Siderosis,  652,  654. 

Signal  symptom  (in  cortical  lesions),  980, 
1021. 

Singultus  (see  Hiccough). 

Sinus  thrombosis,  1015;  and  anaemia,  1015; 
and  chlorosis,  794;  autochthonous,  1015; 
secondary,  in  ear-disease,  1015. 

Siriasis,  395. 

Sitotoxismus,  394. 

Sixth  nerve,  paralysis  of,  1048. 

Skin,  itching  of,  in  uraemia,  867. 

Skoda' s  resonance  in  pleural  effusion,  669; 
in  pneumonia,  119. 

Skull,  of  congenital  syphilis,  243;  of  hydro- 
cephalus, 1029;  of  rickets,  436;  percussion 
of,  1027. 

Sleeping  sickness,  361. 

Slow  heart,  759. 

Small-pox,  56;  complications  of,  64;  con- 
fluent form,  61;  contagiousness  of,  56; 
discrete  form,  60;  eruption  in,  60;  haemor- 
rhagic,  62;  inoculation  in,  56;  vaccinatiou 
in,  56. 

Small  sciatic  nerve,  affections  of,  1072. 

Smell,  affections  of  sense  of  (see  Olfactory 
Nerve),  1038. 

Snake-virus,  purpura  caused,  by,  814. 

SnufBes,  242. 

Softening  of  brain,  1008. 


INDEX. 


1177 


Soil,  influence  of,  in  cholera,  177;  in  tuber- 
culosis, 268;  in  typhoid  fever,  6. 

Solvent  treatment  of  renal  calculi,  896. 

Soor,  443. 

Soi-des,  22. 

Sore  throat,  448. 

Soya  bread,  430. 

Spasm,  congenital  gastric,  495. 

Spasm,  lock,  in  writer's  cramp,  1108. 

Spasmodic  wryneck,  1065. 

Spasms,  in  ergotism,  394;  in  hydrophobia, 
228;  in  hysteria,  1112;  of  face,  1055;  of 
muscles,  after  facial  paralysis,  1055;  pro- 
fessional,  1107;   saltatory,   10S9. 

Spastic  paraplegia  of  adults,  937;  hereditary, 
940;  hysterical,  941;  Erb's  syphilitic,  940; 
in  children,  938;  secondary,  941. 

Specific  infectious  diseases,  1. 

Specific  treatment  of  typhoid  fever,  46. 

Spectra,  fortification,  1102. 

Speech  (see  Aphasia),  988. 

Speech,  in  adenoid  vegetations,  456;  in  bul- 
bar paralysis,  932;  in  insular  sclerosis,  959; 
in  general  paralysis,  962;  in  hereditary 
ataxia,  950;  in  paralysis  agitans,  1078. 

Speech,  scanning,  in  insular  sclerosis,  959. 

Spes  phthisica,  312. 

Spina  bifida,  involvement  of  cauda  equina  in, 
972. 

Spinal  accessory  nerve,  paralysis  of,  1063. 

Spinal  apoplexy,  968. 

Spinal  concussion,  effects  of,  1133. 

Spinal  cord,  diffuse  and  focal  diseases  of, 
964. 

Spinal  cord,  abscess  of,  974;  affections  of 
blood-vessels  of,  966;  anaemia  of,  966; 
chronic  lepto-meningitis  of,  957;  compres- 
sion of,  970;  congestion  of,  966;  embolism 
and  thrombosis  of  vessels  of,  966;  endar- 
teritis of  vessels  of,  967;  fissures  in,  909; 
haemorrhage  into,  968:  lepto-meningitis  of, 
954;  localization  of  functions  of,  905; 
pachymeningitis  of,  953;  sclerosis,  primary 
combined,  of.  949;  syphilis  of,  244;  tuber- 
culosis of,  321;  tumors  of,  973;  unilateral 
lesions  of,  965. 

Spinal  epilepsy,  937. 

Spinal  irritation,  1125. 

Spinal  membranes,  haemorrhage  into,  967. 

Spinal  nerves,  diseases  of,  1067. 

Spinal  neurasthenia,  1125. 

Spinal  paralysis,  atrophic,  942. 

Spirals,  Curschmann's,  631,  633. 

Spirillum  of  relapsing  fevet,  54. 

Spirochacte  of  Obermeier,  53. 

Splanchnoptosis,  541. 

Spleen,  amyloid  degeneration  of,  in  syphilis, 
249;  in  tuberculosis,  298. 

Spleen,  diseases  of,  832;  abscess  of,  834;  In- 
farct of,  834;  tumors  of,  834, 


Spleen,  enlargement  of,  in  congenital  syph- 
ilis, 242,  244;  in  malaria,  207,  216. 

Spleen,  excision  of,  in  leukaemia,  809. 

Spleen,  floating,  543,  833;  pulsating,  805. 

Spleen,  in  ague,  208,  216;  in  anthrax,  226;  in 
cirrhosis  of  liver,  572,  575;  in  Eodgkin's 
disease,  811;  hydatid  of,  372;  in  leukaemia, 
803,  805;  in  rickets,  435,  437;  in  acute  tuber- 
culosis, 276;  in  typhoid  fever,  10,  26;  in 
typhus,  50. 

Spleen,  rupture  of,  833;  in  malaria,  208;  in 
typhoid  fever,  11. 

Splenectomy,  statistics  of,  809,  835. 

Splenic  anaemia,  834. 

Splenic  fever,  224. 

Splenization  of  lung,  292,  635,  643. 

Splenomegaly,  primitive,  834. 

Spondylitis  deformans,  403. 

Sporozoa,  349;  parasitic,  349. 

Spotted  fever,  49,  101. 

Sprue,  511. 

Sputa,  albuminoid,  after  aspiration  of  chest, 
678;  alveolar  cells  in,  622,  635;  amoeba  coli 
in,  201;  in  cancer  of  lung,  664;  in  influenza, 
97;  haematoidin  crystals  in,  580;  in  anthra- 
cosis,  654;  in  asthma,  630;  in  bronchiecta- 
sis, 627;  in  acute  bronchitis,  622;  in  chronic 
bronchitis,  624;  in  putrid  bronchitis,  625; 
in  gangrene  of  lung,  661. 

Sputa,  in  phthisis,  300;  in  pneumonia,  IIS; 
in  acute  pulmonary  tuberculosis,  275; 
prune-juice,  664;  uric-acid  crystals  in,  411. 

Staphylococci,  in  diphtheria,  141;  in  endo- 
carditis, 702;  in  peritonitis,  597;  in  pneu- 
monia, 113;  in  pyaemia,  163;  in  septicaemia, 
162;  in  tonsillitis,  451. 

Status,  epilepticus,  1097;  hystericus,  1119. 

Status  lymphaticus,  826;  sudden  death  in, 
827. 

Stellwag's  sign,  838. 

Stenocardia,  761. 

Stenosis,  of  aortic  orifice,  715;  of  mitral 
orifice,  721;  of  pulmonary  orifice,  727,  767; 
of  tricuspid  orifice,  726. 

Steppage  gait,  1034. 

Stercoraceous  vomiting,  534. 

Stercoral  ulcers  in  colitis,  513. 

Stertor,  in  apoplexy,  1001. 

Stiff  neck,  406. 

Stigmata,  In  hysteria,  1118;  in  purpura,  815. 

Stitch  in  side  in  pneumonia,  115;  in  pleurisy, 
668. 

8tokc8-Adams  syndrome,  760. 

Stolidity  of  face  in  general  paresis,  962. 

Stomach,  acute  cancer  of,  493. 

Stomach,    cancer   of,   486;    absence   of  free 
H(?'l  in,  491;  diagnosis  from  gastric  ulcer 
and  chronic  gastritis.  493;  haemorrhage  In, 
490;  vomiting  In,  490. 
Stomach,  dilatation  of,  474;  tetany  In,  475. 


1178 


INDEX. 


Stomach,  diseases  of,  463. 

Stomach,  atrophy  of,  467;  atony  of,  500; 
chronic  catarrh  of,  466;  erosions  of,  468; 
foreign  bodies  in,  494;  haemorrhage  from, 
481,  495;  hair  tumors  in,  494;  neuroses  of, 
497;  non-cancerous  tumors  in,  494;  tuber- 
culosis of,  319;  ulcer  of,  478;  washing  out 
of  (lavage),  472. 

Stomatitis,  441;  acute,  441;  aphthous,  441; 
epidemic,  347;  fetid,  442;  follicular,  441; 
gangrenous,  444;  mercurial,  444;  neurotica 
chronica,  443;  parasitic,  443;  ulcerative, 
442;  vesicular,  441;  ursemic,  868. 

Stone-cutter's  phthisis,  269,  652. 

Stools,  of  acute  yellow  atrophy,  552;  of 
cholera,  179;  of  dysentery,  194,  197,  198; 
of  typhoid  fever,  23;  in  hsematemesis,  497; 
of  obstructive  jaundice,  549. 

Strabismus,  1048. 

Strangulation  of  bowel,  531,  536. 

"  Strawberry  "  tongue  in  scarlet  fever,  78. 

Streptococci  in  diphtheria,  141;  in  empyema, 
671;    in   endocarditis,    702;    in   pneumonia, 
113;   in  peritonitis,    597;    in   pyaemia,    163;. 
in  scarlet  fever,  77;  in  septicaemia,  162;  in 
tonsillitis,  451. 

Streptococcus  diphtheritis,  142. 

Streptococcus  erysipelatos,  157. 

Streptococcus  pyogenes  in  erysipelas,  157. 

Streptothrix  actinomyces,  235. 

Strictures  and  tumors  of  the  bowel,  533. 

Stricture  of  bile-duct,  560. 

Stricture  of  colon,  cancerous,  533. 

Stricture  of  intestine,  533;  after  dysentery, 
200,  533;  after  tuberculous  ulcer,  319. 

Stricture  of  cesophagus,  460. 

Stricture  of  pylorus,  494. 

Strongyloides  intestinalis,  364. 

Strongylus  duodenalis,  359. 

Strumitis,  836. 

Stuttering  in  mouth-breathers,  456. 

Styrian  peasants,  arsenical  habit  in,  391. 

Subclavian  artery,  murmur  in  and  throbbing 
of,  in  phthisis,  308,  309. 

Subphrenic  peritonitis,  600. 

Subsultus  tendinum  in  typhoid  fever,  29. 

Succussion,  Hippocratic,  683. 

Succussion  splash  in  dilated  stomach,  476. 

Sudamina  in  typhoid  fever,  17. 

Sudden  death  in  angina  pectoris,  762;  in 
aortic  Insufficiency,  712;  in  coronary  artery 
disease,  747;  in  enlarged  thymus,  844;  in 
pleural  effusion,  671;  in  status  lymphati- 
cus,  827;  in  typhoid  fever,  40. 

Sudoral  form  of  typhoid  fever,  18. 

Sugar  in  the  urine,  423. 

Sulphocyanides  in  excess  in  saliva  in  rheu- 
matism, 170. 

Sun-stroke,  395;  after-effects  of,  397. 

Suppression  of  urine,  850. 


Suppurative  nephritis,  887. 

Suppurative  pylephlebitis,  555,  578. 

Suppurative  tonsillitis,  452. 

Suprarenal  bodies,  diseases  of,  828;  haemor- 
rhage into,  832;  tuberculosis  of,  832; 
tumors  of,  832. 

Surgical  kidney,  887. 

Suspension  in  compression  paraplegia,  972. 

Sweating  in  acute  rheumatism,  169;  in  ague, 
212;  in  diabetes,  423;  in  phthisis,  306;  in 
pyaemia,  164;  in  typhoid  fever,  18;  in 
ulcerative  endocarditis,  704;  profuse,  in 
rickets,  436;  unilateral,  in  cervical  caries, 
971;  unilateral,  in  aneurism,  782. 

Sweating  sickness,  346. 

Sydenham's  chorea,  1079. 

Symmetrical  gangrene,  1138. 

Sympathetic  ganglia,  in  Addison's  disease, 
829. 

Sympathetic  nerve  fibres  (see  Vaso-motor). 

Symptomatic  parotitis,  447. 

Syncope,  fatal,  in  diphtheria,  151;  in  cardiac 
disease,  712,  750;  in  phthisis,  317;  in  pleu- 
ral effusion,  671. 

Syncope,  local,  1137. 

Synovial  rheumatism  (see  Gonorehceal 
Rheumatism),  256. 

Synovitis,  gonorrhceal,  257. 

Synovitis,  symmetrical,  in  congenital  syph- 
ilis, 244. 

Syphilides,  macular,  240;  papular,  240;  pus- 
tular, 240;  squamous,  241;  the  late,  241. 

Syphilis,  238;  accidental  infection  in,  238; 
acquired,  240;  amyloid  degeneration  in, 
242;  bone  lesions  of,  244;  congenital,  242; 
early  nerve  lesions  in,  245;  gummata  in, 
239;  hereditary  transmission  of,  238;  modes 
of  infection  in,  238;  of  brain  and  cord,  244, 
1020;  of  circulatory  system,  250;  of  diges- 
tive tract,  249;  of  liver,  248;  of  lung,  247; 
orchitis  in,  251;  primary  stage  of,  240; 
prophylaxis  of,  252;  renal,  250;  secondary 
stage  of,  240;  tertiary  stage  of,  241;  vis- 
ceral, 244. 

Syphilis  and  dementia  paralytica,  242,  246, 
961. 

Syphilis  and  locomotor  ataxia,  242,  920. 

Syphilis  haemorrhagica  neonatorum,  243,  818. 

Syphilitic  arteritis,  250. 

Syphilitic  fever,  240. 

Syphilitic  nephritis,   250. 

Syphilitic  phthisis,  247. 

Syringomyelia,  975. 

Tabes,  diabetic,  426. 

Tabes    dorsalis    (see    Locojmotor    Ataxia), 

920;  in  chronic  ergotism,  394. 
Tabes  dorsalis  spasmodique,  937. 
Tabes  mesenterica,  283. 
Tache  c6r6brale,  17,  278. 


INDEX. 


1179 


Taches  bleuatres,  18,  377. 

Tachycardia,  758,  838;  neurasthenic,  1126; 
paroxysmal,   758. 

Tactile  fremitus,  in  emphysema,  658;  in 
pneumonia,  119;  in  pleural  effusion,  668;  in 
pneumothorax,  682;  in  pulmonary  tubercu- 
losis, 307;  at  right  apex,  307. 

Taenia  echinococcus,  368,  370. 

Taenia  elliptica,  T.  cucumerina,  T.  flavo- 
p\inctata,  T.  nana,  T.  Madagascariensis, 
T.  confusa,  366. 

Taenia  saginata  or  mediocanellata,  366. 

Taenia  solium,  365. 

Tape- worms,  365;  treatment  of,  367. 

Taste,  disturbances  of,  1060;  tests  for  sense 
of,  1060. 

Tea,  neuritis  caused  by,  1035. 

Techomyza  fusca,  379. 

Teeth,  actinomyces  in,  236;  looseness  of,  in 
scurvy,  823;  effects  of  stomatitis  on.  445; 
erosion  of,  445;  Hutchinson's,  243,  445;  of 
infantile  stomatitis,  445. 

Teichopsia,  1102. 

Telegrapher's  cramp,  1108. 

Temperature  sense,  loss  of,  in  syringo- 
myelia, 975;  in  Morvan's  disease,  975. 

Temperature,  subnormal,  in  acute  alcohol- 
ism, 380;  in  acute  tuberculosis,  274;  in 
apoplexy,  1001;  in  heat  exhaustion,  395;  in 
malaria,  209,  215;  in  pulmonary  tubercu- 
losis, 306;  in  tuberculous  meningitis,  279; 
in  uraemia,  866. 

Temporal  lobe,  tumors  of,  1022. 

Temporo-sphenoidal  lobe,  centre  for  hearing 
in,  1056. 

Tender  points  In  neuralgia,  1104;  in  neuras- 
thenia, 1123. 

Tender  toes,  in  typhoid  fever,  29. 

Tendon-reflexes  (see  Reflexes). 

Terminal  infections,  165. 

Tertian  ague,  212. 

Testes,  tuberculosis  of,  326;  syphilis  of,  251 
(see  also  Orchitis). 

Tetanus,  230;  bacillus  of,  231;  neonatorum, 
230. 

Tetanus,  cephalic,  232. 

Tetany,  1109;  after  thyroidectomy,  1110;  epi- 
demic or  rheumatic,  1109;  in  dilatation  of 
the  stomach,  47.5,  1110;  in  myxcedema, 
1110;  in  typhoid  fever,  30. 

Tetrodon,  poisoning  by,  .394. 

Therapeutic  test  in  syphilis,  2.51. 

Therapy,  serum,  in  plague,  192. 

Thermic  fever,  395. 

Thermic  sense,  loss  of.  In  syringomyelia, 
975. 

Third  nerve,  diseases  of,  1045. 

Third  nerve,  recurring  paralysis  of,  1046; 
signs  of  paialysis  of,  1046. 

Thomsrn's  disease,   1149. 


Thoracic  duct,  tuberculosis  of,  273. 

Thorax,  deformity  of,  in  mouth-breathers, 
455;  in  rickets,  436. 

Thorax  in  emphysema,  658;  in  phthisis,  268, 
306. 

Thorn-headed  worms,  365. 

TTiornwaldt's  disease,  457. 

Thread-worm,  353. 

Throbbing  aorta,  786,  1126. 

Thrombi  in  heart,  723;  in  pneumonia,  114. 

Thrombi  in  veins  in  typhoid  fever,  21. 

Thrombi,  marantic,  1015. 

Thrombosis  of  cerebral  arteries,  1008;  of 
cerebral  sinuses,  1015;  of  cerebral  veins, 
1015;  of  portal  vein,  554. 

Thrush,  443. 

Thymic  asthma,  618,  844. 

Thymus  gland,  diseases  of,  843;  abscess  of, 
845;  tumors  of,  845;  persistence  of,  844; 
enlargement  of,  844;  sudden  death  in,  844. 

Thymus  gland,  in  acromegaly,  1143;  and 
exophthalmic  goitre,  845. 

Thyroid  abscess,  836. 

Thyroid  extract,  administration  of,  843, 
1111. 

Thyroid  gland,  aberrant  or  accessory  tumors 
of,  836;  abscess  of,  836;  absence  of,  in 
cretins,  840;  adenomata  of,  836;  cancer  of, 
836;  in  exophthalmic  goitre,  838;  in  goitre, 
836;  in  myxcedema,  842;  sarcoma  of,  836; 
tumors  of,  836. 

Thyroid  gland,  diseases  of,  835. 

Thyroidism,  843. 

Tic  convulsif,  1055. 

Tic  douloureux,  1105. 

Ticlis,  376. 

Tinnitus  aurium,  1057. 

Tintement  metallique,  738. 

Tobacco,  influence  of,  on  the  heart,  764. 

Tongue,  atrophy  of,  1066;  eczema  of,  445; 
geographical,  445;  in  bulbar  paralysis,  932; 
spasm  of,  1067;  tuberculosis  of,  318;  uni- 
lateral hemiatrophy  of,  1067. 

Tongue,  tremor  of,  in  general  paresis,  962; 
ulcer  of  fraenum  in  whooping-cough,  93. 

Tonsillitis,  451;  acute,  451;  albuminuria  in, 
4.52;  endocarditis  in,  452;  in  the  newly  mar- 
ried, 451. 

Tonsillitis,  chronic,  454;  follicular,  451; 
lacunar,  451;  suppurative,  452;  and  rheu- 
matism, 451. 

Tonsils,  abscess  of,  4.52:  calculi  of,  456; 
cheesy  masses  In,  456; enlarged,  454;  tuber- 
culosis of.  318. 

Tonsils,  diseases  of,  451. 

Tophi,  411. 

Topical  diagnosis,  spln.nl.  904:  cerobrnl.  979. 

Torticollis,  406.  1064:  congonltal.  1064:  facial 
asymmetry  In.  1064;  spasmodic,  1005. 

Toxic  gastritis,  465. 


1180 


INDEX. 


Toxines,  in  septicaemia,  161. 
Tracheal  tugging,  780. 
Traction  aneurism,  777. 
Trance  in  tiysteria,  1113,  1119.      -" 
TrauWs  semilunar  space,  669. 
Trauma  as  a  factor,   in  delirium  tremens, 
382;  in  neurasthenia,  1132;  in  pneumonia, 
109;  in  tuberculosis,  270. 
Trematodes,  diseases  caused  by,  351. 
Trembles  in  cattle,  344. 

Tremor,  alcoholic,  381,  1079;  in  Graves'  dis- 
ease,   839;    hereditary,    1079;    hysterical, 
1079,    1115;    in    exophthalmic    goitre,    839; 
lead,     389;     in    paralysis    agitans,     1077; 
Rendu' s  type  of,  1115;  senile,  1079;  simple, 
1079;    toxic,    1079;    volitional,    in    insular 
sclerosis,  959. 
Trichina  spiralis,   354;   distribution  of,   355; 
statistics   of,    in   American   hogs,    355;   in 
Germany,  355;  modes  of  infection,  356. 
Trichiniasis,  354;  epidemics  of,  356;  prophy- 
laxis of,  359. 
Trichocephalus  dispar,  364. 
Trichomonas  vaginalis,  351;  T.  hominis,  351. 
Trichter-brust,  307,  455. 
Tricuspid  orifice,  stenosis  of,  726. 
Tricuspid  valve,  disease  of,  725;  insuflaciency 

of,  725. 
Trigeminus  (see  Fifth  Neeve). 
THsmus,  neonatorum,  230;  hysterical,  1114. 
Trommer's  test,  423. 
Trophic  disorders,  1137. 
Tropical  dysentery,  195. 
Trousseau's  symptom,  in  tetany,  1110. 
Tubal  pregnancy,  ruptured,  simulating  peri- 
tonitis, 600. 
Tubercle  bacilli,  259,  301. 
Tubercle,    diffuse    infiltrated,    272;    miliary, 
270,  295;  changes  in,  271;  structure  of,  270; 
nodular,  270. 
Tubercles,  miliary,  in  chronic  phthisis,  295. 
Tubercula  dolorosa,  1037. 
Tuberculin,  261;  test,  258;  treatment,  3.35. 
Tuberculosis,  acute,  273;  general  or  typhoid 
form,  274;  meningeal  form,  276;  pulmonary 
form,  275. 
Tuberculosis,    258;    bacillus    of,    259,    301; 
changes  produced  by  bacillus,  270;  chronic 
miliary,   295;   of  circulatory  system,   327; 
conditions  influencing  infection,  267;  con- 
genital,   262;    dietetic   treatment   of,    335; 
distribution  of  the  tubercles  in,  270;  dura- 
tion of  pulmonary  form  of,  329;  hereditary 
transmission    of,    262;    individual    prophy- 
laxis in,  330;  infection  by  meat,  267;  infec- 
tion by  milk,  267;  infection  by  inhalation, 
265;   inoculation   of,    264;   in   infants,   316; 
in  old  age,  316;  mastitis,  312;  treatment, 
336;   modes   of   death    in   pulmonary,    317; 
modes  of  Infection  in,  262;  natural  or  spon- 


taneous, cure  of,  331;  of  alimentary  canal, 
317;  of  brain  and  cord,  321;  of  Fallopian 
tubes,  326;  of  genito-urinary  system,  322; 
of  kidneys,  324;  of  liver,  320;  of  lymphatic 
system,  280;  of  mammary  gland,  327;  of 
ovaries,  326;  of  pericardium,  285;  of  peri- 
tonaeum, 286;  of  pleura,  284;  of  prostate, 
326;  of  serous  membranes,  284;  of  testes, 
326;  of  ureters  and  bladder,  325;  of  uterus, 
326;  of  vesiculse  seminales,  326;  pregnancy, 
influence  of,   in,   329;  prophylaxis  in,  330; 
pseudo-,  262;  pulmonary,  289;  and  typhoid 
fever,  33;  and  valvular  disease  of  heart, 
316. 
Tufnell's  treatment  of  aneurism,  784. 
Tumors  of  brain,  1020. 
Tunnel  anaemia,  360. 
Twists  and  knots  in  the  bovcel,  533. 
Tympanites,   in  intestinal  obstruction,   535; 
in  peritonitis,  598;  in  tuberculous  perito- 
nitis, 287;  in  typhoid  fever,  24;  as  a  cause 
of  sudden  heart  failure,  545. 

Typhlitis,  519. 

Typhoid  fever,  1;  abortive  form,  33;  afebrile, 
17,  34;  ambulatory  form,  14,  34;  anaemia 
in,  19;  and  tuberculosis,  33;  bacillus  of,  4; 
chills  in,  17;  circulatory  system  in,  19; 
diabetes  in,  33;  diarrhoea  in,  23;  digestive 
system  in,  22;  Ehrlich's  reaction  in,  30; 
erysipelas  in,  33;  grave  form  of,  34; 
haemorrhage  in,  23;  haemorrhagic,  34;  his- 
torical note  on,  1;  immunity  from,  3;  in 
the  aged,  35;  in  children,  34;  in  the  fcetus, 
35;  in  pregnancy,  35;  laparotomy  in,  47; 
liver  in,  11,  26;  Maidstone  epidemic  of,  6; 
meteorism  in,  24;  mild  form,  33;  modes  of 
conveyance  of,  5;  nervous  system  in,  12, 
28;  noma  in,  33,  35;  osseous  system  in,  32; 
oysters  and,  6;  parotitis  in,  22;  perforation 
of  bowel  in,  10,  25;  peritonitis  in,  25,  47; 
post-typhoid  variations  of  temperature  in, 
16;  prognosis  of,  39;  prophylaxis  of,  40; 
pyuria  in,  31;  relapses  in,  35;  renal  system 
in,  30;  respiratory  system  in,  27;  serum 
therapy  in,  46;  skin  rashes  in,  17;  spleen 
in,  26;  tender  toes  in,  29;  tetany  in,  30; 
varieties  of,  33;  Widai's  reaction  in  typhoid 
fever,  37;  Durham's  theory  of  relapse  in,  36. 

Typhoid  gangrene,  12,  22;  septicaemia,  32. 

Typhoid  spine,  32. 

Typhoid  state  in  obstructive  jaundice,  550; 
in  acute  yellow  atrophy,  552. 

Typho-malarial  fever,  so-called,  39,  214. 

Typhotoxin,  8. 

Typhus  fever,  49;  complications  and  sequelae 
of,  52. 

Typhus  siderans,  52. 

Tyrosin,  552. 

Tyrotoxicon,  393. 

Tyrotoxismus,  393. 


INDEX. 


1181 


Ulcer,  cancerous,  of  intestine,  513;  gastric, 
478;  of  duodenum,  478;  of  bowel  in  dysen- 
tery, 196,  197,  198;  in  typhoid  fever,  9. 

Ulcer  of  mouth,  442;  in  the  new-born,  443; 
in  nursing  women,  443;  of  palate  in  in- 
fants, 443. 

Ulcer,  peptic,  478;  perforating,  of  foot,  in 
tabes,  925;  in  diabetes,  425. 

Ulcerative  endocarditis,  699. 

Ulcers,  Parrot's,  443. 

Ulnar  nerve,  affections  of,  1071. 

Unclnaria  duodenalis,  359. 

Unconsciousness  (see  Coma). 

Und-nlant  fever,  219. 

Uraemia,  865;  cerebral  manifestations  of, 
866;  coma  in,  867;  convulsions  in,  866; 
diagnosis  from  apoplexy,  868;  dyspnoea  in, 
867;  headache  in,  867;  in  Bright's  disease, 
884;  latent,  851;  local  palsies  in,  867; 
oedema  of  brain  in,  997;  stomatitis  in,  868; 
theories  of,  865. 

Urate  (lithate)  of  soda  in  gout,  408. 

Urates  in  the  urine,  860. 

Urates  (lithates),  amorphous,  860. 

Ureter,  blocking  of,  850;  mucous  cysts  of, 
350;  obstructed  by  calculi,  893;  psorosper- 
miasls  of,  350;  tuberculosis  of,  325. 

Urethritis,  gouty,  415. 

Uric  acid,  calculus,  892;  deposition  of,  860; 
in  gout,  408;  in  urine,  860;  "  showers," 
415. 

Uric-acid  diathesis  (see  Lith^mia),  860. 

Uric-acid  headache,  415. 

Uric-acid  theory  of  gout,  408. 

Urinary  calculi,  892. 

Urine,  anomalies  of  the  secretion  of,  850. 

Urine,  density  of,  in  acute  Bright's  disease, 
870;  in  chronic  Bright's  disease,  880;  in 
diabetes,  423;  in  diabetes  insipidus,  433. 

Urine,  haemoglobin  in,  852. 

Urine,  in  acute  yellow  atrophy  of  liver,  552; 
In  grave  anaemia,  799;  in  cholera,  179;  in 
diabetes  insipidus,  433;  in  diabetes  mel- 
litus,  423;  in  diphtheria,  150;  in  erysipelas, 
159;  in  gout,  411,  413,  415;  in  jaundice,  549; 
in  melanotic  sarcoma,  863;  in  pneumonia, 
122;  In  acute  pulmonary  tuberculosis,  312; 
in  typhoid  fever,  30;  oxalates  in,  861;  pus 
in,  858. 

Urine,  quantity  of,  in  chronic  Bright's  dis- 
ease, 880;  in  diabetes  Insipidus,  433;  In 
diabetes  mellltus,  423;  in  Intestinal  ob- 
struction, 535. 

Urine,  retention  of,  in  typhoid  fever,  30. 

Urine,  suppression  of,  8.50;  treatment  of,  851; 
in  cholera,  179;  in  acute  nephritis,  870;  In 
scarlet  fever,  80;  In  acute  Intestinal  ob- 
struction, 535;  obstructive  suppression, 
894. 

Urine,  tests  for  albumin  In,  8.56;  biliary  pig- 


ment in,  549;  blood  in,  852;  albumoses  in, 
857;  peptones  in,  857. 

Urobilin,  increase  of,  in  pernicious  anaemia, 
799. 

Uro-genital  tuberculosis,  322. 

Urticaria,  after  tapping  of  hydatid  cysts, 
372;  epidemica,  379;  giant  form  (see  Neu- 
rotic CEdema),  1141;  with  purpura,  815; 
in  small-pox,  60;  in  typhoid  fever,  17. 

Uterus,  tuberculosis  of,  326. 

Uvula,  oedema  of,  448;  Infarction  of,  448; 
816. 

Vaccination,  (58;  mark,  70;  technique  of,  73; 
rashes,  71;  ulcers,  71;  value  of,  73. 

Vaccine,  antityphoid,  41. 

Vaccine  lymph,  choice  of,  72. 

Vaccinia,  68;  bacteriology  of,  70;  general- 
ized, 71. 

Vaccino-syphilis,  71. 

Vagabond's  discoloration,  377,  831. 

Valvular  disease  of  heart,  707;  and  tubercu- 
losis,  316. 

Varicella,  74;  haemorrhagic,  75. 

Varicella  bullosa,  75;  escharotica,  75. 

Varices,  oesophageal,  in  cirrhosis  of  liver, 
459. 

Variola,  56;  haemorrhaglca,  59,  62,  63;  vera, 
59. 

Variola  haemorrhaglca  pustulosa,  62,  63. 

Variola  sine  eruptione,  64. 

Varioloid,  59,  63. 

Vaso-motor  disorders,  1137. 

Vaso-motor  disturbances  in  caries,  971;  in 
chronic  pleurisy,  680;  in  exophthalmic  goi- 
tre, 839;  in  hemicrania,  1103;  in  myelitis, 
977;  in  neuralgia,  1104. 

Veins,  cerebral,  thrombosis  in,  1015;  dias- 
tolic collapse  of,  697;  pulsation  in,  311, 
1083,  1126;  sclerosis  of,  773. 

Vena  cava,  twist  in,  668. 

Vena  cava,  superior,  perforation  of,  by  aneu- 
rism, 778,  788. 

Venereal  disease,  238. 

Venesection  (see  Bloodlettinq). 

Venous  pulse,  311,  1083,  1126. 

Ventricles  of  brain,  dilatation  of  (hydro- 
cephalus), 1028;  puncture  of,  1030. 

Ventricular  haemorrhage,  999. 

Verruca  necrogenica,  264. 

Vertebrae,  caries  of,  970;  cervical,  carles  of, 
971. 

Vertebral  al-tery,  obstruction  of,  1010. 

Vertigo,  auditory,  10.58;  cerebellar,  986;  In 
arteriosclerosis,  775;  In  brain  tumor,  1021; 
gastric,  469;  labyrinthine,  1058;  endemic 
paralytic,  1059. 

Veslcnlse  semlnalea,  tuberculosis  of.  326. 

Vicarious,  epistaxis,  614;  haemoptysis,  637. 

Vinifi  Ptc,  229. 


1182 


INDEX. 


Visceroptosis,  541. 

Vitiligoidea,  549. 

Vocal  fremitus,  119,  668;  resonance,  120,  670. 

Voice  (see  Speech). 

Voice,  alteration  of,  in  mouth-breathers,  456. 

Volitional  tremor,  959. 

Volvulus,  533,  537. 

Vomica,  296;  signs  of,  in  phthisis,  309. 

Vomit,  black,  186;  coffee-ground,  490. 

Vomiting,  in  Addison's  disease,  830;  in 
Bright' s  disease,  881;  in  cerebral  abscess, 
1026;  in  cerebral  tumor,  1021;  in  chronic 
obstruction  of  intestines,  535;  in  chronic 
ulcerative  phthisis,  311;  in  gall-stone  colic, 
564;  in  gastric  cancer,  490;  in  gastric  ulcer, 
481;  in  acute  obstruction  of  intestines,  534; 
in  tuberculous  meningitis,  278;  in  migraine, 
1103;  in  peritonitis,  598;  in  small-pox,  59; 
nervous,  499;  primary  periodic,  499;  sterco- 
raceous,  534;  uraemic,  867. 

von  Noorden's  dietary  in  obesity,  440. 

Vulvitis,  ulcerative,  in  measles,  87. 

Wall-paper,  poisoning  by  arsenic  in,  390. 

Wart-pox,  63. 

Warts,  post-mortem,  264. 

Washing  out  stomach,  472,  477. 

Water-hammer  pulse,  714. 

Water,   infection  by,   in  diphtheria,  138;  in 

cholera,  177;  in  typhoid  fever,  5. 
"  Water  on  the  brain,"  276. 
Weber,  syndrome  of,  279,  1004,  1023. 
Weil's  disease,  344. 
Werlhoft's  disease,  816. 
Wernicke's  hemiopic  pupillary  inaction,  1044. 


Wet-pack,  84. 

Whip-worm,  364. 

White  softening  of  the  brain,  1009. 

White  thrombi  in  heart,  723. 

Whooping-cough,  92. 

Winckel's  disease  (see  Epidemic  Hemo- 
globinuria OF  THE  New-born),  243,  818, 
853. 

"  Winged  scapulae,"  307. 

Wintrich's  sign,  309. 

Woilles,  maladie  de,  634. 

Wool-sorter's  disease,  224,  226. 

Word-blindness,  992. 

Word-deafness,  992. 

Wormian  bones  in  hydrocephalus,  1029. 

Worms  (see  Parasites). 

Wounds  of  the  heart,  754. 

Wrist-drop,  1071;  in  lead-poisoning,  388. 

Writer's  cramp,  1107. 

Wryneck,  1064;  spasmodic,  1065. 

Xanthelasma,  549. 
Xanthine  calculi,  892. 
Xanthomata,  425,  549,  565. 
Xanthopsia,  353. 
Xerostomia,  447. 

Yellow  fever,  182;  bacteriology  of,  184;  epi- 
demics of,  182. 
Yellow  softening  of  brain,  1009. 
Yellow  vision,  353. 

Zinc,  peripheral  neuritis  from,  1035. 
Zona,   1106. 


(3) 


THE    END. 


PRACTICAL  DIETETICS, 

WITH  SPECIAL   REFERENCE  TO  DIET  IN  DISEASE. 

By  W.  GILMAN  THOMPSON,  M.D., 

Professor  of  Medicine  in  tlie  Cornell  Medical  ColleDre  of  the  City  of  New  York;  Visiting 
Physician  to  the  Presbyterian  and  Bellevue  Hospitals,  New  York. 

LARGE  OCTAVO,  EIGHT  HUNDRED  AND  FOURTEEN  PAGES, 

ILLUSTRATED. 

Cloth,  $5.00. 

SECOND  REVISED  EDITION.    SOLD   ONLY  BY  SUBSCRIPTION. 


"This  is  at  once  the  best  and  most  exhaustive  book  upon  this  sub- 
ject with  which  we  are  familiar.  The  best,  because,  in  the  first  place, 
it  is  written  by  a  teacher  of  therapeutics  who  knows  the  needs  of  the 
practicing  physician,  and  yet  who  has  taught  in  previous  years  as  a 
professor  of  physiology  all  that  one  needs  to  know  in  regard  to  the 
principles  of  digestion  and  assimilation.  For  this  reason  the  author  is 
unusually  well  qualified  to  prepare  a  useful  manual,  but  it  is  not  until 
one  has  perused  the  volume  that  he  thoroughly  grasps  the  scope  and 
depth  of  the  manner  in  which  Dr.  Thompson  has  treated  his  subject." 
—  Therapeutic  Gazette. 

"  The  subject  of  the  dietetic  treatment  of  disease  is  not  an  attractive 
one.  This  fact  explains,  no  doubt,  the  comparatively  little  attention 
given  it  in  college  curriculum  and  daily  study.  When  one  proceeds  to 
examine  the  valuable  contributions  to  this  subject,  the  scientific  inves- 
tigations which  have  been  made  by  the  United  States  Department  of 
Agriculture  at  various  experiment  stations  in  all  parts  of  the  country, 
he  is  convinced  that  it  is  high  time  to  look  into  the  matter  pretty  thor- 
oughly. This  book  is  of  value  for  its  summary  of  the  latter  and  its 
application  of  the  knowledge  to  the  treatment  of  the  disease." — 
Brooklyn  Medical  Journal. 

"  Diet  in  disease  is  most  expansively  considered,  and  complete  and 
reliable  dietaries  for  every  ailment  are  suggested.  The  dietetic  errors 
responsible  for  a  large  number  of  diseases  are  also  fully  discussed. 
Altogether,  it  is  perhaps  the  best  work  extant  upon  the  subject  of 
dietetics." — Hahnemannian  Monthly. 

"A  good  book  and  a  practical  one." — Canadian  Practitioner  and 
Review. 

"  In  the  seven  years  which  have  elapsed  since  the  first  appearance 
of  this  standard  text-book  there  have  not  been  the  many  and  important 
changes  in  dietetics  that  other  departments  of  our  therapeutics  have 
undergone.  Nevertheless,  Dr.  Thompson  has  revised  much  that  was 
published  in  the  first  edition,  and  has  introduced  into  this  one  the  re- 
sults of  more  recent  studies  in  the  economic  values  of  various  dietaries. 
The  general  arrangement  of  the  work  is  unchanged." — N^ew  York 
Medical  Journal. 

D.  APPLETON  AND  -COMPANY,  NEW  YORK. 


INTRODUCTION 

TO    THE    STUDY   OF 

MEDICINE 

By    G.    H.    ROGER 

PROFESSOR    EXTRAORDINARY    IN    THE    FACULTY     OF    MEDICINE    OF    PARIS 

MEMBER    OF    THE    BIOLOGICAL    SOCIETY 

PHYSICIAN    TO    THE     HOSPITAL    OF    PORTE-d' AUBERVILLIERS 

AUTHORIZED   TRANSLATIONS   BY 
M.  S.  GABRIEL,  M.  D. 

WITH  ADDITIONS  BY  THE  AUTHOR 
8vo.      Cloth,  $5.00 

"  Such  a  work,  well  conned,  provides  beginners  in  medicine  with  a  sure  and  wide  founda- 
tion of  systematic  science  on  which  to  base  all  their  future  acquirements.  Dr.  Roger's  unique 
volume  is  to  be  heartily  commended,  not  only  to  would-be  physicians  but  also  to  that  larjje 
class  of  post-graduates  who  do  not  cease  to  be  students  because  they  have  left  college,  and 
would  like  to  know  the  reasons  and  relations  of  things."— Afedtca/  Times,  Denver,  Col. 

"  The  work  throughout  shows  an  essentially  logical  method  of  treatment,  and  covers  a 
very  wide  subject  in  a  manner  which  amply  demonstrates  the  author's  extensive  acquaintance 
with  medical  thought  and  medical  literature.  The  book  can  be  recommended  not  only  to 
students,  but  also  to  practitioners  in  medicine,  as  giving  a  wide  and  philosophical  view  of 
medicine  and  iis  tendencies  at  the  present  day." — Albany  Medical  Annals,  Albany,  N.  Y. 

"  As  a  risume  of  recent  medical  advancement  we  may  expect  this  volume  to  occupy  a 
unique  place.  It  is  something  of  a  novelty  to  turn  the  pages  of  a  medical  work  which  will 
be  most  valuable  to  the  profession  as  a  whole,  not  to  the  specialist  or  individual  student  alone. 
It  is,  however,  well  suited  to  use  as  a  text-book,  and  will  put  students  in  touch  with  medicine 
as  an  all-embracing  science.  But  to  those  of  the  profession— and  there  are  many — who  lack 
opportunity  to  thoroughly  acquaint  themselves  with  the  rapid  strides  which  are  being  made  in 
knowledge  of  the  causation  of  disease,  lesions  and  reactions  of  the  organism  which  are  dis- 
cussed under  pathological  anatomy  and  semeiology,  the  work  will  serve  as  a  substitute  for 
lectures  and  laboratory  experience.  Some  of  the  principal  chapters  deal  with  the  mechanical, 
physical,  chemical,  and  animate  agencies  of  disease,  the  general  etiology  and  pathogenesis  of 
the  infectious  diseases,  nervous  reactions,  disturbances  of  nutrition,  heredity,  inflammation, 
septicemia  and  pyemia,  tumors,  cellular  degenerations,  examination  of  the  sick,  clinical  appli- 
cation of  scientific  procedures,  diagnosis  and  prognosis,  therapeutics,  etc.  An  immense 
amount  of  work  is  evidenced  by  the  text,  and  much  careful  and  scholarly  research.  A  book 
of  this  kind  is  needed,  and  will  be  particularly  appreciated  by  those  who,  without  undervaluing 
the  importance  of  laboratory  investigations,  still  think  clinical  methods  and  the  simpler  means 
of  reaching  a  diagnosis  and  prognosis  should  not  be  forgotten  or  slighted."— A'^ez/;  England- 
Medical  Gazette,  Boston,  Mass. 

D.  APPLETON    AND   COMPANY,  NEW  YORK 


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